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Hypertension is a major risk factor for cardiovascular and renal diseases in the United States and worldwide. Obesity accounts for much of the risk for primary hypertension through several mechanisms, including neurohormonal activation, inflammation, and kidney dysfunction. As the prevalence of obesity continues to increase, hypertension and associated cardiorenal diseases will also increase unless more effective strategies to prevent and treat obesity are developed. Lifestyle modification, including diet, reduced sedentariness, and increased physical activity, is usually recommended for patients with obesity; however, the long-term success of these strategies for reducing adiposity, maintaining weight loss, and reducing blood pressure has been limited. Effective pharmacotherapeutic and procedural strategies, including metabolic surgeries, are additional options to treat obesity and prevent or attenuate obesity hypertension, target organ damage, and subsequent disease. Medications can be useful for short- and long-term obesity treatment; however, prescription of these drugs is limited. Metabolic surgery is effective for producing sustained weight loss and for treating hypertension and metabolic disorders in many patients with severe obesity. Unanswered questions remain related to the mechanisms of obesity-related diseases, long-term efficacy of different treatment and prevention strategies, and timing of these interventions to prevent obesity and hypertension-mediated target organ damage. Further investigation, including randomized controlled trials, is essential to addressing these questions, and emphasis should be placed on the prevention of obesity to reduce the burden of hypertensive cardiovascular and kidney diseases and subsequent mortality.

The widespread treatment of hypertension and resultant improvement in blood pressure have been major contributors to the dramatic age-specific decline in heart disease and stroke. Despite this progress, a persistent gap remains between stated public health targets and achieved blood pressure control rates. Many factors may be important contributors to the gap between population hypertension control goals and currently observed control levels. Among them is the extent to which patients adhere to prescribed treatment. The goal of this scientific statement is to summarize the current state of knowledge of the contribution of medication nonadherence to the national prevalence of poor blood pressure control, methods for measuring medication adherence and their associated challenges, risk factors for antihypertensive medication nonadherence, and strategies for improving adherence to antihypertensive medications at both the individual and health system levels.

A quantitative survey was completed by 103 primary care physicians (PCPs) and 59 cardiologists who regularly prescribed β-blockers to assess knowledge and use of this heterogeneous drug class for hypertension. More cardiologists than PCPs chose β-blockers as initial antihypertensive therapy (30% vs 17%, P < 0.01). Metoprolol and carvedilol were the most commonly prescribed β-blockers. Cardiologists rated "impact on energy" and "arterial vasodilation" as more important than PCPs (P < 0.05/

Prehypertension is associated with increased risk for hypertension and cardiovascular disease. Data are limited on the temporal changes in the prevalence of prehypertension and risk factors for hypertension and cardiovascular disease among US adults with prehypertension. We analyzed data from 30 958 US adults ≥20 years of age who participated in the National Health and Nutrition Examination Surveys between 1999 and 2012. Using the mean of 3 blood pressure (BP) measurements from a study examination, prehypertension was defined as systolic BP of 120 to 139 mm Hg and diastolic BP P trend=0.007). During this time period, the prevalence of several risk factors for cardiovascular disease and incident hypertension increased among US adults with prehypertension, including prediabetes (9.6% to 21.6%), diabetes mellitus (6.0% to 8.5%), overweight (33.5% to 37.3%), and obesity (30.6% to 35.2%). There was a nonstatistically significant increase in no weekly leisure-time physical activity (40.0% to 43.9%). Also, the prevalence of adhering to the Dietary Approaches to Stop Hypertension eating pattern decreased (18.4% to 11.9%). In contrast, there was a nonstatistically significant decline in current smoking (25.9% to 23.2%). In conclusion, the prevalence of prehypertension has decreased modestly since 1999–2000. Population-level approaches directed at adults with prehypertension are needed to improve risk factors to prevent hypertension and cardiovascular disease.

Objective:The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study is the first stroke prevention trial to include protocol-driven intensive management of multiple risk factors. In this prespecified analysis, we aimed to investigate the relationship between risk factor control during follow-up and outcome of patients in the medical arm of SAMMPRIS.Methods:Data from SAMMPRIS participants in the medical arm (n = 227) were analyzed. Risk factors were recorded at baseline, 30 days, 4 months, and then every 4 months for a mean follow-up of 32 months. For each patient, values for all risk factor measures were averaged and dichotomized as in or out of target.Results:Participants who were out of target for systolic blood pressure and physical activity, as well as those with higher mean low-density lipoprotein cholesterol and non–high-density lipoprotein, were more likely to have a recurrent vascular event (stroke, myocardial infarction, or vascular death) at 3 years compared to those who had good risk factor control. In the multivariable analysis, greater physical activity decreased the likelihood of a recurrent stroke, myocardial infarction, or vascular death (odds ratio 0.6, confidence interval 0.4–0.8).Conclusions:Raised blood pressure, cholesterol, and physical inactivity should be aggressively treated in patients with intracranial atherosclerosis to prevent future vascular events. Physical activity, which has not received attention in stroke prevention trials, was the strongest predictor of a good outcome in the medical arm in SAMMPRIS.ClinicalTrials.gov identifier:NCT00576693.

BackgroundApproximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress.Methods and findingsTo determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, 'other'). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R2 = 0.36) in claims paid/beneficiary.ConclusionsIdentifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.

Objectives: The aim of this study was to determine if carvedilol improved structural and functional changes in the left ventricle and reduced mortality in patients with hypertensive heart disease. Methods: Blood pressure, heart rate, echocardiographic parameters, and laboratory variables, were assessed pre and post treatment with carvedilol in 98 eligible patients. Results: Carvedilol at a median dose of 50 mg/day during the treatment period in hypertensive heart disease lowered blood pressure 10/10 mmHg, heart rate 10 beats/min, improved left ventricular ejection fraction from baseline to follow-up (median: 6 years) (36%–47%)) and reduced left ventricular end-diastolic and end-systolic dimensions (62 vs 56 mm; 53 vs 42 mm, respectively, all p-values Conclusion: Carvedilol reduced cardiac dimensions and improved left ventricular ejection fraction and cardiac remodeling in patients with hypertensive heart disease. These treatment-related changes had a favorable effect on survival.

