Guidelines for treatment of hypertension in the elderly--2002 revised version

Clinical Practice Guidelines for Hypertension: Evaluation of Quality Using the AGREE II Instrument

INTRODUCTION

Hypertension is an important public health challenge. The purpose of clinical practice guidelines (CPGs) is to provide explicit recommendations for clinical practice, reduce inadequate variations, optimize results, minimize risks, and promote cost-effective practice. Therefore, a highly methodological quality development process for CPGs is more likely to yield a CPG that contains relevant and appropriate recommendations.

METHOD

To assess the quality of CPGs for the prevention and treatment of hypertension, a systematic search was performed using the following literature databases: PubMed, Excerpta Medica Database (EMBASE), Web of Science, the National Guideline Clearinghouse (NGC), Chinese National Knowledge Infrastructure (CNKI), Wan fang Data, VIP, and Chinese Biomedical Literature Database (CBM). Then the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument was used to assess the quality of the CPGs.

RESULTS

Forty-one CPGs were identified (ten CPGs in Chinese and 31 CPGs in English). The results for the overall recommendation were as follows: strongly recommended (15 %), recommended (29 %), weakly recommended (51 %), and not recommended (5 %). The scores for all domains (mean ± standard deviations) were "scope and purpose" (58.65 ± 12.67 %), "stakeholder involvement" (48.07 ± 11.41 %), "rigor of development" (27.31 ± 12.29 %), "clarity of presentation" (53.89 ± 11.09 %), "applicability" (40.10 ± 13.33 %), and "editorial independence" (38.75 ± 16.43 %). All differences were statistically insignificant for all domains (P > 0.05) according to publication time. CPGs using an evidence-based (EB) method were of a higher quality than non-EBs for all domains, but the differences were significant for the following domains: "Scope and Purpose," "Rigor of Development," "Applicability," and "Editorial Independence" (P < 0.05). The scores for the CPGs developed based on associations and society appeared slightly higher than those developed by individuals. However, the differences were insignificant for all domains (P > 0.05).

CONCLUSION

A more systematic approach for the development and report of these guidelines is recommended. The AGREE II instrument can be a useful tool to improve the quality of guidelines.

Factors Affecting Hypertension among the Malaysian Elderly

Hypertension is a common chronic disease in the elderly. This study aimed to determine the effects of age, ethnicity, gender, education, marital status, nutritional parameters, and blood elements on the risk of high blood pressure in the Malaysian elderly. This research was conducted on a group of 2322 non-institutionalized Malaysian elderly. The hierarchy binary logistic regression analysis was applied to estimate the risk of hypertension in respondents. Approximately, 45.61% of subjects had hypertension. The findings indicated that the female gender (Odds ratio (OR) = 1.54), an increase in body weight (OR = 1.61), and an increase in the blood levels of albumin (OR = 1.51), glucose (OR = 1.92), and triglycerides (OR = 1.27) significantly increased the risk of hypertension in subjects (p < 0.05). Conversely, an increase in both dietary carbohydrates (OR = 0.74), and blood cholesterol level (OR = 0.42) significantly reduced the risk of hypertension in samples (p < 0.05). Furthermore, the results showed that ethnicity was a non-relevant factor to increase the risk of hypertension in subjects. It was concluded that female gender, an increase in body weight, and an increase in the blood levels of glucose, triglycerides, and albumin enhanced the risk of high blood pressure in the Malaysian elderly. In addition, an increase in both dietary carbohydrates and blood cholesterol level decreased hypertension in subjects.

Diagnosis of pheochromocytoma: a clinical practice guideline appraisal using AGREE II instrument

OBJECTIVE

The objective of this study was to assess the quality of clinical practice guidelines providing diagnostic recommendations on pheochromocytoma (PHEO) using the new Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to promote the development of clinical guidelines.

RESEARCH DESIGN AND METHODS

We searched MEDLINE and electronic databases for guidelines published between 2001 and 2010 regarding the diagnosis of PHEO. The methodological quality of guidelines for three fields for the diagnosis of PHEO was evaluated using the new AGREE II instrument by two independent appraisers. We also compared two different types of guidelines to determine the superior guideline.

