Effect of stress management on blood pressure in mild primary hypertension.

OBJECTIVE--To establish whether stress management had a larger effect than a control treatment on resting blood pressure, ambulatory blood pressure, and left ventricular mass. DESIGN--A 12 week baseline period of habituation to measurement of blood pressure was followed by randomisation to either stress management or mild exercise for six months and follow up six months later. SETTING--General practice, district general hospital, and medical school. PATIENTS--Of the 184 patients aged under 60 with mild primary hypertension who entered the baseline habituation period, 88 were excluded because they failed to meet the entry criteria or they withdrew from the study. The remaining 46 men and 50 women underwent treatment. INTERVENTIONS--10 clinical sessions and daily practice at home of either stress management based on relaxation or non-aerobic stretching exercises. Mildly stressful 15 minute interviews before and after treatment. MAIN OUTCOME MEASURES--Diastolic and systolic blood pressure in the clinic and during 12 hours of ambulatory recording, and left ventricular mass measured by echocardiography. RESULTS--The patients'' blood pressure fell during habituation (systolic pressure from 152 mmHg to 140 mmHg, diastolic pressure from 98 to 93 mm Hg), but neither resting nor ambulatory blood pressure was changed by the treatments. Left ventricular mass was also unchanged. Blood pressure rose during the stressful interview, but this rise was reduced by stress management (systolic pressure rose by 7.4 mmHg before treatment and by 3.7 mmHg after treatment). CONCLUSION--Stress management of a type advocated for treating mild primary hypertension is ineffective in lowering blood pressure in patients who are well habituated to measuring blood pressure.     

Relaxation therapy and continuous ambulatory blood pressure in mild hypertension: a controlled study.

OBJECTIVE--To determine the long term effects of relaxation therapy on 24 hour ambulatory intra-arterial blood pressure in patients with mild untreated and uncomplicated hypertension. DESIGN--Four week screening period followed by randomisation to receive either relaxation therapy or non-specific counselling for one year. Ambulatory intra-arterial blood pressure was measured before and after treatment. SETTING--Outpatient clinic in Amsterdam''s university hospital. SUBJECTS--35 Subjects aged 20-60 who were being treated by general practitioners for hypertension but were referred to take part in the study. At three consecutive screening visits all subjects had a diastolic blood pressure without treatment of 95-110 mm Hg. Subjects were excluded if they had damaged target organs, secondary hypertension, diabetes mellitus, a cholesterol concentration greater than 8 mmol/l, or a history of malignant hypertension. INTERVENTIONS--The group allocated to relaxation therapy was trained for eight weeks (one hour a week) in muscle relaxation, yoga exercises, and stress management and continued exercising twice daily for one year with monthly visits to the clinic. The control group had the same attendance schedule but had no training and were requested just to sit and relax twice a day. All subjects were asked not to change their diet or physical activity. MAIN OUTCOME MEASURE--Changes in ambulatory intra-arterial blood pressure after one year of relaxation therapy or non-specific counselling. RESULTS--Mean urinary sodium excretion, serum concentration of cholesterol, and body weight did not change in either group. Diastolic pressures measured by sphygmomanometry were 2 and 3 mm Hg lower in subjects in the relaxation group and control group respectively at the one year follow up compared with initial readings. The mean diastolic ambulatory intra-arterial pressure during the daytime had not changed after one year in either group, but small treatment effects could not be excluded: the mean change for the relaxation group was -1 mm Hg (95% confidence interval -6 to 3.9 mm Hg) and for the control group -0.4 mm Hg (-5.3 to 4.6 mm Hg). Mean ambulatory pressure in the evening also had not changed over the year, and in both groups nighttime pressure was 5 mm Hg higher. The variability in blood pressure was the same at both measurements. CONCLUSIONS--Relaxation therapy was an ineffective method of lowering 24 hour blood pressure, being no more beneficial than non-specific advice, support, and reassurance--themselves ineffective as a treatment for hypertension.     

Obesity as a determinant for response to antihypertensive treatment.

