Genome scan linkage results for longitudinal systolic blood pressure phenotypes in subjects from the Framingham Heart Study

The relationship between elevated blood pressure and cardiovascular and cerebrovascular disease risk is well accepted. Both systolic and diastolic hypertension are associated with this risk increase, but systolic blood pressure appears to be a more important determinant of cardiovascular risk than diastolic blood pressure. Subjects for this study are derived from the Framingham Heart Study data set. Each subject had five records of clinical data of which systolic blood pressure, age, height, gender, weight, and hypertension treatment were selected to characterize the phenotype in this analysis. We modeled systolic blood pressure as a function of age using a mixed modeling methodology that enabled us to characterize the phenotype for each individual as the individual's deviation from the population average rate of change in systolic blood pressure for each year of age while controlling for gender, body mass index, and hypertension treatment. Significant (p = 0.00002) evidence for linkage was found between this normalized phenotype and a region on chromosome 1. Similar linkage results were obtained when we estimated the phenotype while excluding values obtained during hypertension treatment. The use of linear mixed models to define phenotypes is a methodology that allows for the adjustment of the main factor by covariates. Future work should be done in the area of combining this phenotype estimation directly with the linkage analysis so that the error in estimating the phenotype can be properly incorporated into the genetic analysis, which, at present, assumes that the phenotype is measured (or estimated) without error.     

Community nurse assessment of cardiovascular behavioural risk factors--a qualitative analysis within the CroHort study

The aim of our study was to identify major determinants of cardiovascular behavioural risk factors among subjects at increased risk of cardiovascular disease (CVD). The data for the qualitative analysis were obtained from the Croatian Adult Health Cohort Study (CroHort). The data analysis was based on the principles of Grounded Theory. We have generated the concept of an individual in a vicious circle of risky health behaviour, defined by the low level of motivation and unfavourable personal characteristics which in interaction with unsupportive social environment adversely influence one's health behaviour, leading to negative health outcomes that produce negative effects on one's motivation and social environment. Community nurses assessed that the respondents often weren't adequately recognising their CVD risk and were very reluctant about the change in their risky habits. Our results are supported by the quantitative analysis and are complementing other analyses of the cardiovascular risks within the CroHort study.     

Obesity‐related hypertension: Pathogenesis,cardiovascular risk,and treatment—A position paper of the The Obesity Society and the American Society of Hypertension

In light of the worldwide epidemic of obesity, and in recognition of hypertension as a major factor in the cardiovascular morbidity and mortality associated with obesity, The Obesity Society and The American Society of Hypertension agreed to jointly sponsor a position paper on obesity‐related hypertension to be published jointly in the journals of each society. The purpose is to inform the members of both societies, as well as practicing clinicians, with a timely review of the association between obesity and high blood pressure, the risk that this association entails, and the options for rational, evidenced‐based treatment. The position paper is divided into six sections plus a summary as follows: pathophysiology, epidemiology and cardiovascular risk, the metabolic syndrome, lifestyle management in prevention and treatment, pharmacologic treatment of hypertension in the obese, and the medical and surgical treatment of obesity in obese hypertensive patients. Obesity (2012)     

Nutritional effects on blood pressure

PURPOSE OF REVIEW: There has not been a thorough recent evaluation of the nutritional effects on blood pressure. Apart from outstanding clinical trials like Dietary Approaches to Stop Hypertension, there have been controversial papers on a number of factors influencing blood pressure. This paper is a systematic review of the current literature as it relates to hypertension. RECENT FINDINGS: Results from many meta-analyses and well controlled clinical trials on the effects of a variety of nutritional factors are presented in this review. Evidence suggests that dietary sodium intake needs reduction. There is a seemingly inverse relationship between protein intake and blood pressure, but data are inconclusive. High monounsaturated fat and fish oil appear to be beneficial. Several studies on dietary fiber indicate that the strongest evidence for blood pressure lowering effects is in hypertensive as opposed to normotensive participants. Vegetarians seem to have lower levels of hypertension and cardiovascular disease risk. Low carbohydrate diets show short-term beneficial effects but are not sustained. High levels of potassium, magnesium, calcium and soy seem to have some benefit, but results remain inconclusive. Weight reduction positively impacts blood pressure. SUMMARY: More compelling research defining specific factors is needed to inform the public as to steps needed to reduce blood pressure and improve cardiovascular risk.     