RESULTS

Four special guidelines and six general guidelines related to the diagnosis of PHEO were included in the study. According to AGREE II, two guidelines performed well in recommending biochemical evaluations. One guideline was good for radiodiagnosis, but no guideline was good for recommending genetic testing. The best-performing domain of the AGREE II instrument was domain 1 (D1) (scope and purpose), while the worst performing domain was D5 (applicability) in both types of guidelines. The special guideline was significantly better than the general guideline in D4 (P < 0.01), while the general guideline performed better in D6. There were no differences in the other four domains.

CONCLUSIONS

The quality and rigour of guidelines for the diagnosis of PHEO vary. It is difficult to identify one guideline that performed well in all three fields for the diagnosis of PHEO based on the AGREE II instrument. Therefore, additional studies and greater efforts should be taken to provide high-quality guidelines that serve as a useful and reliable tool for clinical decision making in diagnosing PHEO according to the AGREE II instrument.

Effects of intensive antihypertensive treatment on Chinese hypertensive patients older than 70 years

This study was performed to investigate whether intensive antihypertensive treatment with achieved blood pressure (BP) ≤140/90 mm Hg, as compared with standard treatment with achieved BP ≤150/90 mm Hg, could further improve cardiovascular outcomes in Chinese hypertensive patients older than 70 years. A total of 724 participants were randomly assigned to intensive or standard antihypertensive treatment. After a mean follow-up of 4 years, the mean achieved BP was 135.7/76.2 mm Hg in the intensive treatment group and 149.7/82.1 mm Hg in the standard treatment group. The visit-to-visit variability in systolic BP and diastolic BP was lower in the intensive group than that in the standard group. Intensive antihypertensive treatment, compared with the standard treatment, decreased total and cardiovascular mortality by 41.7% and 50.3%, respectively, and reduced fatal/nonfatal stroke by 42.0% and heart failure death by 62.7%. Cox regression analysis indicated that the mean systolic BP (P=.020; 95% confidence interval, 1.006-1.069) and the standard deviation of systolic BP (P=.033; 95% confidence interval, 1.006-1.151) were risk factors for cardiovascular endpoint events. Intensive antihypertensive treatment with achieved 136/76 mm Hg was beneficial for Chinese hypertensive patients older than 70 years. Long-term visit-to-visit variability in systolic BP was positively associated with the incidence of cardiovascular events.

Elderly and drugs: risks and necessity of rational use

In recent decades, the world has undergone a demographic transformation with a rapid growth of the elderly population, resulting in an increased demand for funds to maintain their health and drug consumption. Pharmacokinetic and pharmacodynamic changes occurring in the elderly can interfere directly in the adverse effects of drugs and increase the risk of intoxication. In addition, there are external factors interfering with the pharmacotherapy of the elderly, such as inappropriate use and the lack of access to information. Many therapeutic classes of drugs should be used with caution or avoided in the elderly population, such as anti-inflammatory and some anti-hypertensive drugs, diuretics and digitalis. If not managed carefully, these medicines can affect the safety and quality of life in the elderly. Thus, the aim of this review was to identify drugs that should be used with caution in elderly patients in order to avoid intoxication and/or adverse drug events.

Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS)

The benefits of lowering a systolic blood pressure below 140 mmHg in elderly hypertension remain controversial. This study is a prospective, randomized, open-label study with blinded assessment of endpoints to compare the 2-year effect of strict treatment to maintain systolic blood pressure below 140 mmHg with that of mild treatment to maintain systolic blood pressure below 160 but at or above 140 mmHg in elderly hypertensive patients. Patients with essential hypertension (65-85 years old, with a pretreatment systolic blood pressure of above 160 mmHg) were randomly assigned to receive strict treatment (n=2,212) or mild treatment (n=2,206). The baseline drug was efonidipine hydrochloride, a long-acting calcium antagonist. The primary endpoint was the combined incidence of cardiovascular disease and renal failure, and the secondary endpoints were total deaths and any safety problems. Although final blood pressures (systolic/diastolic) were significantly lower in the strict-treatment group compared with the mild-treatment group (135.9/74.8 vs. 145.6/78.1 mmHg; p<0.001), the incidence of the primary endpoint was similar in the two groups (86 patients in each group; p=0.99). Total deaths were 54 in the strict-treatment group vs. 42 in the mild-treatment group (p=0.22), and treatment was withdrawn because of adverse events in 36 patients in each group (p=0.99). An interaction between age and treatment for the primary endpoints (p=0.03) was seen. Complex clinical features associated with aging seem to have obscured the difference in effect between the two treatments. Further studies are needed to assess the optimal treatment strategy for hypertension in the elderly.