Professor Stevo Julius’ extraordinary scientific contributions during the past half-century advanced our understanding on the pathogenesis, prevention, and treatment of hypertension. His early work showed a relationship between anger, increased sympathetic drive, and reduced parasympathetic tone was fundamental to hyperkinetic borderline hypertension. The investigators provided evidence that sympathetic overactivity led to β-adrenoceptor downregulation and structural and functional cardiac and vascular changes. These changes, rather than autoregulation, contributed to the transition from high to normal cardiac output with a progressive rise in blood pressure. Through population-based studies, Professor Julius confirmed a key role for sympathetic activation, especially faster heart rates, in the early phase of hypertension. Faster heart rates coincided with cardiometabolic abnormalities including hyperinsulinemia, insulin resistance, and dyslipidemia. The investigators subsequently showed that increased vascular α-adrenergic tone induced resistance to insulin-mediated glucose disposal in skeletal muscle. Professor Julius and colleagues documented that angiotensin-receptor blockade safely lowered blood pressure in prehypertensives and slowed the transition to hypertension. He then partnered with long-term colleagues on multinational studies in middle-aged and older hypertensives at high cardiovascular risk. These studies showed that (1) failure to control blood pressure during the first 6 months of a clinical trial led to a significant increase in cardiovascular events, (2) patients controlled on more antihypertensive medications had less benefit of treatment than individuals controlled on monotherapy, and (3) faster heart rates were associated with worse outcomes in treated hypertensives. Clinicians are better prepared to prevent and treat hypertension by understanding the life work of Dr. Julius and colleagues.

Objectives: The Quality and Care Model Committee for a clinically integrated network requested a comparative analysis on the projected cardiovascular benefits of implementing either the 2013 and 2014 cholesterol guideline in a South Carolina patient population. A secondary request was to assess the relative risk of the two guidelines based on the literature. Methods: Electronic health data were obtained on 1,580,860 adults aged 21–80 years who had had one or more visits from January 2013 to June 2015; 566,688 had data to calculate 10-year atherosclerotic cardiovascular disease (ASCVD10) risk. Adults with end-stage renal disease ( n = 7852), congestive heart failure ( n = 19,818), alcohol or drug abuse ( n = 68,547), or currently on statins ( n = 154,964) were excluded leaving 315,508 for analysis. Estimated reduction in ASCVD10 assumed that: (a) moderate-intensity statins lowered low-density lipoprotein cholesterol (LDL-C) by 35% and high-intensity statins by 50%; (b) ASCVD events declined 22% for each 1 mmol/l fall in LDL-C. Results: Among the 315,508 adults in the analysis, 131,289 (41.6%) were eligible for statins according to the 2013 guideline and 137,375 (43.5%) to the 2014 guideline. The 2013 and 2014 guidelines were estimated to prevent 6780 and 5915 ASCVD events over 10 years with: (a) relative risk reductions of 29.0% and 21.8%; (b) absolute risk reductions of 5.2% and 4.3%; (c) number needed-to-treat (NNT) of 19 and 23, respectively. The greater projected cardiovascular protection with the 2013 guideline was largely related to greater use of high-dose statins, which carry a greater risk for adverse events. The literature indicates that the NNT for benefit with high-intensity versus moderate-intensity statins is 31 in high-risk patients with a number needed-to-harm of 47. Conclusions: The 2013 guideline is projected to prevent more clinical ASCVD events and with lower NNTs than the 2014 guideline, yet both have substantial benefit. The 2013 guideline is also expected to generate more adverse events, but the risk-benefit profile appears favor .

The US Preventive Services Task Force cholesterol guideline recommended statins for fewer adults than the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline by setting a higher 10-year atherosclerotic cardiovascular disease threshold (≥10.0% vs ≥7.5%) and requiring concomitant diabetes mellitus, hypertension, dyslipidemia, or cigarette smoking. The 2017 ACC/AHA hypertension guideline lowered the hypertension threshold, increasing 2016 guideline statin-eligible adults. Cross-sectional data on US adults aged 40 to 75 years enabled estimated numbers for the 2013 guideline and 2016 guideline with hypertension thresholds of ≥140/≥90 mm Hg and ≥130/80 mm Hg, respectively, on: (1) untreated, statin-eligible adults for primary atherosclerotic cardiovascular disease prevention (25.40, 14.72, 15.35 million); (2) atherosclerotic cardiovascular disease events prevented annually (124 000, 70 852, 73 199); (3) number needed to treat (21, 21, 21); and (4) number needed to harm (38, 143, 143) per 1000 patient-years for incident diabetes mellitus (42 800, 6700, 7100 cases per year). Despite the lower hypertension threshold, the 2013 cholesterol guideline qualifies approximately 10 million more adults for statins and prevents approximately 50 600 more primary atherosclerotic cardiovascular disease events but induces approximately 35 700 more diabetes mellitus cases annually than the 2016 guideline.

The Cardiometabolic Think Tank was convened on June 20, 2014, in Washington, DC, as a "call to action" activity focused on defining new patient care models and approaches to address contemporary issues of cardiometabolic risk and disease. Individual experts representing >20 professional organizations participated in this roundtable discussion. The Think Tank consensus was that the metabolic syndrome (MetS) is a complex pathophysiological state comprised of a cluster of clinically measured and typically unmeasured risk factors, is progressive in its course, and is associated with serious and extensive comorbidity, but tends to be clinically under-recognized. The ideal patient care model for MetS must accurately identify those at risk before MetS develops and must recognize subtypes and stages of MetS to more effectively direct prevention and therapies. This new MetS care model introduces both affirmed and emerging concepts that will require consensus development, validation, and optimization in the future.

Prehypertension (blood pressure 120-139/80-89 mmHg) affects ~25-50% of adults worldwide, and increases the risk of incident hypertension. The relative risk of incident hypertension declines by ~20% with intensive lifestyle intervention, and by 34-66% with single antihypertensive medications. To prevent one case of incident hypertension in adults with prehypertension and a 50% 5-year risk of hypertension, 10 individuals would need to receive intensive lifestyle intervention, and four to six patients would need to be treated with antihypertensive medication. The relative risk of incident cardiovascular disease (CVD) is greater with 'stage 2' (130-139/85-89 mmHg) than 'stage 1' (120-129/80-84 mmHg) prehypertension; only stage 2 prehypertension increases cardiovascular mortality. Among individuals with prehypertension, the 10-year absolute CVD risk for middle-aged adults without diabetes mellitus or CVD is ~10%, and ~40% for middle-aged and older individuals with either or both comorbidities. Antihypertensive medications reduce the relative risk of CVD and death by ~15% in secondary-prevention studies of prehypertension. Data on primary prevention of CVD with pharmacotherapy in prehypertension are lacking. Risk-stratified, patient-centred, comparative-effectiveness research is needed in prehypertension to inform an acceptable, safe, and effective balance of lifestyle and medication interventions to prevent incident hypertension and CVD.