Beyond the Evidence of the New Hypertension Guidelines. Blood pressure measurement - is it good enough for accurate diagnosis of hypertension? Time might be in, for a paradigm shift (I)

Despite widespread availability of a large body of evidence in the area of hypertension, the translation of that evidence into viable recommendations aimed at improving the quality of health care is very difficult, sometimes to the point of questionable acceptability and overall credibility of the guidelines advocating those recommendations.The scientific community world-wide and especially professionals interested in the topic of hypertension are witnessing currently an unprecedented debate over the issue of appropriateness of using different drugs/drug classes for the treatment of hypertension. An endless supply of recent and less recent "drug-news", some in support of, others against the current guidelines, justifying the use of selected types of drug treatment or criticising other, are coming out in the scientific literature on an almost weekly basis. The latest of such debate (at the time of writing this paper) pertains the safety profile of ARBs vs ACE inhibitors.To great extent, the factual situation has been fuelled by the new hypertension guidelines (different for USA, Europe, New Zeeland and UK) through, apparently small inconsistencies and conflicting messages, that might have generated substantial and perpetuating confusion among both prescribing physicians and their patients, regardless of their country of origin.The overwhelming message conveyed by most guidelines and opinion leaders is the widespread use of diuretics as first-line agents in all patients with blood pressure above a certain cut-off level and the increasingly aggressive approach towards diagnosis and treatment of hypertension. This, apparently well-justified, logical and easily comprehensible message is unfortunately miss-obeyed by most physicians, on both parts of the Atlantic.Amazingly, the message assumes a universal simplicity of both diagnosis and treatment of hypertension, while ignoring several hypertension-specific variables, commonly known to have high level of complexity, such as:- accuracy of recorded blood pressure and the great inter-observer variability,- diversity in the competency and training of diagnosing physician,- individual patient/disease profile with highly subjective preferences,- difficulty in reaching consensus among opinion leaders,- pharmaceutical industry's influence, and, nonetheless,- the large variability in the efficacy and safety of the antihypertensive drugs.The present 2-series article attempts to identify and review possible causes that might have, at least in part, generated the current healthcare anachronism (I); to highlight the current trend to account for the uncertainties related to the fixed blood pressure cut-off point and the possible solutions to improve accuracy of diagnosis and treatment of hypertension (II).     

A long-term "memory" of HIF induction in response to chronic mild decreased oxygen after oxygen normalization

Background

Cardiovascular diseases (CVD) are the leading cause of death and the third cause of disability in Europe. Prevention programmes should include interventions aimed at a reduction of medical risk factors (hypertension, hypercholesterol, hyperglycemia, overweight and obesity) as well as behavioural risk factors (sedentary lifestyle, high fat intake and low fruit and vegetable intake, smoking). The aim of this study is to investigate the effects of a multifaceted, multidisciplinary electronic prevention programme on cardiovascular risk factors.

Methods/Design

In a randomized controlled trial, one group will receive a maximal intervention (= intervention group). The intervention group will be compared to the control group receiving a minimal intervention. An inclusion of 350 patients in total, with a follow-up of 3 years is foreseen. The inclusion criteria are age between 25–65 and insured by the Onderlinge Ziekenkas, insuring for guaranteed income in case of illness for self-employed. The maximal intervention group receives several prevention consultations by their general practitioner (GP) using a new type of cardiovascular risk calculator with personalised feedback on behavioural risk factors. These patients receive a follow-up with intensive support of health behaviour change via different methods, i.e. a tailored website and personal advice of a multidisciplinary team (psychologist, physiotherapist and dietician). The aim of this strategy is to reduce cardiovascular risk factors according to the guidelines. The primary outcome measures will be cardiovascular risk factors. The secondary outcome measures are cardiovascular events, quality of life, costs and incremental cost effectiveness ratios. The control group receives prevention consultations using a new type of cardiovascular risk calculator and general feedback.