Clinical value of urinary kidney biomarkers for estimation of renal impairment in elderly Chinese with essential hypertension

The purpose of this work was to observe the excretion of specific types of urinary proteins and urinary enzymes in elderly essential hypertension patients, for early detection and targeted treatment of hypertensive nephropathy in the elderly. A total of 120 elderly essential hypertensive patients and 38 healthy elderly volunteers were involved. The urinary excretion rate of retinal-binding protein (RBP), transferrin (Tf), albumin (Alb), and urinary enzyme N-acetyl-beta-D-glucosaminidase (NAG) activity were determined. Patients were divided into two groups according to their creatinine clearance (Cockroft-Gault formula). There were 88 patients in group A, whose glomerular filtration rate (GFR) was >or=80 mL/min, and 32 patients in group B with a GFR <80 mL/min. Among the essential hypertensive patients, urinary excretion rates of RBP, Alb, Tf, and NAG were increased in both groups compared with the healthy controls. But the amount of urinary protein differed between group A and group B. The excretion rate of specific urinary protein and urinary enzyme had a positive relationship with the duration of course of hypertension. We believe that specific types of urinary proteins and urinary enzymes may be useful markers for early diagnosis of hypertensive nephropathy; they can also be regarded as a clinical indicator of the progression of hypertensive nephropathy, serving in the assessment of therapeutic effects.

Evaluation of morning blood pressure elevation and autonomic nervous activity in hypertensive patients using wavelet transform of heart rate variability

To evaluate morning autonomic nervous activity and blood pressure profiles in hypertensive patients by analyzing heart rate variability and ambulatory blood pressure. Data from 82 patients with untreated essential hypertension were analyzed. We evaluated the 24-h profile of blood pressure and that of indices of autonomic nervous activity, i.e., the high frequency component (HF) and low frequency component/HF (LF/HF), which were obtained by wavelet transform of heart rate variability. Patients were classified by dipping status (nondippers, n=28; dippers, n=32; extreme-dippers, n=8; and risers, n=14) and morning blood pressure profile (large, n=9; small, n=60; and inverted, n=13). Nocturnal systolic blood pressure in extreme-dippers was significantly lower than that in the other groups; that in the risers was significantly higher (p<0.05). There were no significant group differences in daytime systolic blood pressure. Daytime and 24-h HF levels were significantly higher in the dipper vs. the riser group (p<0.05). Morning blood pressure elevation negatively correlated to preawake (p<0.01) and nocturnal blood pressure (p<0.05), but not to daytime and post-awake blood pressure. The preawake/postawake ratio of systolic blood pressure positively correlated to that of LF/HF (p<0.01) and negatively correlated to preawake HF levels (p<0.05). Multivariate regression analysis revealed that preawake HF levels (p=0.037) and preawake/postawake ratio of LF/HF (p=0.033) were independently correlated with morning blood pressure elevation ratio. Our results suggest that activation of HF before waking and LF/HF during waking might play an important role in the development of morning blood pressure elevation.

Impact of hypertension on medical economics: A 10-year follow-up study of national health insurance in Shiga, Japan

Hypertension and related cardiovascular diseases may lead to an increase in medical costs for patients. We attempted to clarify the relationship between hypertension and long-term medical costs by a cohort study utilizing existing data as well as baseline blood pressures and medical costs over a 10-year period. The participants included 4191 Japanese National Health Insurance beneficiaries aged 40-69 years, living in one area, who were not taking anti-hypertensive medication and did not have a history of major cardiovascular disease. They were classified into four categories according to their blood pressure. We evaluated the mean medical costs per month, cumulative hospitalization, and all-cause mortality for each blood pressure category. Hypertension-related medical costs attributable to hypertensive individuals, as compared to normotensive individuals, were estimated. There was a positively graded correlation between blood pressure and personal total medical costs, especially for men. The odds ratio for cumulative hospitalization and hazard ratio for all-cause mortality in severe hypertensive men were also higher than those in normotensive men. However, the hypertension-related medical costs for mild to moderate hypertensives were higher than those for severe hypertensives. The hypertension-related medical costs for all hypertensives accounted for 23.7% of the total medical costs for the Japanese population. In conclusion, high blood pressure was a useful predictor for excess medical costs; moreover, concomitant hypertension, regardless of the grade, increased the medical costs of Japanese National Health Insurance beneficiaries.