Remote patient monitoring systems (RMS) have gained increasing popularity in recent years. RMS have great potential to improve medical services by providing more affordable, timely, and accessible care. This paper describes an effective low-cost RMS that is readily deployable. The system targets chronic disease patients and attempts to reduce patient visits to the hospital and healthcare costs. The system is comprised of three modules: (1) an application for data acquisition, processing, and transmission, (2) an adaptable set of "personalized" sensors for measuring vitals and reporting emergency situations, and (3) a secure communication module for remote patient-physician interactions. The users interface with the RMS through an application installed on a mobile device. Using a return of investment (ROI) cost-benefit analysis and a cohort of 2.7 million patients, we estimate that through the implementation of such a system, the patients and the healthcare system would see benefits within one year.

To optimize the translation of clinical trial evidence that antihypertensive treatment reduces recurrent stroke risk into clinical practice, it is important to assess the frequency of long-term antihypertensive drug persistence after stroke and identify the factors associated with low persistence. Structured telephone interviews to determine antihypertensive regimen persistence 1-year post-stroke hospitalization were conducted in 270 stroke survivors, of which 212 (78.5%) were discharged on antihypertensive therapy (two thirds on >1 drug class). Continued use of any antihypertensive agent at 1 year of follow-up was relatively high (87.3%); however, persistence on all or two or more drug classes prescribed at discharge was relatively low (38.7%). Continued use varied by drug class, with the highest rates among angiotensin-converting enzyme inhibitor (69.1%) and the lowest rates among diuretic (24.4%) users. Black patients (adjusted odds ratio, 0.35; 95% confidence interval, 0.16-0.78) and those with a high comorbidity burden (adjusted odds ratio , 0.39; 95% confidence interval, 0.18-0.86) were less likely to exhibit persistence on prescribed treatments 1-year post-stroke hospitalization. These results indicate the need for further study to identify appropriate persistence of antihypertensive therapies for secondary stroke prevention and to investigate reasons for racial disparities in persistence on prescribed treatments in a real-world clinical setting.

Disparate vascular outcomes in diabetes by race and/or ethnicity may reflect differential risk factor control, especially pre-Medicare. Assess concurrent target attainment for glycohemoglobin7%, non-high density lipoprotein-cholesterol130 mg/dL, and blood pressure140/90 mm Hg in white, black, and Hispanic diabetics65 years and ≥65 years of age. The National Health and Nutrition Examination Surveys 1999-2010 data were analyzed on diagnosed and undiagnosed diabetics ≥18 years old. Concurrent target attainment was higher in whites (18.7%) than blacks (13.4% [P = .02] and Hispanics [10.3%, P.001]65 years but not ≥65 years of age; 20.0% vs. 15.9% [P = .13], 19.5% [P = .88]). Disparities in health care insurance among younger whites, blacks, and Hispanics, respectively, (87.4% vs. 81.1%, P.01; 68.0%, P.001) and infrequent health care (0-1 visits/y; 14.3% vs. 15.0%, P = not significant; 32.0%, P.001) declined with age. Cholesterol treatment predicted concurrent control in both age groups (multivariable odds ratio2, P.001). Risk factor awareness and treatment were lower in Hispanics than whites. When treated, diabetes and hypertension control were greater in whites than blacks or Hispanics. Concurrent risk factor control is low in all diabetics and could improve with greater statin use. Insuring younger adults, especially Hispanic, could raise risk factor awareness and treatment. Improving treatment effectiveness in younger black and Hispanic diabetics could promote equitable risk factor control.

Pre-hypertension, defined as blood pressure 120–139/80–89 mmHg, affects ~70 million people in the US. Blood pressures in the upper half of the pre-hypertensive range are linked with roughly threefold greater risk of incident hypertension than normal blood pressure

The common assumption is that blood pressure (BP) will decrease on subsequent readings. The objective of this study is to examine the prevalence and direction of BP classification change with repeat measurements and compare common clinical characteristics of groups of patients who do and do not have a change in BP classification. A nationally representative subsample of 1725 adolescents aged 13 to 18 years from the National Health and Nutrition Survey were analyzed. Three BP measurements were obtained. Patients were classified based on the first and the average of 3 BP measurements as having normal BP, hypertension, and/or prehypertension. Of the 1725 adolescents, 1569 (90.9%) maintained BP classification, 107 (6.2%) had a reduction in their classification, and 49 (2.9%) had an increase in their classification. Comparing the two groups that changed BP classification to the group without change, C‐reactive protein and body mass index (BMI) z score were significantly higher in the groups that had a change in BP classification (P=.02 and

Background— Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ≈25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. Methods and Results— To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed. Hypertension was defined by blood pressure ≥140/≥90 mm Hg, current medication treatment, and 2-told hypertension status; blood pressure Conclusions— Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and antihyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic, and cardiovascular disease patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention.

This paper examines baseline characteristics from a prospective, cluster-randomized trial in 32 primary care offices. Offices were first stratified by percentage of minorities and level of clinical pharmacy services and then randomized into 1 of 3 study groups. The only differences between randomized arms were for marital status (P=.03) and type of insurance coverage (P

OBJECTIVES: We explored whether high blood pressure is associated with metabolic, inflammatory and prothrombotic dysregulation in patients with metabolic syndrome. METHODS: We evaluated 135 consecutive overweight/obese patients. From this group, we selected 75 patients who were not under the regular use of medications for metabolic syndrome as defined by the current Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults criteria. The patients were divided into metabolic syndrome with and without high blood pressure criteria (≥130/≥85 mmHg). RESULTS: Compared to the 45 metabolic syndrome patients without high blood pressure, the 30 patients with metabolic syndrome and high blood pressure had significantly higher glucose, insulin, homeostasis model assessment insulin resistance index, total cholesterol, low-density lipoprotein-cholesterol, triglycerides, uric acid and creatinine values; in contrast, these patients had significantly lower high-density lipoprotein-cholesterol values. Metabolic syndrome patients with high blood pressure also had significantly higher levels of retinol-binding protein 4, plasminogen activator inhibitor 1, interleukin 6 and monocyte chemoattractant protein 1 and lower levels of adiponectin. Moreover, patients with metabolic syndrome and high blood pressure had increased surrogate markers of sympathetic activity and decreased baroreflex sensitivity. Logistic regression analysis showed that high-density lipoprotein, retinol-binding protein 4 and plasminogen activator inhibitor-1 levels were independently associated with metabolic syndrome patients with high blood pressure. There is a strong trend for an independent association between metabolic syndrome patients with high blood pressure and glucose levels. CONCLUSIONS: High blood pressure, which may be related to the autonomic dysfunction, is associated with metabolic, inflammatory and prothrombotic dysregulation in patients with metabolic syndrome.