Discussion

This trial incorporates interventions by GPs and other health professionals aiming at a reduction of medical and behavioural cardiovascular risk factors. An assessment of clinical, psychological and economical outcome measures will be performed.

Trial registration

ISRCTN23940498     

The changing pattern of cardiovascular risk factors: the CroHort study

Croatia has a long tradition of non-communicable disease prevention, but also obstacles to the implementation of preventive programs related to the general attenuation of public health and primary health care sector. The aim of this study was to determine trends in behavioral and biomedical risk factors and evaluate primary non-communicable disease and cardiovascular prevention. Physical inactivity was a leading risk factor with increasing trend and prevalence of 33.9% and 38.9% in men and women in 2008. In 2008, obesity was present in 26.1% and 34.1%, and hypertension in 65.8% and 59.7% of men and women. During the follow-up only smoking and alcohol consumption in men decreased significantly, while alcohol consumption and obesity in women, and hypertension in both sexes significantly increased. In the present situation, with the existing trends and environment it will not be possible to stop negative trends. Revitalization of public health activities and primary health care is essential.     

The Cost-Effectiveness of Low-Cost Essential Antihypertensive Medicines for Hypertension Control in China: A Modelling Study

Background

Hypertension is China’s leading cardiovascular disease risk factor. Improved hypertension control in China would result in result in enormous health gains in the world’s largest population. A computer simulation model projected the cost-effectiveness of hypertension treatment in Chinese adults, assuming a range of essential medicines list drug costs.

Methods and Findings

The Cardiovascular Disease Policy Model-China, a Markov-style computer simulation model, simulated hypertension screening, essential medicines program implementation, hypertension control program administration, drug treatment and monitoring costs, disease-related costs, and quality-adjusted life years (QALYs) gained by preventing cardiovascular disease or lost because of drug side effects in untreated hypertensive adults aged 35–84 y over 2015–2025. Cost-effectiveness was assessed in cardiovascular disease patients (secondary prevention) and for two blood pressure ranges in primary prevention (stage one, 140–159/90–99 mm Hg; stage two, ≥160/≥100 mm Hg). Treatment of isolated systolic hypertension and combined systolic and diastolic hypertension were modeled as a reduction in systolic blood pressure; treatment of isolated diastolic hypertension was modeled as a reduction in diastolic blood pressure. One-way and probabilistic sensitivity analyses explored ranges of antihypertensive drug effectiveness and costs, monitoring frequency, medication adherence, side effect severity, background hypertension prevalence, antihypertensive medication treatment, case fatality, incidence and prevalence, and cardiovascular disease treatment costs. Median antihypertensive costs from Shanghai and Yunnan province were entered into the model in order to estimate the effects of very low and high drug prices. Incremental cost-effectiveness ratios less than the per capita gross domestic product of China (11,900 international dollars [Int$] in 2015) were considered cost-effective. Treating hypertensive adults with prior cardiovascular disease for secondary prevention was projected to be cost saving in the main simulation and 100% of probabilistic simulation results. Treating all hypertension for primary and secondary prevention would prevent about 800,000 cardiovascular disease events annually (95% uncertainty interval, 0.6 to 1.0 million) and was borderline cost-effective incremental to treating only cardiovascular disease and stage two patients (2015 Int$13,000 per QALY gained [95% uncertainty interval, Int$10,000 to Int$18,000]). Of all one-way sensitivity analyses, assuming adherence to taking medications as low as 25%, high Shanghai drug costs, or low medication efficacy led to the most unfavorable results (treating all hypertension, about Int$47,000, Int$37,000, and Int$27,000 per QALY were gained, respectively). The strengths of this study were the use of a recent Chinese national health survey, vital statistics, health care costs, and cohort study outcomes data as model inputs and reliance on clinical-trial-based estimates of coronary heart disease and stroke risk reduction due to antihypertensive medication treatment. The limitations of the study were the use of several sources of data, limited clinical trial evidence for medication effectiveness and harms in the youngest and oldest age groups, lack of information about geographic and ethnic subgroups, lack of specific information about indirect costs borne by patients, and uncertainty about the future epidemiology of cardiovascular diseases in China.