OBJECTIVE--To test the hypothesis that beta blockers lower blood pressure more effectively than calcium entry blockers in obese hypertensive patients and that calcium entry blockers are more effective in lean patients. DESIGN--Double blind, randomised controlled trial of treatment over six weeks. SETTING--Tertiary referral centre. SUBJECTS--42 white men with uncomplicated mild to moderate essential hypertension (World Health Organisation stage I or II); 36 completed the study. INTERVENTION--Patients were randomised to metoprolol 50-100 mg twice daily or isradipine 2.5-5.0 mg twice daily for six weeks after a two week run in phase. MAIN OUTCOME MEASURE--Blood pressure after six weeks of treatment. RESULTS--When stratified according to treatment and presence of obesity (body mass index < or = 27 kg/m2), the mean (SD) fall in blood pressure in the beta blocker group was 24 (13)/18 (10) mm Hg in obese patients and 18 (19)/12 (13) mm Hg in lean patients. In the calcium entry blocker group, the fall in blood pressure was 21 (15)/17 (6) mm Hg in lean patients and 18 (11)/8 (10) mm Hg in obese patients. After taking age and blood pressure before treatment into account there was a significant interaction between obesity and drug therapy (p = 0.019) with a better diastolic blood pressure response to calcium entry blockers in lean patients and to beta blockers in obese hypertensive patients. CONCLUSION--Obesity affects the efficacy of metoprolol and isradipine in reducing blood pressure.     

松龄血脉康胶囊联合低剂量厄贝沙坦治疗65岁以上高血压患者疗效观察

目的观察松龄血脉康胶囊联合低剂量厄贝沙坦治疗65岁以上老年高血压病患者的临床疗效。方法将90例65岁以上高血压患者随机分为松龄血脉康胶囊联合低剂量厄贝沙坦治疗组和高剂量厄贝沙坦对照组。治疗组给予松龄血脉康胶囊1.5g,每天3次,同时加厄贝沙坦75mg/d;对照组单纯给予厄贝沙坦150mg/d治疗。两组治疗周期为1个月进行比较血压控制情况及不良反应等指标水平。结果治疗后,两组患者收缩压和舒张压均较治疗前下降,差异有统计学意义(P0.05);治疗后两组患者的收缩压、舒张压比较,差异无统计学意义(P0.05)。结论松龄血脉康联合低剂量厄贝沙坦治疗高血压疗效确切,无明显不良反应,值得临床应用。     

Prognosis in diabetic nephropathy.

OBJECTIVE--To assess the effect of long term antihypertensive treatment on prognosis in diabetic nephropathy. DESIGN--Prospective study of all insulin dependent diabetic patients aged under 50 with onset of diabetes before the age of 31 who developed diabetic nephropathy between 1974 and 1978 at Steno Memorial Hospital. SETTING--Outpatient diabetic clinic in tertiary referral centre. PATIENTS--Forty five patients (20 women) with a mean age of 30 (SD 7) years and a mean duration of diabetes of 18 (7) years at onset of persistent proteinuria were followed until death or for at least 10 years. INTERVENTIONS--Antihypertensive treatment was started a median of three (0-13) years after onset of nephropathy. Four patients (9%) received no treatment, and 9 (20%), 13 (29%), and 19 (42%) were treated with one, two, or three drugs, respectively. The median follow up was 12 (4-15) years. MAIN OUTCOME MEASURES--Arterial blood pressure and death. RESULTS--Mean blood pressure at start of antihypertensive treatment was 148/95 (15/50) mm Hg. Systolic blood pressure remained almost unchanged (slope -0.01 (95% confidence interval -0.39 to 0.37) mm Hg a year) while diastolic blood pressure decreased significantly (0.87 (0.65 to 1.10) mm Hg a year) during antihypertensive treatment. The cumulative death rate was 18% (8 to 32%) 10 years after onset of nephropathy, in contrast to previous reports of 50% to 77% 10 years after onset of nephropathy. As in previous studies, uraemia was the main cause of death (9 patients; 64%). CONCLUSIONS--The prognosis of diabetic nephropathy has improved during the past decade largely because of effective antihypertensive treatment.     

Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up.