Association between carotid hemodynamics and asymptomatic white and gray matter lesions in patients with essential hypertension

The aim of this study was to clarify the magnitude of common carotid artery (CCA) structural and hemodynamic parameters on brain white and gray matter lesions in patients with essential hypertension (EHT). The study subjects were 49 EHT patients without a history of previous myocardial infarction, atrial fibrillation, diabetes mellitus, impaired glucose tolerance, chronic renal failure, symptomatic cerebrovascular events, or asymptomatic carotid artery stenosis. All patients underwent brain MRI and ultrasound imaging of the CCA. MRI findings were evaluated by periventricular hyperintensity (PVH), deep and subcortical white matter hyperintensity (DSWMH), and état criblé according to the Japanese Brain dock Guidelines of 2003. Intima media thickness (IMT), and mean diastolic (Vd) and systolic (Vs) velocities were evaluated by carotid ultrasound. The Vd/Vs ratio was further calculated as a relative diastolic flow velocity. The mean IMT and max IMT were positively associated with PVH, DSWMH, and état criblé (mean IMT: rho=0.473, 0.465, 0.494, p=0.0007, 0.0014, 0.0008, respectively; max IMT: rho=0.558, 0.443, 0.514, p=0.0001, 0.0024, 0.0004, respectively). Vd/Vs was negatively associated with état criblé (rho=-0.418, p=0.0038). Carotid structure and hemodynamics are potentially related to asymptomatic lesions in the cerebrum, and might be predictors of future cerebral vascular events in patients with EHT.

Comportamento subagudo da pressão arterial após o treinamento de força em hipertensos controlados

Diversos estudos têm demonstrado um efeito benéfico do exercício de força sobre a redução da pressão arterial (PA) pós-exercício, mas ainda são escassas as pesquisas envolvendo pessoas hipertensas. Dessa forma, o presente estudo tem como objetivo comparar as respostas de PA em sujeitos hipertensos medicados após duas sessões de exercício de força com diferentes volumes de treinamento. Para tal, foram estudados 20 indivíduos de ambos os gêneros (61 ± 12 anos) com hipertensão controlada por fármacos e participantes de um programa de exercícios, porém sem experiência no treinamento de força. O estudo foi realizado em três dias não consecutivos. Primeiramente, foi determinada a carga de 10 repetições máximas em cada exercício da seqüência (supino reto, leg-press horizontal, remada em pé e rosca tríceps). Nos demais dias, os mesmos exercícios foram realizados com uma (SER1) ou três (SER3) séries. A aferição da PA foi executada pelo método auscultatório no momento pré-exercício, imediatamente após o término de cada sessão e durante 60 minutos após o término dos exercícios. A ANOVA de medidas repetidas identificou que em ambas as sessões os valores da PA sistólica (PAS) e diastólica (PAD), medidos imediatamente após o término dos exercícios, foram mais elevados (p < 0,05) que os do pré-exercício. O acompanhamento em 60 minutos exibiu, após SER1, uma redução dos valores de PAS apenas no 40º minuto, enquanto não foram encontradas reduções para a PAD. Já após SER3, observou-se uma queda dos níveis de PAS que perdurou por todo o período de monitorização. Para PAD, foram encontradas reduções apenas no 30º e 50º minuto pós-exercício. Conclui-se que uma sessão de treinamento de força pode promover reduções nos níveis de PAS em indivíduos hipertensos medicados e parece ser necessário um maior volume de treinamento para que tal efeito ocorra.