Conclusions

Expanded hypertension treatment has the potential to prevent about 800,000 cardiovascular disease events annually and be borderline cost-effective in China, provided low-cost essential antihypertensive medicines programs can be implemented.     

Ambulatory blood pressure monitoring in the prediction of cardiovascular events and effects of chronotherapy: rationale and design of the MAPEC study

Ambulatory blood pressure (BP) measurements (ABPM) correlate more closely with target organ damage and cardiovascular events than clinical cuff measurements. ABPM reveals the significant circadian variation in BP, which in most individuals presents a morning increase, small post-prandial decline, and more extensive lowering during nocturnal rest. However, under certain pathophysiological conditions, the nocturnal BP decline may be reduced (non-dipper pattern) or even reversed (riser pattern). This is clinically relevant because the non-dipper and riser circadian BP patterns constitute a risk factor for left ventricular hypertrophy, microalbuminuria, cerebrovascular disease, congestive heart failure, vascular dementia, and myocardial infarction. Hence, there is growing interest in how to best tailor and individualize the treatment of hypertension according to the specific circadian BP pattern of each patient. All previous trials that have demonstrated an increased cardiovascular risk in non-dipper as compared to dipper patients have relied on the prognostic significance of a single ABPM baseline profile from each participant without accounting for possible changes in the BP pattern during follow-up. Moreover, the potential benefit (i.e., reduction in cardiovascular risk) associated with the normalization of the circadian BP variability (conversion from non-dipper to dipper pattern) from an appropriately envisioned treatment strategy is still a matter of debate. Accordingly, the MAPEC (Monitorización Ambulatoria de la Presión Arterial y Eventos Cardiovasculares, i.e., Ambulatory Blood Pressure Monitoring and Cardiovascular Events) study was designed to investigate whether the normalization of the circadian BP profile toward more of a dipper pattern by chronotherapeutic strategies (i.e., specific timing during the 24 h of BP-lowering medications according to the 24 h BP pattern) reduces cardiovascular risk. The prospective MAPEC study investigates 3,000 diurnally active men and women >/=18 yrs of age. At inclusion, BP and wrist activity are measured for 48 h. The initial evaluation also includes a detailed medical history, an electrocardiogram, and screening laboratory blood and urine tests. The same evaluation procedure is scheduled yearly or more frequently (quarterly) if treatment adjustment is required for BP control. Cardiovascular morbidity and mortality are thus evaluated on the basis of changes in BP during follow-up. The MAPEC study, now on its fourth year of follow-up, investigates the potential decrease in cardiovascular, cerebrovascular, and renal risk from the proper modeling of the circadian BP profile by the timed administration (chronotherapy) of antihypertensive medication, beyond the reduction of clinic-determined daytime or ABPM-determined 24 h mean BP levels.     

Cardiovascular disease and trace metals.

Cardiovascular disease is a major cause of morbidity and mortality in the U.K. and other developed countries. In the U.K., mortality from coronary heart disease has increased progressively over the past 25 years, particularly in males. This paper examines the possible role of trace metals in the development of cardiovascular disease, with particular reference to the effects of cobalt, cadmium and lead in myocardial disease, atherosclerosis and hypertension. It is concluded that cobalt is an unimportant factor in community levels of cardiovascular disease, that cadmium has striking effects on blood pressure in animals and that there is some evidence for an association between environmental lead and high blood pressure.     