OBJECTIVE--Determination of the long term incidence of uraemia, hypertension, and toxaemia in pregnancy associated with non-obstructive focal renal scarring after pyelonephritis in childhood 25-35 years earlier. DESIGN--27 Year follow up of patients with non-obstructive focal scarring identified from a retrospective review of intravenous urograms performed in childhood between 1951 and 1967. SETTING--Paediatric primary referral centre and urological clinic in tertiary referral centre. PATIENTS--30 Patients (mean age 33 (range 22-41] with non-obstructive focal renal scarring first detected between 1951 and 1967 and a history of febrile urinary tract infection. MAIN OUTCOME MEASURE--Hypertension and complications of renal damage. RESULTS--Three patients had developed end stage renal disease, seven had developed hypertension, two of 16 women had a history of toxaemia during pregnancy, and seven patients had undergone renal surgery during follow up. Of the 20 patients who had neither had renal surgery nor had end stage renal disease, all had a significantly lower glomerular filtration rate and renal plasma flow and higher diastolic blood pressure, mean arterial blood pressure, plasma renin activity, and serum beta 2 microglobulin concentration than 13 healthy age matched controls. Diastolic blood pressure and plasma renin activity were positively correlated (r = 0.50, p less than 0.05) and so were fractional sodium excretion and both systolic and diastolic blood pressures (r = 0.54, p less than 0.01, r = 0.51, p less than 0.01 respectively). The progress of renal damage was unrelated to the incidence of recurrent infections. CONCLUSIONS--Children with focal renal scarring due to pyelonephritis are at high risk of serious long term consequences. It is essential that they are given adequate attention and care during adolescence and pregnancy.     

Can general practitioners use training in relaxation and management of stress to reduce mild hypertension?

To see whether general practitioners could effectively carry out training in relaxation and management of stress to reduce mild hypertension a study was carried out with a subsample of phase 2 of the Medical Research Council''s treatment of mild hypertension trial.¹ In the main mild hypertension trial patients had been receiving either an active drug or placebo for six years. In phase 2 a subsample of these patients were randomly allocated either to continue or to stop receiving the active drug or placebo. In a further subsample patients were again randomised to receive or not to receive relaxation therapy. This factorial design presented an additional opportunity to assess whether patients controlled with active drugs might have their blood pressure maintained by this behavioural therapy once drug treatment was stopped and to assess whether blood pressure might be further reduced by this therapy in patients who had been under regular medical supervision for as long as six years and who had already received non-pharmacological advice. The therapy was conducted by general practitioners in group sessions once a week for eight weeks. The training in relaxation was accompanied by galvanic skin resistance biofeedback. At one year follow up blood pressure in the relaxation subgroups was either maintained (in the group who had stopped receiving drugs) or reduced further (in the group who had continued receiving drugs and in both placebo groups), while in the control group it had increased in all the subgroups, but particularly in those who had stopped receiving drugs. Differences in changes in blood pressure between the relaxation and control groups were significant. There were five new cardiovascular events, including evidence of myocardial ischaemia in blindly coded electrocardiograms in the control group, compared with one in the treatment group.General practitioners, if motivated, can successfully apply this technique of training those with mild hypertension in relaxation and management of stress.     

Randomised controlled comparative study of methyldopa and oxprenolol in treatment of hypertension in pregnancy.

One hundred pregnant women with hypertension (defined as diastolic blood pressure at or above 95 mm Hg) were allocated at random to treatment with methyldopa or oxprenolol and were compared with nonhypertensive controls matched according to parity and gestation at delivery. The patients were also stratified into those entering the study early (before 32 weeks'' gestation) and those entering late (after 32 weeks'' gestation). Although there were no differences in diastolic blood pressure between the hypertensive groups before or during treatment, in the early entry group the systolic blood pressure at entry of those allocated to oxprenolol was significantly higher than that of those receiving methyldopa; this difference remained throughout the treatment period. Also in the early entry group further increments of drug treatment were required to control blood pressure of patients receiving oxprenolol than in those receiving methyldopa. The eventual fetal outcome for all patients treated with methyldopa was the same as that for those treated with oxprenolol; birth weight, placental weight, head circumference, and Apgar score were not significantly different and there were no stillbirths in either group.     

Protection of kidney function and decrease in albuminuria by captopril in insulin dependent diabetics with nephropathy.