Prevalent hypertension in National Health and Nutrition Examination Surveys (NHANES) is traditionally defined as blood pressure (BP) ≥140 mm Hg systolic and/or ≥90 diastolic and/or currently taking antihypertensive medications. When estimating prevalent hypertension, American Heart Association (AHA) statistical updates include the traditional definition of hypertension (tHTN) and untreated individuals with nonhypertensive BP told twice that they were hypertensive (nontraditional [ntHTN]). The characteristics of ntHTN and their impact on the clinical epidemiology of hypertension and Healthy People prevention and control goals are undefined. NHANES 1999-2002, 2003-2006, and 2007-2010 were analyzed. The ntHTN group was younger and had less diabetes and lower BP than the tHTN group but higher BP than the normotensive group. When classifying ntHTN as hypertensive, prevalent hypertension increased approximately 3% and control 5% to 6% across NHANES periods. In 2007-2010, the Healthy People 2010 goal of controlling BP in 50% of all hypertensive patientss was attained when ntHTN was classified as hypertension (56.5% [95% confidence interval (CI), 54.2-58.7]) and nonhypertension (51.8% [95% CI, 49.6-53.9]). When including ntHTN in prevalent hypertension estimates, the Healthy People 2020 goal of controlling BP in 60% of hypertensive patients becomes more attainable, whereas reducing prevalent hypertension to 26.9% (31.8% [95% CI, 30.5-33.1]) vs 28.7% [95% CI, 27.5-30.0]) becomes more challenging.

Left ventricle remodeling is a common consequence of uncontrolled hypertension. Hypertension treatment including renin-angiotensin-aldosterone system inhibition and beta-blockers offers cardiac protection. Carvedilol uses in cardiomyopathy from different etiology have shown good results in left ventricle reverse remodeling. There is a lack of information regarding carvedilol use in hypertensive cardiomyopathy. The main objective in this study was to evaluate the use of carvedilol in hypertensive patients with reduced left ventricle ejection fraction. We evaluate 98 subjects with reduced left ventricle ejection fraction (55 years age, 59 males, 64 white, 34 nonwhite) before and after at least six months of carvedilol use. Clinical data, laboratory tests, and echocardiogram were evaluated at least 6 months before and after carvedilol was added to the treatment. Other causes of cardiomyopathy, including coronary artery disease, were excluded. A hundred percent of patients was taking diuretic and renin-angiotensin-aldosterone system inhibitors. Twenty eight percent were using statins, 19% were using antidiabetic drugs, and 29% were taking digoxin. Blood pressure and heart rate (144/92 mmHg, 84 bpm) decreased significantly after (130/82 mmHg, 70 bpm) carvedilol treatment. Ejection fraction improved in 68.5% patients. Let ventricle diastolic diameter decreased from 62 to 56 mm, left ventricle systolic diameter decreased from 53 to 42 mm, left ventricle mass index decreased from 145 to 129 g/m 2 , left ventricle relative posterior wall increased from 0.32 to 0.36. Carvedilol, in addition to antihypertensive drugs, showed improvement in hemodynamic parameters, and in echocardiographic structural and functional parameters in hypertensive cardiomyopathy patients.

The association of anthropometric (waist circumference) and hemodynamic (blood pressure) changes with abnormalities in glucose and lipid metabolism has been motivation for a lot of discussions in the last 30 years. Nowadays, blood pressure, body mass index/abdominal circumference, glycemia, triglyceridemia, and HDL-cholesterol concentrations are considered in the definition of Metabolic syndrome, referred as Visceral adiposity syndrome (VAS) in the present review. However, more than 250 years ago an association between visceral and mediastinal obesity with hypertension, gout, and obstructive apnea had already been recognized. Expansion of visceral adipose tissue secondary to chronic over-consumption of calories stimulates the recruitment of macrophages, which assume an inflammatory phenotype and produce cytokines that directly interfere with insulin signaling, resulting in insulin resistance. In turn, insulin resistance (IR) manifests itself in various tissues, contributing to the overall phenotype of VAS. For example, in white adipose tissue, IR results in lipolysis, increased free fatty acids release and worsening of inflammation, since fatty acids can bind to Toll-like receptors. In the liver, IR results in increased hepatic glucose production, contributing to hyperglycemia; in the vascular endothelium and kidney, IR results in vasoconstriction, sodium retention and, consequently, arterial hypertension. Other players have been recognized in the development of VAS, such as genetic predisposition, epigenetic factors associated with exposure to an unfavourable intrauterine environment and the gut microbiota. More recently, experimental and clinical studies have shown the autonomic nervous system participates in modulating visceral adipose tissue. The sympathetic nervous system is related to adipose tissue function and differentiation through beta1, beta2, beta3, alpha1, and alpha2 adrenergic receptors. The relation is bidirectional: sympathetic denervation of adipose tissue blocks lipolysis to a variety of lipolytic stimuli and adipose tissue send inputs to the brain. An imbalance of sympathetic/parasympathetic and alpha2 adrenergic/beta3 receptor is related to visceral adipose tissue storage and insulin sensitivity. Thus, in addition to the well-known factors classically associated with VAS, abnormal autonomic activity also emerges as an important factor regulating white adipose tissue, which highlights complex role of adipose tissue in the VAS.