Blood Pressure Control in Hypertensive Patients With a History of Stroke

The targets for lowering blood pressure (BP) in hypertensive stroke patients remain unclear. We assessed the current status of BP control in hypertensive patients with a history of stroke, investigating 413 hypertensive patients (age range, 19 to 93; mean age, 62 +/- 12 years) who visited the hypertension and stroke clinic at Kyushu University Hospital. We compared the clinical characteristics of these hypertensive patients with a history of stroke, including brain infarction, transient ischemic attack, and brain hemorrhage (age range, 29-86; mean age, 66 +/- 12 years; n = 95) with those of patients without such a history (age range, 19-93; mean age, 61 +/- 12 years; n = 318). Clinic BP was measured by physicians with a mercury sphygmomanometer, and the averaged BP determined at 2 occasions in 2002 was used for analysis. Systolic BP was similar among the patients with and without a history of stroke (134 +/- 15 vs 137 +/- 14 mm Hg; P = not significant), but diastolic BP was significantly lower in patients with stroke than in those without stroke (76 +/- 10 vs 82 +/- 10 mm Hg; P < .05). When strict BP control was defined as <130/85 mm Hg, the rate of strict BP control was higher in the stroke patients than in those without stroke (35.8% vs 19.8%; P < .01). The average number of antihypertensive drug classes used was similar in the 2 groups (1.7 +/- 0.9 and 1.8 +/- 1.0, respectively). Calcium antagonists were the most frequently used drugs in both groups. Diuretics and beta-blockers were prescribed less frequently to the patient with ischemic stroke than to those without stroke. BP levels were lower in the patients with brain hemorrhage than in those with lacunar and atherothrombotic infarction. In our outpatient clinic, BP levels were lower in the stroke patients than in the patients without stroke, which may reflect physicians' awareness of the importance of strict BP control in stroke patients, as has been suggested by several recent clinical intervention trials.

Control of blood pressure as measured at home and office, and comparison with physicians' assessment of control among treated hypertensive patients in Japan: First Report of the Japan Home versus Office Blood Pressure Measurement Evaluation (J-HOME) study

The Japan Home versus Office Blood Pressure Measurement Evaluation (J-HOME) study was conducted to measure the control of blood pressure (BP) as evaluated by home BP measurement among 3,400 patients with essential hypertension (mean age: 66 years; females: 55%) receiving antihypertensive treatment in primary care settings in Japan. The purpose of this first report was to compare characteristics of BP control as measured at home and in the clinic (office) and define their association with BP control as evaluated by physicians. Mean systolic/diastolic BP (SBP/DBP) values were 140/82 mmHg for home BP and 143/81 mmHg for office BP. BP levels were not adequately controlled among approximately 60% of the patients, according to reference values described in the national guidelines (office BP: <140/90 mmHg; home BP: <135/85 mmHg). Even among patients evaluated by physicians as having excellent or fairly good BP control, office and home SBP values were insufficiently controlled in approximately 50%. Although the tendency was more remarkable among older patients, whose recommended target BP levels are higher than those of middle-aged patients in the Japanese Hypertension Society 2000 criteria, office and home BP values were not adequately controlled in approximately 50% of the middle-aged patients whose BP control was evaluated as good. Our findings suggest that an important reason why home and office BP values are not adequately controlled is that physicians approve relatively higher BP levels under treatment, even among middle-aged patients.

Two cases of renovascular hypertension and ischemic renal dysfunction: reliable choice of examinations and treatments

We experienced two aged patients with atherosclerotic renovascular stenosis associated with hypertension and ischemic nephropathy. Both patients exhibited sudden rise in blood pressure (BP) and progressive aggravation of renal dysfunction. In these patients, the use of contrast medium to screen for renal artery stenosis (RAS) ran the risk of further deterioration of renal function. We therefore used magnetic resonance angiography (MRA), which is less conducive to renal damage, to screen for RAS. One-sided RAS was treated by percutaneous transluminal angioplasty of the renal artery (PTRA) and stenting. As a result, BP decreased in both patients. Serum creatinine (Cr) decreased slightly in one patient, whereas, in the other, serum Cr increased transiently and then decreased and stabilized to pre-treatment levels. Thus, although it is unclear whether the combination of PTRA and stenting is among the best treatments for patients with RAS and moderate-to-severe renal dysfunction, PTRA and stenting are clearly of benefit in selected patients. In addition, recent progress in characterizing the pathophysiology of ischemic nephropathy associated with renovascular hypertension has created interest in the therapeutic potential of angiotensin II receptor antagonists, sympatholytic agents, and antioxidants. Therefore, we discuss the therapeutic utility of PTRA and stenting and the above-mentioned medications in patients with RAS and renal dysfunction.