STUDY OBJECTIVE--To assess whether long term inhibition of angiotensin converting enzyme with captopril and frusemide or bendrofluazide protects kidney function in diabetic nephropathy. DESIGN--Non-randomised controlled before-after trial of matched hypertensive insulin dependent diabetics with nephropathy treated with captopril and frusemide or bendrofluazide. SETTING--Outpatient diabetic clinic in tertiary referral centre. PATIENTS--Treatment group of 18 hypertensive insulin dependent diabetics with nephropathy (mean age 33), who had not been treated previously. Control group of 13 patients (mean age 32) fulfilling the same entry criteria from a prospective study. INTERVENTIONS--Treatment group was given daily captopril 37.5-100.0 mg and frusemide (mean) 98 mg (10 patients) or bendrofluazide (mean) 4 mg (seven). Treatment was continued for about two and a half years. Controls were not treated. END POINT--Measurement of arterial blood pressure, albuminuria, and glomerular filtration. MEASUREMENTS AND MAIN RESULTS--Baseline values were identical in treated and untreated groups respectively: mean blood pressure 146/93 (SE 3/1) mm Hg v 137/95 (2/1) mm Hg; geometric mean albuminuria 982 (antilog SE 1.2) micrograms/min v 936 (1.2) micrograms/min; and mean glomerular filtration rate 98 (SE 5) ml/min/1.73 m2 v 96 (6) ml/min/1.73 m2. Mean arterial blood pressure fell by 8.7 (1.3) mm Hg with captopril and rose by 6.6 (1.5) mm Hg in controls, (p less than 0.001); Albumin excretion decreased to 390 (1.1) micrograms/min with captopril and rose to 1367 (1.3) micrograms/min in controls (p less than 0.001). The rate of decrease in glomerular filtration rate was lower with captopril (5.8 (0.7) ml/year v 10.0 (1.3) ml/year) (p less than 0.01). Rate of fall in glomerular filtration rate and mean arterial blood pressure were significantly correlated (n = 31, r = 0.37, p less than 0.05). CONCLUSIONS--Captopril is a valuable new drug for treating hypertension in insulin dependent diabetics with nephropathy.     

高血压患者血压控制水平、血脂水平及颈动脉斑块与冠脉病变的关系

目的:探讨血压控制水平、血脂水平和颈动脉斑块与高血压患者冠脉病变程度和病变支数的关系。方法:回顾性分析2014年01月至2016年05月收住于南京中医药大学附属江苏省中西医结合医院心血管科的原发性高血压患者273例,按血压控制水平分为达标组和未达标组。按颈动脉超声结果判断有无斑块,冠状动脉造影结果使用Gensini评分和病变支数表示,并检测血脂指标。结果:血压控制达标者130人(47.61%),颈动脉有斑块者193例(70.70%)。与血压控制达标患者相比,血压控制不达标者冠脉病变支数及冠脉狭窄程度得分均明显增加(P0.05)。血压不达标合并斑块患者冠脉病变支数和狭窄程度与血压达标无斑块、血压达标合并斑块及血压不达标无斑块患者相比均明显增加(P0.001)。患者HDL-C水平与冠状动脉狭窄程度呈负相关(r=-0.139,P=0.022),AI与冠状动脉狭窄程度呈正相关(r=0.136,P=0.025),LDL/HDL-C和AI与冠脉病变支数均呈正相关,分别为(r=0.128,P=0.035)和(r=0.137,P=0.023)。结论:血压控制不佳,高血脂和颈动脉斑块形成可增加高血压患者冠脉病变的严重程度。     

Decision to treat mild hypertension after assessment by ambulatory monitoring and World Health Organisation recommendations.

OBJECTIVE--To determine if one ambulatory blood pressure recording over 12 hours could detect those patients with mild hypertension who needed treatment according to the World Health Organisation-International Society of Hypertension (ISH) guidelines based on the causal measurement of diastolic blood pressure at successive visits to a clinic. DESIGN--Comparison of decision to treat based on one ambulatory measurement over 12 hours and standard blood pressure measurements over six months in the same patients. SETTING--Outpatient hypertension clinic. SUBJECTS--130 men and women with diastolic blood pressure of 90-104 mm Hg at second visit to clinic. MAIN OUTCOME MEASURES--Blood pressure measurements over six months. Measurement from ambulatory monitoring. Decision to treat. RESULTS--Of the 130 patients included, 108 were followed up over the six months. Treatment was started according to WHO-ISH criteria in 44 (13 at the third visit, 13 at the fourth, 18 at the fifth). According to the selected criteria for ambulatory blood pressure monitoring 41 patients would have been treated. Both methods agreed that the same 27 patients required treatment and the same 50 did not, but they did not agree in 31 patients. When calculated at the optimal diastolic blood pressure threshold determined by a receiver operating characteristic curve, the sensitivity, specificity, and positive predictive value of ambulatory blood pressure monitoring were 71% (95% confidence interval 57% to 84%), 82% (72% to 92%), and 66% (51% to 81%), respectively. CONCLUSION--If the WHO-ISH criteria are accepted as the standard for deciding to treat patients with mild hypertension the predictive value of one ambulatory blood pressure recording over 12 hours is too low to detect with confidence those patients who need treatment when managed according to these criteria.     