Cardiovascular risk management of hypertension and hypercholesterolaemia in the Netherlands: from unifactorial to multifactorial approach

About 30?years ago, the first Dutch unifactorial guidelines on hypertension and hypercholesterolaemia were developed. These guidelines have been revised several times, often after publication of landmark studies on new generations of drugs. In 1978, cut-off points for pharmacological treatment of hypertension were based on diastolic blood pressure values ≥115?mmHg, and in 2000 they were lowered to >100?mmHg. From 1997 onwards, cut-off points for systolic blood pressure values >180?mmHg were introduced, which became leading. In 1987, cut-offs for hypercholesterolaemia of ≥8?mmol/l were set and from 2006 pharmacological treatment was based on a total/HDL cholesterol ratio >8. Around 2000, treatment decisions for hypertension and/or hypercholesterolaemia were no longer based on high levels of individual risk factors, but on a multifactorial approach based on total risk of cardiovascular diseases (CVD), determined by a risk function. In the 2006 multidisciplinary guideline on cardiovascular risk management, the Framingham risk tables were replaced by European SCORE risk charts. A cut-off point of 10% CVD mortality was set in the Netherlands. In 2011, this cut-off point changed to 20% fatal plus nonfatal CVD risk. Nowadays, 'the lower the risk factors, the lower the absolute risk' is the leading paradigm in CVD prevention.     

Lifestyle modifications to prevent and control hypertension. 6. Recommendations on potassium,magnesium and calcium. Canadian Hypertension Society,Canadian Coalition for High Blood Pressure Prevention and Control,Laboratory Centre for Disease Control at Health Canada,Heart and Stroke Foundation of Canada

OBJECTIVE: To provide updated, evidence-based recommendations on the consumption, through diet, and supplementation of the cations potassium, magnesium and calcium for the prevention and treatment of hypertension in otherwise healthy adults (except pregnant women). OPTIONS: Dietary supplementation with cations has been suggested as an alternative or adjunctive therapy to antihypertensive medications. Other options include other nonpharmacologic treatments for hypertension. OUTCOMES: The health outcomes considered were changes in blood pressure and in morbidity and mortality rates. Because of insufficient evidence, no economic outcomes were considered. EVIDENCE: A MEDLINE search was conducted for the period 1966-1996 with the terms hypertension and potassium, magnesium and calcium. Reports of trials, meta-analyses and review articles were obtained. Other relevant evidence was obtained from the reference lists of articles identified, from the personal files of the authors and through contacts with experts. The articles were reviewed, classified according to study design, and graded according to the level of evidence. VALUES: A high value was placed on the avoidance of cardiovascular morbidity and premature death caused by untreated hypertension. BENEFITS, HARMS AND COSTS: The weight of the evidence from randomized controlled trials indicates that increasing intake of or supplementing the diet with potassium, magnesium or calcium is not associated with prevention of hypertension, nor is it effective in reducing high blood pressure. Potassium supplementation may be effective in reducing blood pressure in patients with hypokalemia during diuretic therapy. RECOMMENDATIONS: For the prevention of hypertension, the following recommendations are made: (1) The daily dietary intake of potassium should be 60 mmol or more, because this level of intake has been associated with a reduced risk of stroke-related mortality. (2) For normotensive people obtaining on average 60 mmol of potassium daily through dietary intake, potassium supplementation is not recommended as a means of preventing an increase in blood pressure. (3) For normotensive people, magnesium supplementation is not recommended as a means of preventing an increase in blood pressure. (4) For normotensive people, calcium supplementation above the recommended daily intake is not recommended as a means of preventing an increase in blood pressure. For the treatment of hypertension, the following recommendations are made. (5) Potassium supplementation above the recommended daily dietary intake of 60 mmol is not recommended as a treatment for hypertension. (6) Magnesium supplementation is not recommended as a treatment for hypertension. (7) Calcium supplementation above the recommended daily dietary intake is not recommended as a treatment for hypertension. VALIDATION: These guidelines are consistent with the results of meta-analyses and recommendations made by other organizations. They have not been clinically tested. SPONSORS: The Canadian Hypertension Society, the Canadian Coalition for High Blood Pressure Prevention and Control, the Laboratory Centre for Disease Control at Health Canada, and the Heart and Stroke Foundation of Canada.     