The Systolic Blood Pressure (SBP, mm Hg) Intervention Trial (SPRINT) showed that targeting SBP

Hypertension control may offer less protection from incident cardiovascular disease (CVDi ) in adults with than without apparent treatment-resistant hypertension (aTRH), ie, blood pressure uncontrolled while taking three or more antihypertensive medications or controlled to

Clinical guidelines recommend averaging ≥ 2 blood pressure (BP) measurements on each visit. Only one BP is measured on many clinical visits, especially if the value is

Prehypertension is a major risk factor for hypertension. Blacks have more prevalent and severe hypertension than whites, but it is unknown whether progression from prehypertension is accelerated in blacks. We examined this question in a prospective cohort study of 18 865 nonhypertensive persons (5733 black [30.4%] and 13 132 white [69.6%]) aged 18 to 85 years. Electronic health record data were obtained from 197 community-based outpatient clinics in the Southeast United States. Days elapsing from study entry to hypertension diagnosis, mainly blood pressure ≥140 mm Hg systolic and/or ≥90 mm Hg diastolic on 2 consecutive visits established conversion time within a maximum observation period of 2550 days. Cox regression modeling was used to examine conversion to hypertension as a function of race, while controlling for age, sex, baseline systolic and diastolic blood pressures, body mass index, diabetes mellitus, and chronic kidney disease. The covariable adjusted median conversion time when 50% became hypertensive was 365 days earlier for blacks than whites (626 versus 991 days; P P

Background— Despite progress, many hypertensive patients remain uncontrolled. Defining characteristics of uncontrolled hypertensives may facilitate efforts to improve blood pressure control. Methods and Results— Subjects included 13 375 hypertensive adults from National Health and Nutrition Examination Surveys (NHANESs) subdivided into 1988 to 1994, 1999 to 2004, and 2005 to 2008. Uncontrolled hypertension was defined as blood pressure ≥140/≥90 mm Hg and apparent treatment-resistant hypertension (aTRH) when subjects reported taking ≥3 antihypertensive medications. Framingham 10-year coronary risk was calculated. Multivariable logistic regression was used to identify clinical characteristics associated with untreated, treated uncontrolled on 1 to 2 blood pressure medications, and aTRH across all 3 survey periods. More than half of uncontrolled hypertensives were untreated across surveys, including 52.2% in 2005 to 2008. Clinical factors linked with untreated hypertension included male sex, infrequent healthcare visits (0 to 1 per year), body mass index 2 , absence of chronic kidney disease, and Framingham 10-year coronary risk P P P 20% ( P Conclusion— Untreated, undertreated, and aTRH patients have consistent characteristics that could inform strategies to improve blood pressure control by decreasing untreated hypertension, reducing therapeutic inertia in undertreated patients, and enhancing therapeutic efficiency in aTRH.

Aliskiren is the first direct renin inhibitor approved for the treatment of hypertension. Blood pressure (BP) control in stage 2 hypertension with aliskiren monotherapy has not been reported. This was a post hoc analysis of the subgroup of patients with stage 2 systolic hypertension (baseline mean sitting systolic BP [msSBP]≥160 mmHg) who completed the 12-week monotherapy phase of a 6-month, double-blind, randomized study. A total of 175 patients were randomized to aliskiren 150 mg (n = 88) or ramipril 5 mg (n = 87) with optional up-titration to aliskiren 300 mg or ramipril 10 mg, respectively, at weeks 6 and 12. In the subgroup of patients with stage 2 systolic hypertension, aliskiren lowered msSBP and mean sitting diastolic BP (msDBP) by 22.3/12.7 mmHg from baseline to week 12; compared with a reduction of 18.1/10.2 mmHg with ramipril. The maximum BP reductions achieved with aliskiren were 60.0/34.0 mmHg (from a baseline of 172.7/107.3 mmHg). Aliskiren was noninferior (P < 0.0001) to ramipril for SBP reduction with nonsignificant superiority (P = 0.052), and superior (P = 0.043) to ramipril for DBP reduction. The proportion of patients who achieved BP control (

Thiazide diuretics can impair glucose metabolism and increase new-onset diabetes. Adding an angiotensin receptor blocker to diuretics may protect against these metabolic effects; however, the mechanism of this protection is unclear.To explore potential mechanisms, a 16-week multicenter trial was conducted to ascertain the relative glucose metabolism effects of combined hydrochlorothiazide and angiotensin receptor blocker (valsartan) therapy compared with hydrochlorothiazide and calcium channel blocker (amlodipine) treatment in 412 centrally obese hypertensive individuals (BMI = 35 +/- 7 kg/m, seated BP = 159 +/- 8/94 +/- 8 mmHg, and mean age 56 years). Individuals were randomized to valsartan/hydrochlorothiazide, with force-titration to 320/25 mg or hydrochlorothiazide, with titration to hydrochlorothiazide 25 mg and amlodipine 10 mg, respectively. Changes from baseline to week 16 in fasting and 2-h postprandial glucose and insulin levels after an oral glucose load were measured.At week 16, clinic blood pressure reductions were similar (P0.05) in both groups. Fasting and 2-h glucose levels increased (P0.05) with the amlodipine combination but not with the valsartan combination. In concert with these glucose responses, postprandial insulin increases from baseline were substantially greater with valsartan than with amlodipine plus hydrochlorothiazide group (P = 0.001). The glucose responses were inversely related to insulin responses at the study conclusion.The novel observation of this investigation was that the combination of valsartan and hydrochlorothiazide was associated with greater glucose-stimulated insulin secretory and lesser glycemic excursion responses than the amlodipine combination group. Thus, this data suggests that adding an angiotensin receptor blocker attenuates the negative effects of thiazides on pancreatic beta-cell glucose-induced insulin secretion.

The mechanism underlying blood pressure reduction in the high fruits and vegetables arm of the Dietary Approaches to Stop Hypertension (DASH) Study is unknown but may include potassium, magnesium and fiber. This study was designed to separate minerals and fiber from other components of DASH on blood pressure in abdominally obese metabolic syndrome subjects with prehypertension to Stage 1 hypertension (obese hypertensives). Fifteen obese hypertensives and 15 lean normotensives were studied on a standardized usual diet, randomized to DASH or usual diet supplemented with potassium, magnesium and fiber to match DASH, then crossed over to the complementary diet. All diets were three weeks long, isocaloric and matched for sodium and calcium. In obese hypertensives, blood pressure was lower after 3 weeks on DASH than usual diet (-7.6±1.4/-5.3±1.4 mmHg, p0.50). DASH is more effective than potassium, magnesium, and fiber supplements for lowering blood pressure in obese hypertensives, which suggest that high fruits and vegetables DASH lowers blood pressure and improves endothelial function in this group by nutritional factors in addition to potassium, magnesium and fiber.