老年高血压患者健康管理的效果分析

目的：对社区老年高血压病人实行健康管理,探讨其在高血压治疗中的临床效应。方法：对老年高血压患者分为实验组和对照组。对照组未实施健康管理,实验组实施健康管理,两组治疗药物方案相同,观察降压效果。结果：统计处理,两组老年高血压病人在相同时间里的降压效果差异具有显著性,实验组血压控制较前好（P〈0．05）。结论：健康管理在老年高血压治疗中效果明显。（健康管理能减少老年高血压患者的,降低医疗经济负担）     

Atenolol in essential hypertension during pregnancy.

OBJECTIVE--To determine the effect of atenolol on the outcome of pregnancy in women with essential hypertension. DESIGN--Prospective, randomised, double blind, placebo controlled study. SETTING--Hospital clinic. PATIENTS--33 Women with mild essential hypertension (systolic blood pressure 140-170 mm Hg or diastolic pressure 90-110 mm Hg on two occasions at least 24 hours apart) consecutively referred to two obstetric medical clinics. Four patients in the placebo group were withdrawn from the study: control of blood pressure was inadequate in two, one developed breathlessness, and one changed her mind about participating. The mean gestation in the 29 remaining women on entry to the study was 15.9 weeks. MAIN OUTCOME MEASURES--Blood pressure and birth weight. INTERVENTION--14 Women received placebo. 15 Women received atenolol 50 mg daily initially, increasing until either the blood pressure was less than 140/90 mm Hg or a dose of 200 micrograms daily was reached. RESULTS--The mean blood pressure on entry was 148/86 mm Hg in the group given atenolol and 144/86 mm Hg in the group given placebo. During treatment the mean diastolic pressure was significantly reduced by atenolol compared with placebo (to 74 v 81 mm Hg; difference in means (95% confidence interval) 7.0 (2.9 to 10.0) mm Hg) but the effect on systolic pressure was marginal (132 v 136 mm Hg; 4.0 (-1.4 to 8.6) mm Hg). Babies in the atenolol group had a significantly lower birth weight than those in the placebo group (2620 g v 3530 g; 910 (440 to 1380)g). CONCLUSION--Atenolol given from the end of the first trimester in patients with mild hypertension is associated with intrauterine growth retardation. When taken in conjunction with the results of a previous study in which methyldopa was given these findings indicate that benefit is unlikely to result from treating mild essential hypertension in pregnancy.     

门诊高血压患者健康教育加个体化治疗的效果观察

摘要目的：探讨门诊高血压患者健康教育加个体化治疗的效果。方法：选取在本院门诊收治原发性高血压的患者258例,随机均分为观察组和对照组,每组129例。观察组使用健康教育和个体化治疗,而对照组使用常规治疗。记录并比较两组治疗前后对高血压病掌握情况,血压下降率,服药依从性,治疗后达标、并发症情况。结果：治疗前,观察组对高血压病掌握情况与对照组差异无统计学意义（P〉0．05）;治疗后,观察组对高血压诊断（91．5％）、高血压病因（98．4％）、高血压症状（100．0％）、高血压并发症（92．2％）掌握情况明显比对照组要好,差异有统计学意义（P〈0．05）;观察组服药依从性明显好于对照组,差异具有统计学意义（P〈0．05）;观察组的血压下降率为81．4％,明显高于对照组49．6％,差异具有统计学意义（P〈0．05）;观察组的达标率高达74．4％,明显高于对照组的34．9％,差异具有统计学意义（P〈0．01）;观察组未达标率和并发症发生率分别为25．6％和9-3％,明显低于对照组的65．1％和20．9％,差异有统计学意义（P〈0．01）。结论：对不同高血压患者采用健康教育加个体化的治疗方法,对提高高血压的控制率和降低相应并发症的发生率有非常好的临床效果,值得临床进一步推广和应用。     

Malignant hypertension in women of childbearing age and its relation to the contraceptive pill.