Interaction between Amlodipine and Simvastatin in Patients with Hypercholesterolemia and Hypertension

3-Hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors are often prescribed in association with antihypertensive agents, including calcium antagonists. Simvastatin is an HMG-CoA reductase inhibitor that is metabolized by the cytochrome P450 (CYP) 3A4. The calcium antagonist amlodipine is also metabolized by CYP3A4. The purpose of this study was to investigate drug interactions between amlodipine and simvastatin. Eight patients with hypercholesterolemia and hypertension were enrolled. They were given 4 weeks of oral simvastatin (5 mg/day), followed by 4 weeks of oral amlodipine (5 mg/day) co-administered with simvastatin (5 mg/day). Combined treatment with simvastatin and amlodipine increased the peak concentration (C(max)) of HMG-CoA reductase inhibitors from 9.6 +/- 3.7 ng/ml to 13.7 +/- 4.7 ng/ml (p < 0.05) and the area under the concentration-time curve (AUC) from 34.3 +/- 16.5 ng h/ml to 43.9 +/- 16.6 ng h/ml (p < 0.05) without affecting the cholesterol-lowering effect of simvastatin. This study is the first to determine prospectively the pharmacokinetic and pharmacodynamic interaction between amlodipine and simvastatin.

Effects of a New Calcium Channel Blocker, Azelnidipine, on Systemic Hemodynamics and Renal Sympathetic Nerve Activity in Spontaneously Hypertensive Rats

Antihypertensive treatment with dihydropyridine calcium channel blockers elicits sympathetic nerve activation, which may contribute to cardiovascular events. However, recent clinical studies showed that treatment with azelnidipine, a new dihydropyridine calcium channel blocker, significantly reduced blood pressure in hypertensive patients while either maintaining or actually decreasing heart rate (HR). In this study, we examined the effects of azelnidipine and amlodipine on systemic hemodynamics and renal sympathetic nerve activity (RSNA) in anesthetized spontaneously hypertensive rats (SHR). We also examined the effects of these agents on baroreflex functions by infusing phenylephrine (30 microg/kg/min, i.v.) and sodium nitroprusside (10 microg/kg/min, i.v.) into azelnidipine- or amlodipine-treated SHR. Fifty min after administration of azelnidipine (10 microg/kg/min for 10 min, i.v.), mean arterial pressure (MAP) significantly decreased from 153+/-5 to 122+/-5 mmHg; however, HR and integrated RSNA did not change significantly (from 352+/-9 to 353+/-10 beats/ min and 115+/-5% of baseline, respectively). Infusion of amlodipine (50 microg/kg/min for 10 min) elicited similar effects on MAP (from 152+/-5 to 120+/-4 mmHg). However, amlodipine significantly increased HR (from 351+/-9 to 375+/-11 beats/min) and integrated RSNA (165+/-5% of baseline). Analyses of baroreflex function curves revealed that azelnidipine-treated rats showed a smaller baroreflex function than amlodipine-treated rats (p<0.05). These data suggest that azelnidipine possesses sympathoinhibitory effects, which may be one reason why it had less pronounced effects on HR in hypertensive patients.

Hypertension in the Elderly

Elderly individuals with hypertension show specific characteristics as a result of advancing arteriosclerosis, a high frequency of isolated systolic hypertension, increased pulse pressure and orthostatic hypotension. The necessity to treat hypertension in the elderly, including isolated systolic hypertension, has been demonstrated in many large-scale intervention trials. Young-old (65-74 years of age) hypertensive patients should be treated the same as nonelderly hypertensive patients. In old-old (75-84 years of age) patients with mild hypertension (140-159/90-99 mm Hg), the recommended target blood pressure (BP) is <140/90 mm Hg. In old-old (75-84 years of age) and oldest-old (> or =85 years of age) patients with systolic BP > or =160 mm Hg, cautious treatment is required. An intermediate target BP of <150 mm Hg is appropriate, followed by a final target BP of <140 mm Hg, if tolerated. Nonmedical therapy, such as salt restriction, exercise and weight reduction, is useful in the elderly. However, individualised management of nonmedical therapy is necessary to avoid deterioration of quality of life resulting from strict management of the patient's lifestyle. Diuretics, calcium channel antagonists, ACE inhibitors and angiotensin II type 1 receptor antagonists have been established as first-line antihypertensive drugs in the elderly. Use of combination therapy helps to achieve target BPs. The starting dose of each drug should be half the usual dose for nonelderly patients, and may be increased at intervals of >4 weeks, with achievement of the target BP in 3-6 months or longer. In hypertensive patients with co-morbid diseases, the target BP should be determined individually and antihypertensive drugs selected bearing in mind the patient's clinical circumstances. Avoiding hypoperfusion of target organs is very important in elderly hypertensive patients. When treating hypertension in elderly patients, the approach should be to identify individual pathophysiological characteristics and lower the BP cautiously and slowly.

The Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients (JATOS): Protocol, Patient Characteristics, and Blood Pressure during the First 12 Months

The benefits of a systolic blood pressure (BP) below 150-160 mmHg are well established; whether a systolic BP of less than 140 mmHg provides additional benefits remains controversial. This study was designed to compare the 2-year effect of a strict treatment to maintain systolic BP below 140 mmHg (group A) and that of a mild treatment to maintain systolic BP at between 140 and below 160 mmHg (group B). The study design followed the Prospective Randomized Open Blinded End-point (PROBE) study. The subjects were elderly patients (65-85 years old) who consistently had a systolic BP of 160 mmHg or higher. The baseline drug was efonidipine hydrochloride (efonidipine), a long-acting dihydropiridine calcium antagonist. The primary endpoints were stroke, cardiac disease, vascular disease, and renal failure. After a run-in period of 2 to 4 weeks, 2,165 patients were assigned to group A and 2,155 patients to group B. There were no significant differences between the groups in sex, age, baseline BP, or other cardiovascular risk factors. The systolic BP was 7.2 mmHg lower (p < 0.0001) and the diastolic BP 2.4 mmHg lower (p < 0.0001) in group A than in group B after 12 months of treatment. As of this interim analysis, primary endpoints have occurred in 87 patients (stroke in 58 patients, cardiac disease in 27 patients, occlusive arterial disease in 1 patient, and renal failure in 1 patient). Five patients have died of stroke and 2 patients of myocardial infarction. The primary-endpoint-related morbidity rate was 20.9/1,000 patient-years, and the mortality rate was 1.7/1,000 patient-years. Currently available results indicate that this study, one of the largest randomized trials of antihypertensive therapy in elderly patients in Japan, was conducted safely. The final results are expected to provide important and practical information for the management of hypertension in elderly patients.

Role of prehypertension in the development of coronary atherosclerosis in Japan

BACKGROUND

Hypertension is an important risk factor of coronary heart disease. A new guidelines for hypertension prevention and management in The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in the United States recommended lifestyle modification or medical treatment for subjects with prehypertension. However, whether prehypertension increases the risk of coronary atherosclerosis in the Japanese population is still unknown.

METHODS

A cross-sectional study in a clinical setting was conducted. The subjects were 705 patients (417 males and 288 females) aged 30 years and older who underwent a first-time coronary angiography for suspected or known coronary heart disease at 5 major cardiology departments in the Fukuoka metropolitan area between September 1996 and August 1997.

RESULTS

Compared to subjects with normal blood pressure, those with prehypertension had an increased risk of coronary atherosclerosis even after adjusting for other factors.

CONCLUSION

Prehypertension may be an important clinical entity which requires treatment in the Japanese population.

Predictors of Controlled Ambulatory Blood Pressure in Treated Hypertensive Patients with Uncontrolled Office Blood Pressure