PURPOSE Recent evidence supports a signifi cant association between the intake of dietary fi ber and levels of infl ammatory markers. The objective of this study was to determine whether daily fi ber supplementation would reduce levels of infl ammatory markers. METHODS This study was a prospective randomized controlled trial at a single university medical center. Participants were overweight or obese adults with no history of heart disease. The intervention was psyllium supplementation at either 7 or 14 g/d for 3 months compared with no supplements in a control group. The main outcome measure was change in level of high-sensitivity C-reactive protein (hsCRP) concentration; secondary outcomes included changes in interleukin-6 (IL- 6) levels, fi brinogen levels, and white blood cell (WBC) count. Protocol completers attended at least 2 visits and took more than 75% of the prescribed fi ber dose. RESULTS In this intent-to-treat analysis (n = 158), there were no signifi cant dif- ferences between either of the 2 treatment groups and the control group in the amount of change in CRP, fi brinogen, or IL-6 levels or in WBC count (P >.05). In the analysis of protocol completers (n = 132), there also were no signifi cant dif- ferences between the groups except for a small decrease in fi brinogen level in the high-fi ber group (-6 mg/dL (-0.18 μmol/L) compared with 13 mg/dL (0.38 μmol/L) in the control group, P

We analyzed cardiovascular disease mortality risks associated with obesity using participant-level meta-analysis of data from the Black Pooling Project for Black and White individuals. The adjusted relative risks (ARRs) were stronger among White participants than among Black participants for coronary heart disease AAR=1.21 (95% confidence interval [CI]=1.07, 1.36) versus 0.87 (95% CI=0.69, 1.09), respectively, and cardiovascular disease ARR=1.18 (95% CI=1.07, 1.29) versus 0.91 (95% CI=0.77, 1.05), repectively. The results suggest that obesity is an independent risk factor in White people, and additional study of body size and disease progression is necessary in the assessment of racial disparities.

More than 1 medication is required in many hypertensive patients to reach blood pressure (BP) goals, and initial treatment with 2 agents has been recommended for patients whose BP level is >20/10 mm Hg above target. Diuretics reduce BP levels and the incidence of target organ complications and together with angiotensin‐converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers, which are recommended in patients with comorbid cardiovascular disease, nephropathy, or diabetes, are effective antihypertensive combinations. Calcium channel blockers (CCBs) are also effective antihypertensive agents, and evidence suggests that a CCB/ACEI combination is well tolerated and also decreases the risk of cardiovascular and renal disease. Some evidence suggests that this combination may improve endothelial function more than either agent alone, and its use could potentially lead to better cardiovascular outcomes than a diuretic/ACEI or diuretic/ARB combination. The ongoing Avoiding Cardiovascular Events Through Combination Therapy in Patients Living With Systolic Hypertension (ACCOMPLISH) trial compares these 2 effective combinations (ie, an ACEI/diuretic and ACEI/CCB) as initial treatment for reducing cardiovascular morbidity and mortality in older high‐risk hypertensive patients. The results of this trial, when reported, should help to clarify the relative benefits of these different therapies.

Paul J Nietert,1 Stephanie R Shaftman,1 Richard M Silver,2 Bethany J Wolf,1 Brent M Egan,3 Kelly J Hunt,1 Edwin A Smith2 1Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA; 2Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA; 3Greenville Health System, Care Coordination Institute, Greenville, SC, USA Background: Raynaud phenomenon (RP) is a temporary vasoconstrictive condition that often manifests itself in the fingers in response to cold or stress. It often co-occurs with certain chronic diseases that impact mortality. Our objective was to determine whether RP has any independent association with survival. Methods: From 1987–1989, a total of 830 participants of the Charleston Heart Study cohort completed an in-person RP screening questionnaire. Two definitions of RP were used: a broad definition that included both blanching (pallor) and cyanotic color changes and a narrow definition that included only blanching. All-cause and cardiovascular disease (CVD) mortality were compared between subjects with and without RP using race-specific survival models that adjusted for age, sex, baseline CVD, and 10-year risk of coronary heart disease. Results: Using the narrow RP definition, we identified a significant interaction between older age and the presence of RP on all-cause mortality. In the broad RP definition model, the presence of RP was not associated with CVD mortality among blacks; however, among whites, the presence of RP was associated with a 1.6-fold increase in the hazard associated with CVD-related death (hazard ratio: 1.55, 95% confidence interval: 1.10–2.20, P=0.013). Conclusion: RP was independently associated with mortality among older adults in our cohort. Among whites, RP was associated with increased CVD-related death. It is possible that RP may be a sign of undiagnosed vascular disease. Keywords: Raynaud disease, cohort studies, cardiovascular diseases, survival analysis

Correspondencia: Heno Ferreira Lopes • Unidade de Hipertensao do InCor Av. Dr. Eneas de Carvalho Aguiar, 44 Sala 8 B II 05403-000 – Sao Paulo, SP E-mail: hipheno@incor.usp.br Recebido em 05/09/05 • Aceito em 08/09/05 Nesta revisao, sera examinada a importância do sistema nervoso autonomo na fisiopatologia e complicacoes da sindrome metabolica. A sindrome metabolica significa a constelacao de fatores de risco relacionados com a resistencia a insulina e obesidade com padrao de distribuicao de gordura central. Enquanto a sindrome da resistencia a insulina tem chamado a atencao nas tres ultimas decadas, a sindrome metabolica ganhou mais evidencia apos a publicacao e revisao do World Health Organization’s Expert Committee Report (WHO) no diagnostico e classificacao do diabete melito em 1998 e das diretrizes do National Cholesterol Education Program (Adult Treatment Panel [ATP] III) nos Estados Unidos em 20011-3. Embora as definicoes sejam de certa forma diferentes, ambas predizem um aumento significante no risco de doenca coronaria e doenca cardiovascular como um todo4-6.

This article highlights the proceedings of a symposium presented at the 28th Annual Meeting of the Research Society on Alcoholism in Santa Barbara, CA, on June 28, 2005, organized and chaired by Peter Miller. The presentations included (1) Screening for Alcohol Use Disorders in Surgical and Trauma Patients, presented by Claudia Spies; (2) Are Serum Levels of %CDT and GGT Related to Severity of Liver Biopsy Inflammation, Fibrosis, and Steatohepatitis in Patients with Hepatitis C? by Martin Javors; (3) Biochemical Alcohol Screening in the Treatment of Hypertension, presented by Peter Miller; and (4) The Cost-Effectiveness of a New Biomarker, CDT, in a Primary Care Sample, by Michael Fleming. Presentations were discussed by Raymond Anton.