Ambulatory Blood Pressure Monitoring in the Prediction of Cardiovascular Events and Effects of Chronotherapy: Rationale and Design of the MAPEC Study

Ambulatory blood pressure (BP) measurements (ABPM) correlate more closely with target organ damage and cardiovascular events than clinical cuff measurements. ABPM reveals the significant circadian variation in BP, which in most individuals presents a morning increase, small post‐prandial decline, and more extensive lowering during nocturnal rest. However, under certain pathophysiological conditions, the nocturnal BP decline may be reduced (non‐dipper pattern) or even reversed (riser pattern). This is clinically relevant because the non‐dipper and riser circadian BP patterns constitute a risk factor for left ventricular hypertrophy, microalbuminuria, cerebrovascular disease, congestive heart failure, vascular dementia, and myocardial infarction. Hence, there is growing interest in how to best tailor and individualize the treatment of hypertension according to the specific circadian BP pattern of each patient. All previous trials that have demonstrated an increased cardiovascular risk in non‐dipper as compared to dipper patients have relied on the prognostic significance of a single ABPM baseline profile from each participant without accounting for possible changes in the BP pattern during follow‐up. Moreover, the potential benefit (i.e., reduction in cardiovascular risk) associated with the normalization of the circadian BP variability (conversion from non‐dipper to dipper pattern) from an appropriately envisioned treatment strategy is still a matter of debate. Accordingly, the MAPEC (Monitorización Ambulatoria de la Presión Arterial y Eventos Cardiovasculares, i.e., Ambulatory Blood Pressure Monitoring and Cardiovascular Events) study was designed to investigate whether the normalization of the circadian BP profile toward more of a dipper pattern by chronotherapeutic strategies (i.e., specific timing during the 24 h of BP‐lowering medications according to the 24 h BP pattern) reduces cardiovascular risk. The prospective MAPEC study investigates 3,000 diurnally active men and women ≥18 yrs of age. At inclusion, BP and wrist activity are measured for 48 h. The initial evaluation also includes a detailed medical history, an electrocardiogram, and screening laboratory blood and urine tests. The same evaluation procedure is scheduled yearly or more frequently (quarterly) if treatment adjustment is required for BP control. Cardiovascular morbidity and mortality are thus evaluated on the basis of changes in BP during follow‐up. The MAPEC study, now on its fourth year of follow‐up, investigates the potential decrease in cardiovascular, cerebrovascular, and renal risk from the proper modeling of the circadian BP profile by the timed administration (chronotherapy) of antihypertensive medication, beyond the reduction of clinic‐determined daytime or ABPM‐determined 24 h mean BP levels.     

Hypertension: the sodium connection

It appears from epidemiologic, population, and individual studies that sodium is capable of raising blood pressure and its attendant cardiovascular complications in susceptible individuals. Potassium loss occurs with sodium loading and may modulate the blood pressure responses to sodium. Populations known to be at greater risk for the development of hypertension and its cardiovascular sequelae, such as blacks, older individuals, and those over the age of 40 years are also known to be less efficient in handling sodium. Furthermore, they are more apt to be sodium-sensitive than -resistant. The phenomena of sensitivity and resistance, demonstrable in both normotensive and hypertensive individuals, can be identified by rapid sodium and volume loading and depletion as well as by modest reduction in dietary sodium intake. Finally, preliminary evidence suggests that sodium sensitivity may be predictable by genetic markers as well as by demographic characteristics.     