Eleven of 34 women aged 15-44 with malignant phase hypertension were taking oral contraceptives at presentation. All had had normal blood pressure before starting to take the pill. In four the interval between the start of oral contraception and the diagnosis of malignant hypertension was less than four months, and in eight no other cause for the hypertension was found. Underlying renal disease and renal failure were less common among pill users than among non-users with malignant hypertension who were of similar age. No pill user became normotensive after withdrawal of the pill, but blood pressure was well controlled (diastolic less than 90 mm Hg) in three patients taking only one drug. By contrast, all 23 non-users needed two or more antihypertensive drugs to control blood pressure. Ten year survival was 90% among pill users and 50% among non-users. These results suggest that oral contraceptives may be a common cause of malignant hypertension in women of child-bearing age. If the pill is stopped and underlying renal disease excluded the long term prognosis for such patients is excellent.     

Outpatient Treatment Trial of Mild and Severe Hypertension

Not much is known about the feasibility or the advantages of treatment of subjects with only mild hypertension. There are also many unresolved problems in the outpatient management of hypertension of any severity. In this study an analysis is made of the results of a controlled treatment trial of 56 subjects with mild hypertension, 26 of whom were treated with active drug and 30 initially with placebo, and a treatment programme involving 81 patients with moderate or severe hypertension, all of whom received treatment with active drug. The drugs used in this study were bethanidine, debrisoquine, and guanethidine.Follow-up for 12 months or more was achieved in 87% of individuals admitted to the study with mild hypertension and in 80% with severe hypertension. Many subjects with only mildly raised blood pressure were found to have cardiac enlargement on chest x-ray (up to 45%) and left ventricular hypertrophy on electrocardiogram (up to 51%). Rapid rates of rise of blood pressure were observed in many placebo-treated subjects; but good blood pressure control was achieved in 63 out of 104 patients (61%) receiving active drug in both the mild and the severe hypertension groups. The drugs used showed approximately equal effectiveness in controlling blood pressure.     

脑梗死患者颈动脉粥样硬化的相关因素分析

目的:探讨脑梗死患者颈动脉粥样硬化的危险因素。方法:选取148例脑梗死患者作为实验组和同期住院的80例非脑梗死疾病患者为对照组,检测并比较各组年龄、吸烟、血压、饮酒、糖尿病、血脂、同型半胱氨酸和磷脂酶A2等指标,然后进行卡方检验、相关性和Logistic回归分析。结果:实验组颈动脉粥样硬化检出率为82.43%,对照组为12.5%,其差异具有统计学意义(P0.05)。高龄、吸烟、高血压、高血脂、高同型半胱氨酸血症、高磷脂酶A2(LP-PLA2)血症是经动脉粥样硬化的危险因素,且血浆同型半胱氨酸水平、LP-PLA2水平、血压与颈动脉斑块稳定性有关(P0.05)。结论:颈动脉粥样硬化是脑梗死的病理基础,与高龄、吸烟、高血压、高血脂、高同型半胱氨酸血症、高磷脂酶A2(LP-PLA2)血症有关,对高同型半胱氨酸血症、LP-PLA2和高血压患者要关注其斑块的稳定性。     

Coronary flow reserve and the J curve relation between diastolic blood pressure and myocardial infarction.

The results of several large studies of hypertension and follow up studies on insured people have indicated that the lower the blood pressure the better for longevity. These studies excluded subjects with overt ischaemia. More recently long term studies of hypertension that included patients with more severe forms of hypertension and did not exclude those with overt ischaemia have shown a J shaped relation between diastolic blood pressure during treatment and myocardial infarction; the lowest point (the J point) was at a diastolic blood pressure (phase V) between 85 and 90 mm Hg. The J curve seems to be independent of treatment, pulse pressure, and the degree of fall in diastolic blood pressure and is unlikely to be caused by poor left ventricular function. The most probable explanation is that subjects who have severe stenosis of the coronary artery as well as hypertension have a poor coronary flow reserve, which makes the myocardium vulnerable to coronary perfusion pressures that are tolerated by patients without ischaemia, particularly at high heart rates. An optimal diastolic blood pressure (phase V) for such patients is about 85 mm Hg, though particular caution is appropriate when treating very old patients (84 and over) and patients aged 60-79 who have isolated systolic hypertension.     