Background Adipocyte-derived factors and regulators likely contribute to the metabolic syndrome (MetS) in patients with central obesity. This study was undertaken to assess the contribution of leptin, adiponectin, and acylation stimulating protein (ASP-C3ades/ARG) to hemodynamic (blood pressure [BP]) and metabolic (insulin, glucose, lipids) features of MetS. Methods In this study, leptin, adiponectin, and C3ades/ARG were measured at baseline and in response to an infusion of Intralipid® and heparin in 12 lean healthy controls and 12 patients with MetS. Results Baseline plasma leptin (27.6 ± 6.2 vs. 10.9 ± 3.8 ng/mL, p

See related article, pp 440–446 The study by Friedberg et al, “Effectiveness of a tailored behavioral intervention to improve hypertension control,” addresses a vital and well-recognized health issue.1 Specifically, the burden of uncontrolled hypertension is substantial, despite a near doubling in hypertension control from 27% in 1988 to 1994 to 53% in 2009 to 2010.2 Yet in 2010, hypertension-related disease contributed to >10 million years of life lost from ischemic heart disease, stroke, hypertensive heart disease, chronic kidney disease, other cardiovascular and circulatory diseases.3 Treatment and control of hypertension reduce fatal and nonfatal cardiovascular events, especially when combined with effective hypercholesterolemia management.4 In addition to the health toll, the economic burden of cardiovascular diseases in 2010 was ≈$445 billion with a projected increase to roughly $1.1 trillion in 2030.5 A disproportionate share of the increase is likely to occur among individuals ≥65 years. Million Hearts estimated that 1 000 000 cardiovascular events could be prevented in the United States in a 5-year period from 2013 to 2017, with hypertension control a featured component of the success plan.6 Effective, affordable, and highly scalable interventions that can significantly improve hypertension control are important. In the study by Friedberg et al,1 the effects of 2 different monthly telephone-based interventions for 6 months were compared with usual care (UC). They found that a monthly 30-minute telephonic intervention delivered by well-trained psychologists, and which accounted for the patients stage of readiness to change (stage-based intervention [SBI]), improved hypertension control compared with UC (64.6% versus 45.8%; P =0.001). In contrast, a monthly telephonic health education intervention (HEI) using the same well-trained individuals, which was not adapted to the patient’s stage of readiness to change, did not significantly improve hypertension compared with UC (54.3% versus 45.8%; …

Platelet and white blood cell counts are higher among some insulin-resistant patients and may contribute to atherothromboembolic complications. Metabolic syndrome patients are insulin resistant, often hypertensive, and at high cardiovascular disease risk, yet the relationship of platelets to the metabolic syndrome is unknown. Platelet and white blood cell counts were obtained from 135 volunteers who had measurements of blood pressure, fasting triglycerides, high-density lipoprotein cholesterol, and glucose. A body mass index >30 kg/m2 served as a surrogate for increased waist circumference. Subjects were subdivided into three groups by the number of metabolic syndrome criteria, i.e., no metabolic syndrome risk factor (MS-0; n = 40), one or two metabolic syndrome risk factors (MS1-2; n = 61), and three to five metabolic syndrome risk factors (MS3-5; n = 34). Platelet counts were increased significantly from 226+/-8 to 257+/-8 and 276+/-10 (x10(3)/mm3) in the MS-0, MS1-2, and MS3-5 groups, respectively (p < 0.01), after adjustment for age, gender, ethnicity, total cholesterol, and low-density lipoprotein cholesterol. White blood cell counts were also increased across the three groups (5.4+/-0.2, 6.2+/-0.2, and 6.6+/-0.3 [x10(3)/mm3]; p < 0.01) after multivariate adjustment. Compared with patients with zero to two metabolic syndrome risk factors, metabolic syndrome patients have higher platelet and white blood counts, which may serve as markers of a prothrombotic and proinflammatory state and contributors to atherothromboembolic risk.

OBJECTIVE Pulsatile arterial compression (AC) of the ventrolateral medulla (VLM) has been postulated to cause neurogenically mediated essential hypertension (EHTN). We aimed to establish whether the association between AC of specifically the retro-olivary sulcus (ROS) of the VLM and EHTN was significant, while controlling for other risks associated with EHTN. DESIGN Case-control study. METHODS Posterior fossa magnetic resonance imaging scans of 131 subjects, including 58 subjects with EHTN and 73 normotensives, were reviewed to determine the presence of AC in the ROS. The history of other risk factors for EHTN was obtained by reviewing medical records. RESULTS Multivariate logistic regression analysis of these data shows a significant association between AC in the ROS (right and/or left) and EHTN [odds ratio (OR) = 3.03, 95% confidence interval (CI) = 1.30, 7.06]. This analysis was done controlling for other known EHTN risk factors such as age, race, sex, diabetes, and obesity. A secondary analysis also controlling for these variables shows that AC of both the right and left ROS are independently associated with EHTN (right AC: OR = 5.04, 95% CI = 1.33, 19.17; left AC: OR = 3.39, 95% CI = 1.20, 9.60). CONCLUSIONS In this retrospective study of subjects with EHTN and normotensive controls that had undergone magnetic resonance imaging of the posterior fossa, AC of the ROS on either side of the medulla is a significant independent risk factor in EHTN. Further studies are required to determine whether this is true for the general population of patients with neurogenically mediated EHTN.

Among diabetic hypertensive patients, ethnic differences in blood pressure control and outcomes have been attributed in part to greater reluctance of providers to prescribe combination antihypertensive regimens to African Americans than to Caucasians. African Americans purportedly receive fewer angiotensin‐converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs), which reduce target organ complications. To assess these issues, cross‐sectional data were analyzed from 19,864 diabetic hypertensives from 62 primary care clinics. Among diabetic hypertensives, African Americans (N=6230) were less likely than Caucasians (N=8041) to have blood pressure (BP) ≤130/80 mm Hg at their last clinic visit (23.1% [23.0%–23.2%] vs. 30.7% [30.6%–30.9%]) despite a greater number of prescriptions for antihypertensive medications (2.67 [2.63‐2.70] vs. 2.23 [2.20‐2.26]). African Americans were more likely than Caucasians to have an ACEI and/or ARB prescribed and to receive prescriptions for at least two antihypertensive medications that included an ACEI or ARB (64.1 % [63.8%–64.4%] vs. 53.1% [52.8%–53.4%]). Among diabetic hypertensives, African Americans are less likely than Caucasians to attain BP

An expanded occurrence of the metabolic syndrome in the U.S. population, especially in the Southeastern United States, has raised awareness of a need to revise our approach to the management of global cardiovascular risk factors while underscoring a need for more aggressive interventions and prevention measures. In defining the components of the metabolic syndrome and the interrelationship among obesity, hypertension, dyslipidemia, and insulin resistance, a basic framework for the medical management of this syndrome has been defined. In Part I of the consensus report prepared by the Workgroup on Medical Guidelines of the Consortium for Southeastern Hypertension Control (COSEHC), we analyze the components of the metabolic syndrome, discuss its pathophysiology, and recommend an approach to the quantitative analysis of the risk factors contributing to excess cardiovascular death in the region.