The prevalence of cardiovascular disease risk factors in patients from Croatian Zagorje County treated at Department of Medicine, Zabok General Hospital from 2000 to 2006

The aim of the study was to assess the prevalence of risk factors for cardiovascular disease in patients treated for coronary heart disease (CHD) at Department of Medicine, Zabok General Hospital during the 2000-2006 period. Cardiovascular diseases are a group of diseases that occur due to arterial. The risk factors that lead to the development and occurrence of cardiovascular disease are hypertension, cigarette smoking, hyperholesterolemia, hypertriglyceridemia, diabetes mellitus and positive family history. Additional factors favoring the occurrence of cardiovascular disease include overweight, inadequate physical activity, and emotional stress. Data on all patients hospitalized and diagnosed with CHD at Department of Medicine, Zabok General Hospital during the 2000-2006 period were analyzed for the prevalence of risk factors for CHD, i.e. hypertension, cigarette smoking, hypercholesterolemia, hypertriglyceridemia, diabetes mellitus and positive family history of cardiovascular disease. Hypercholesterolemia was defined by a cholesterol level higher than 5.1 mmol/L, hypertension from history data and blood pressure measurement on admission greater than 140/90 mmHg, diabetes mellitus from history data, and hypertriglyceridemia by a triglyceride level greater than 1.7 mmol/L. Information on heredity and cigarette smoking was collected from history and a questionnaire filled out on admission. All laboratory values were determined on patient admission to the hospital. Analysis of the risk factors for CHD recorded in patients from Zagorje County during the 2000-2006 period revealed hypertension to be the most common risk factor in our patients. According to sex, CHD was found to show a male preponderance. According to age at admission, CHD predominated in the > 70 age group, which accounted for one third of all patients, followed by a comparable proportion of the 50-60 and 60-70 age groups, i.e. still active population groups. As CHD is one of the leading health threats worldwide, estimated to remain so at least by 2020, it is fully justified to invest all efforts in the study of cardiovascular disease. New research projects should be focused on the prevention and early detection of the disease, improvement of diagnosis procedures, introduction of novel therapeutic options, use of new concepts, and due survey of the measures taken. CHD poses great socioeconomic burden upon every community in industrialized societies because of the ever younger age at onset. Actions should be taken to improve awareness of the CHD risks and morbidity in the population at large, stimulating favorable lifestyle and dietary modifications, and one's own health awareness, in order to upgrade the control of risk factors for and morbidity of cardiovascular disease.     

Patients’ Knowledge,Attitudes, Behaviour and Health Care Experiences on the Prevention,Detection, Management and Control of Hypertension in Colombia: A Qualitative Study

Hypertension is a leading cause of premature death worldwide and the most important modifiable risk factor for cardiovascular disease. Effective screening programs, communication with patients, regular monitoring, and adherence to treatment are essential to successful management but may be challenging in health systems facing resource constraints. This qualitative study explored patients’ knowledge, attitudes, behaviour and health care seeking experiences in relation to detection, treatment and control of hypertension in Colombia. We conducted in-depth interviews and focus group discussions with 26 individuals with hypertension and 4 family members in two regions. Few participants were aware of ways to prevent high blood pressure. Once diagnosed, most reported taking medication but had little information about their condition and had a poor understanding of their treatment regime. The desire for good communication and a trusting relationship with the doctor emerged as key themes in promoting adherence to medication and regular attendance at medical appointments. Barriers to accessing treatment included co-payments for medication; costs of transport to health care facilities; unavailability of drugs; and poor access to specialist care. Some patients overcame these barriers with support from social networks, family members and neighbours. However, those who lacked such support, experienced loneliness and struggled to access health care services. The health insurance scheme was frequently described as administratively confusing and those accessing the state subsidized system believed that the treatment was inferior to that provided under the compulsory contributory system. Measures that should be addressed to improve hypertension management in Colombia include better communication between health care professionals and patients, measures to improve understanding of the importance of adherence to treatment, reduction of co-payments and transport costs, and easier access to care, especially in rural areas.     

