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Even though it has been more than a decade since renal denervation (RDN) was first used to treat hypertension and an intense effort on researching this therapy has been made, it is still not clear how RDN fits into the antihypertensive arsenal. There is no question that RDN lowers blood pressure (BP), it does so to an extent at best corresponding to one antihypertensive drug. The procedure has an excellent safety record. However, it remains clinically impossible to predict whose BP responds to RDN and whose does not. Long-term efficacy data on BP reduction are still unconvincing despite the recent results in the SPYRAL HTN-ON MED trial; experimental studies indicate that reinnervation is occurring after RDN. Although BP is an acceptable surrogate endpoint, there is complete lack of outcome data with RDN. Clear indications for RDN are lacking although patients with resistant hypertension, those with documented increase in activity of the sympathetic system and perhaps those who desire to take fewest medication may be considered. ispartof: JOURNAL OF HYPERTENSION vol:40 issue:10 pages:1859-1875 ispartof: location:Netherlands status: published

Purpose of review Hypertension is the most important noncommunicable disease risk factor in India with an estimated burden of 200 million persons. Nationwide studies and meta-analyses have reported increasing prevalence. We summarize unique features of hypertension in India. Recent findings Two recent nationwide studies to determine hypertension prevalence have been performed-Fourth National Family Health Survey and Fourth District Level Health Survey/Annual Health Survey. Age-adjusted hypertension was more in men (24.5%) than women (20.0%). Hypertension is more common in developed states of the country, urban populations and better socioeconomic status individuals. Urban-rural convergence and greater hypertension in younger men and women are unique findings. There is low status of its awareness, treatment and control. Diabetes prevalence is high in hypertension suggesting importance of insulin resistance. Prevalence of resistant hypertension is high. Pharmacoepidemiology studies have reported widespread use of all classes of antihypertensive drugs with increasing use of renin-angiotensin system blockers. There are limited studies focused on genetic epidemiology. Summary Hypertension is widely prevalent in India with large regional variation, greater prevalence in urban areas and the young. Treatment and control status are low. Diabetes is important comorbidity and resistant hypertension is frequent. There is widespread use of newer antihypertensive drugs.

See related article, pp e13–e115 Global high blood pressure control and prevention is a major goal of the World Hypertension League (WHL), which strives to support and promote population strategies for the reduction in risks of hypertension-related outcomes. The implementation of hypertension management protocols and recommendations based on evidence from clinical studies is associated with the risk reduction in stroke, as well as cardiovascular and renal disease.1 The impact of the structured hypertension guidelines can be seen in the Figure where the risks of elevated blood pressure identified in the 1920s and the benefit of blood pressure reduction from the Veterans Administration studies was associated with declines in population stroke mortality.2–5 As evidence in the Table, the decline in stroke mortality coincides with the reduction of population blood pressure pressures which was consistent with the lowered blood pressure thresholds and targets described in the sequential recommendations from the Guidelines.6–12 View this table: Table. Mean and 90th …

The most recent guidelines for the diagnosis and management of hypertension1 have radically redefined what constitutes high blood pressure (BP) and normal BP. This dramatic feature of the new guidelines will likely influence the management of hypertension globally but especially in countries such as India already facing an enormous public health challenge (with the previous definition of hypertension ≥140/90 mm Hg). The new classification designates a BP level of ≥130/80 mm Hg as hypertension (Table). Although the new definition of hypertension is based on considerable evidence and abundant data, the global ramifications are nearly unimaginable at present. The new classification is scientifically sound on the basis of the established link between the level of BP (starting at a systolic BP level of 115 mm Hg) and the risk of cardiovascular disease.2 How do we apply and translate the …

Endothelin-1 is an endothelium-derived compound that exerts a variety of hemodynamic and structural alterations in the cardiovascular and pulmonary circuits. The endothelin system is activated in an assortment of disorders and disease states, such as systemic hypertension, pulmonary hypertension, atherosclerosis, acute coronary syndromes, and congestive heart failure. The actions of endothelin are mediated by two types of receptors: ETA and ETB, which are widely distributed in the cardiovascular system. The complexity of biophysical effects mediated by these two types of receptors dictates the therapeutic implications, that is, selective (ETA) versus dual (ETA/ ETB) receptor antagonism. Preliminary experimental and clinical studies reveal a role played by endothelin as a pathogenetic substance and, conversely, a possible role for endothelin antagonism in clinical medicine.

True refractory hypertension is unusual in clinical practice, thanks to the widespread availability of antihypertensive drugs and national mandate to optimize blood pressure control levels in the community. However, at times the blood pressure may become refractory to initial drug therapy. When the blood pressure levels do not reach a target level despite usual therapy, hypertension is considered refractory. There should be proper evaluation of such patients to determine the factor(s) responsible for resistance to therapy. In many patients, proper adjustment of drug doses, including effective use of diuretics, restores the blood pressure level. For some patients, potent drug therapy, such as hydralazine or minoxidil, must be considered. Based upon clinical course, work-up for secondary causes of hypertension should be considered in selected patients. Refractory hypertension requires proper analysis of etiologic factors and consideration of rational drug selection, and at times, work-up for secondary causes of hypertension.

The Need for a New Approach, Norman M. Kaplan The Rationale, Michael H. Alderman Uncomplicated Hypertension, William C. Cushman and Henry R. Black The Elderly Hypertensive, Tomasz Grodzicki and Franz H. Messerli The Obese, Dyslipidemic, and/or Diabetic Hypertensive, Myron H. Weinberger Therapy for the Black Hypertensive, Iris R. Keys and Elijah Saunders Hypertension in Patients with Cardiac Disease, Robert J. Cody Hypertension with Cerebrovascular Disease, Olaf B. Paulson and Svend Strandgaard Hypertension with Renal Disease, Robert J. Heyka and Donald G. Vidt Hypertension in Pregnancy, Phyllis August and Marshall D. Lindheimer Hypertension and Endocrine Disease, Sheldon G. Sheps and William F. Young, Jr. Hypertensive Crises, C. Venkata S. Ram Drug-Induced Hypertension, John J. Curtis Improving Patient Compliance in the Management of Hypertension, R. Brian Haynes

Calcium antagonists have added a new dimension to the therapy of hypertension. They have proved to be versatile, effective drugs for the short- and long-term management of hypertension. Since these drugs have favourable effects on tissue blood flow, they offer the hope of providing tissue protection in hypertensive patients. Some investigators have claimed that the effectiveness of calcium antagonists in hypertension is age-dependent, older subjects showing a better response than younger individuals. However, a careful analysis reveals that calcium antagonists are effective in all age groups and the magnitude of response may be related to the level of pretreatment blood pressure.