Loss of circadian rhythm of blood pressure following acute stroke

Background  

Epidemiology of acute stroke in developing countries differs from that in the developed world, for example, the age at stroke, risk factors, subtypes of stroke and prognosis. Hypertension remains a dominant risk factor and prognostic indicator in patients with stroke in all communities. The risk of stroke is directly related to elevations of blood pressure. A number of clinical studies have shown that the control of hypertension leads to a reduction in the incidence of stroke in a community. However there is still considerable controversy surrounds the changes in blood pressure in various subtypes of strokes and problem of management of elevated BP after stroke. We studied the circadian rhythm of blood pressure in patients following acute stroke.     

Results of the Ontario Survey on the Prevalence and Control of Hypertension

Background

Available information on the prevalence and management of hypertension in the Canadian population dates back to 1986–1992 and probably does not reflect the current status of this major risk factor for cardiovascular disease. We sought to evaluate the current prevalence and management of hypertension among adults in the province of Ontario.

Methods

Potential respondents from randomly selected dwellings within target neighbourhoods in 16 municipalities were contacted at their homes to request participation in the study. For potential respondents who agreed to participate, blood pressure was measured with an automated device. Estimation weights were used to obtain representative estimates of population parameters. Responses were weighted to the total adult population in Ontario of 7 996 653.

Results

From 6436 eligible dwellings, contact was made with 4559 potential participants, of whom 2992 agreed to participate. Blood pressure measurements were obtained for 2551 of these respondents (age 20–79 years). Hypertension, defined as systolic blood pressure of 140 mm Hg or more, diastolic blood pressure of 90 mm Hg or more, or treatment with an antihypertensive medication, was identified in 21.3% of the population overall (23.8% of men and 19.0% of women). Prevalence increased with age, from 3.4% among participants 20–39 years of age to 51.6% among those 60–79 years of age. Hypertension was more common among black people and people of South Asian background than among white people; hypertension was also associated with higher body mass index. Among participants with hypertension, 65.7% were undergoing treatment with control of hypertension, 14.7% were undergoing treatment but the hypertension was not controlled, and 19.5% were not receiving any treatment (including 13.7% who were unaware of their hypertension). The extent of control of hypertension did not differ significantly by age, sex, ethnic background or comorbidities.

Interpretation

In Ontario, the overall prevalence of hypertension is high in the older population but appears not to have increased in recent decades. Hypertension management has improved markedly among all age groups and for both sexes.Hypertension is a major risk factor for premature cardiovascular morbidity and mortality. Epidemiologic studies have indicated that, for people 40–69 years of age, each increase of 20 mm Hg in usual systolic blood pressure is associated with a doubling of mortality rates for stroke and ischemic heart disease.¹ In 2002 the World Health Organization estimated that at least 50% of cases of cardiovascular disease and at least 75% of strokes were caused by elevated blood pressure.² At the same time, randomized clinical trials have demonstrated that these risks can be markedly reduced by antihypertensive drug therapy. The substantial burden of suffering associated with hypertension, combined with the availability of feasible and accurate means of detection and a clear benefit from treatment have led to worldwide recommendations for hypertension screening and management.Currently available Canadian data on the prevalence and management of hypertension are based on Canadian Heart Health Surveys that took place between 1986 and 1992. At that time, 22% of adult Canadians had hypertension, but only 16% of these had their blood pressure treated and controlled.³ These data are clearly out of date, and there has been no way of assessing the impact of changes in lifestyle, including higher rates of obesity and a sedentary lifestyle, on the prevalence of hypertension or determining whether hypertension management has improved with the widespread use of newer classes of antihypertensive drugs such as calcium antagonists and blockers of the renin–angiotensin system.We sought to evaluate the current prevalence and management of hypertension among adults in the province of Ontario.