Although some treated hypertensive patients have controlled 24-h ambulatory blood pressure (ABP) despite their uncontrolled office blood pressure (BP), the factors relating to the control of 24-h ABP remain unknown. We conducted a study to assess 24-h ABP and its association with other cardiovascular risk factors, including echocardiographic left ventricular hypertrophy (LVH), in elderly hypertensive patients (n =41) with uncontrolled office BP (>140/90 mmHg) during long-term medication. Although a majority of the patients had isolated elevation of office systolic BP (SBP), there was no significant relationship between office SBP and 24-h SBP, and about half of the patients had controlled 24-h ABP (125+/-8/69+/-6 mmHg). Patients with controlled 24-h ABP (125+/-8/69+/-6 mmHg) had similar office BP (150+/-6/77+/-5 vs. 150+/-7/79+/-7 mmHg), but lower left ventricular mass index (LVMI) (123+/-34 vs. 156+/-34 g/m(2)) and body mass index (BMI) (24.4+/-2.1 vs. 26.4+/-3.6 kg/m(2)) compared with those with uncontrolled 24-h ABP (149+/-13/78+/-7 mmHg). Multivariate analysis showed that LVMI and BMI were independently associated with controlled 24-h ABP, and the control status of 24-h ABP was highly dependent on the presence of LVH and obesity. Therefore, absence of LVH and obesity may be useful for predicting the level of control of 24-h ABP in treated patients whose office BP is uncontrolled without ABP measurements.

Efficacy of a Multicomponent Program (Patient-Centered Assessment and Counseling for Exercise plus Nutrition [PACE+ Japan]) for Lifestyle Modification in Patients with Essential Hypertension

With conventional lifestyle modification programs, it can be difficult for hypertensive individuals to modify their lifestyles and maintain the changes. We assessed whether a multicomponent program (patient-centered assessment and counseling for exercise plus nutrition [PACE+ Japan]) based on behavior theory and social cognitive theory would be effective for treating patients with essential hypertension. We examined 57 outpatients aged 62+/-10 years with essential hypertension irrespective of antihypertensive drug treatment. Participants were randomly divided into two groups: 1) a PACE+ Japan follow-up group (n =18), who were given an action-plan sheet and systemic health counseling by a physician and counselor every 4 weeks for 24 weeks, and 2) a PACE+ Japan-only group (n =20), who were given an action-plan sheet but did not receive counseling. An age- and sex-matched control group (n =19) was also selected. The decrease in systolic blood pressure (SBP) (Delta SBP=SBP at 24 weeks minus that at 0 weeks) in the PACE+ Japan follow-up group was significantly greater than that in the control group. In addition, the Delta percentage of Fat (%Fat) and Delta urinary sodium extraction (U-Na) in the PACE+ Japan follow-up group were significantly greater than those in the control group. With regard to changes in total energy expenditure, exercise energy expenditure and total energy intake between 0 weeks and 24 weeks, significant improvements were observed for the PACE+ Japan follow-up group. Delta U-Na was determined to significantly predict Delta SBP as assessed by stepwise selection. In addition, the partial correlation coefficient of Delta SBP with Delta U-Na was 0.361 (p =0.011) as assessed by a multiple regression analysis. Therefore, PACE+ Japan follow-up counseling was associated with a reduction in SBP, which in turn was associated with reduction in U-Na. This new program may be effective for reducing blood pressure in hypertensives.

Effect of Low-Intensity Aerobic Exercise Training on Arterial Compliance in Postmenopausal Women

Regular aerobic exercise training attenuates age-related reduction in central arterial compliance, an independent risk factor of cardiovascular diseases. We tested the hypothesis that even low-intensity exercise training could increase central arterial compliance in postmenopausal women. Using B-mode ultrasound, we studied the central arterial compliance of 15 postmenopausal females (age: 52-66 years) before and after a 12-week aerobic exercise intervention. Subjects performed aerobic exercise training of the same energy expenditure (cycle exercise, total 900 kcal/week, 3-5 sessions/week) at two different exercise intensities: 7 trained at low intensity (40% heart rate reserve: L-TR) and 8 trained at moderate intensity (70% heart rate reserve: M-TR). Arterial compliance increased after exercise training in the L-TR group (0.70+/-0.32 vs. 1.06+/-0.55 mm2/mmHgX10(-1), p <0.05) and in the M-TR group (0.82+/-0.37 vs. 1.14+/-0.39 mm2/mmHgX10(-1), p <0.05). There was no significant difference in increases of arterial compliance in either group (L-TR: 0.35+/-0.38 vs. M-TR: 0.32+/-0.33 mm2/mmHgX10(-1)). These results suggest that the improvement of central arterial compliance by aerobic exercise training might not be influenced by the intensity of exercise training if the energy expenditure of the training is the same. Accordingly, even low-intensity exercise training may have the effect of improving central arterial compliance.