Self-Interest versus Group-Interest in Antiviral Control

Antiviral agents have been hailed to hold considerable promise for the treatment and prevention of emerging viral diseases like H5N1 avian influenza and SARS. However, antiviral drugs are not completely harmless, and the conditions under which individuals are willing to participate in a large-scale antiviral drug treatment program are as yet unknown. We provide population dynamical and game theoretical analyses of large-scale prophylactic antiviral treatment programs. Throughout we compare the antiviral control strategy that is optimal from the public health perspective with the control strategy that would evolve if individuals make their own, rational decisions. To this end we investigate the conditions under which a large-scale antiviral control program can prevent an epidemic, and we analyze at what point in an unfolding epidemic the risk of infection starts to outweigh the cost of antiviral treatment. This enables investigation of how the optimal control strategy is moulded by the efficacy of antiviral drugs, the risk of mortality by antiviral prophylaxis, and the transmissibility of the pathogen. Our analyses show that there can be a strong incentive for an individual to take less antiviral drugs than is optimal from the public health perspective. In particular, when public health asks for early and aggressive control to prevent or curb an emerging pathogen, for the individual antiviral drug treatment is attractive only when the risk of infection has become non-negligible. It is even possible that from a public health perspective a situation in which everybody takes antiviral drugs is optimal, while the process of individual choice leads to a situation where nobody is willing to take antiviral drugs.     

A new era in hypertension research: discussing the findings of ALLHAT

The key question in hypertension research today is, "Does it matter how elevated blood pressure is lowered?" The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) initiated in 1994 serves as a model for comparative trials. Its strengths include its independent sponsorship, scope and design. The alpha-blocker arm was stopped early; doxazosin was shown to be clearly inferior to low-dose chlorthalidone not only in preventing heart failure, but also stroke, in spite of similar blood pressure reduction. The findings have major public health implications as pointed out by Krakoff in this journal. Other commentaries by Gavras and Gavras and Hooper discuss possible mechanisms behind the excess of cardiovascular events in doxazosin-treated patients.     

Trends in Prevalence,Awareness, Treatment and Control of Hypertension during 2001-2010 in an Urban Elderly Population of China

Objective

As the most important risk factors of cardiovascular disease, pre-hypertension and hypertension are important public health challenges. Few studies have focused on the trends of pre-hypertension and hypertension specifically for the aging population in China. Given the anticipated growth of the elderly population in China, there is an urgent need to document the conditions of pre-hypertension and hypertension in this aging population.

Methods

We conducted two cross-sectional surveys of Chinese adults aged ≥60 years in 2001 and 2010. A total of 2,272 (943 males, 1,329 females) and 2,074 (839 males, 1,235 females) participants were included in the two surveys, respectively.

Results

The age- and sex-standardized prevalence of hypertension significantly increased from 60.1% to 65.2% from the 2001 to the 2010 survey. Among the participants with hypertension, the awareness, treatment and control of hypertension all significantly increased from 69.8% to 74.5%, 50.3% to 63.7%, and 15.3% to 30.3%, respectively, from 2001 to 2010. A logistic regression showed that a higher education level, a higher BMI, a family history of hypertension and doctor-diagnosed cardiovascular disease were significantly associated with hypertension awareness and treatment.

Conclusion

Hypertension prevalence increased rapidly between the years surveyed. Although the awareness, treatment and control of hypertension improved significantly, the values of these variables remained low. More attention should be given to the elderly because the population is aging worldwide, and urgent action, optimal treatment approaches and proper public health strategies must be taken to prevent and manage hypertension.