Background Although insulin resistance and metabolic syndrome are often used synonymously, concordance is not established. Methods Metabolic, hemodynamic, and hormonal data were analyzed on 141 patients in the Trial of Preventing Hypertension (TROPHY) Sub-Study with high-normal blood pressure (BP) (130 to 139/85 to 89 mm Hg [mean ± SD, 133 ± 8/85 ± 6 mm Hg]; age, 48 ± 9 years; body mass index 30 ± 5 kg/m2). Results Fifty-three of 141 subjects (37.6%; ∼3/8) had the metabolic syndrome based on three or more of the five risk factors (BP, waist circumference, fasting triglycerides, HDL-cholesterol, glucose). To maintain consistency in proportions, insulin resistance was defined as the upper 3/8 of the distribution on the homeostatic model assessment (HOMA), which uses fasting glucose and insulin and a modified Matsuda-DeFronzo index, based on fasting, 1- and 2-h glucose and insulin values. Among metabolic syndrome patients, 57% and 55% were in the upper 3/8 of the distribution for insulin resistance by HOMA and Matsuda-DeFronzo, respectively. Among subjects without the metabolic syndrome, 26% and 27% were insulin resistant by HOMA and Matsuda-DeFronzo criteria. The proportion of patients with metabolic syndrome and insulin resistance increased strongly and similarly with increasing body mass index. However, metabolic syndrome and insulin resistance were different compared with their respective controls in the lower 5/8 of the distribution, in waist/hip ratios, fasting and 1-h insulin, HDL-cholesterol, heart rate, and systolic BP responses to exercise and plasma renin, angiotensin, and aldosterone. Conclusions The findings suggest that metabolic syndrome and insulin resistance are not synonymous anthropometrically, metabolically, hemodynamically, or hormonally in patients with high-normal BP.

To review outcomes of diabetic patients treated with losartan in two recent randomized, double-blind, clinical trials and compare outcomes to similar studies in diabetics.The Reduction in ENdpoints with the Angiotensin II Antagonist Losartan (RENAAL) study recruited 1513 patients with type 2 diabetes and nephropathy. The Losartan Intervention For Endpoint reduction (LIFE) study recruited 9193 hypertensive patients with left ventricular hypertrophy (LVH) including 1195 with diabetes mellitus. The maximum losartan dose in both studies was 100 mg daily. All study patients could receive additional antihypertensive medications, excluding angiotensin converting enzyme inhibitors (ACEIs) and other angiotensin receptor blockers (ARBs), if blood pressures (BP)140/90 mmHg were not achieved. In RENAAL, the control group received placebo whereas in LIFE, controls received atenolol. BP reductions were comparable in the treatment and control groups of both studies. In RENAAL, the primary outcome was the composite of doubling of serum creatinine, end-stage renal disease, or death. In LIFE, the primary composite outcome was cardiovascular death and non-fatal myocardial infarction or stroke.In RENAAL, losartan reduced the primary composite end-point 16% (p = 0.02) and the incidence of end-stage renal disease (ESRD) 28% (p = 0.002). In LIFE, the primary composite endpoint among diabetics was reduced 24% (p = 0.03), cardiovascular mortality was reduced 37% (p = 0.03) and total mortality was reduced 39% (p = 0.002).In diabetic patients with nephropathy, losartan reduces progression to endstage renal disease. In hypertensive diabetic patients with LVH, losartan reduces cardiovascular morbidity and mortality and total mortality. Angiotensin receptor blockade with losartan appears to confer benefits beyond BP reduction in diabetic patients at high-risk for cardiovascular and renal events.

The objective of this study was to determine the relationship of C‐reactive protein (CRP) and blood pressure (BP) across the range of BP categories including prehypertension. The Third National Health and Nutrition Examination Survey (NHANES III) data collected from 1988 to 1994 were analyzed. In unadjusted analyses, there was a step‐wise increase in the probability of elevated CRP across a wide range of BP categories. Prehypertensive participants had a higher prevalence of elevated CRP than normotensive people (27.4% vs. 19.8%; p

Patients with the metabolic syndrome have three or more of five cardiovascular risk factors and increased oxidative stress, arterial stiffness and pressor responses to exercise, which may contribute to their threefold greater risk for coronary heart disease. In addition to lowering basal blood pressure (BP), angiotensin receptor blockers (ARBs) may benefit metabolic syndrome patients by reducing oxidative stress, arterial stiffness, and pressor responses to exercise. Twelve patients, 7 women and 5 men, with the metabolic syndrome (aged 45 ± 2 years, BP 145 ± 5/85 ± 2 mm Hg, waist girth 110 ± 3 cm, triglycerides 186 ± 23 mg/dL, HDL cholesterol 44 ± 2 mg/dL, glucose 99 ± 3 mg/dL) were studied off medications, while on modest sodium restriction (∼100 mmol/d). Patients were randomized to the ARB losartan or placebo for 3 weeks then crossed over to the complement for 3 weeks. Studies were performed at the end of each phase following an overnight fast. Serum lipids and biomarkers of oxidative stress (F2-isoprostanes, thiobarbituric acid reacting substances) were unchanged by losartan, whereas large artery elasticity at rest, measured with the HDI PulseWave, increased from 13.6 ± 0.7 on placebo to 16.2 ± 1.1 mL/mm Hg on losartan, P < .05. Losartan lowered systolic BP pre-exercise from 142 ± 3 to 131 plusmn; 3 mm Hg (P < .001) and systolic BP after 6 min of treadmill exercise from 192 ± 6 to 169 ± 5 mm Hg (P < .001). Losartan lowered systolic BP (−23 ± 3 v −11 ± 2 mm Hg, P < .05) and pulse pressure (−4 ± 1 v −15 ± 2 mm Hg, P < .05) more during exercise than rest. Losartan reduces the pressor response to exercise, perhaps by enhancing arterial compliance. In addition to lowering basal BP, angiotensin receptor blockade in patients with metabolic syndrome improves arterial compliance and reduces pressor reactivity to exercise.

Oxidative stress emerges as a potential factor in the pathogenesis of hypertension and a common signal transduction mechanism by which various risk factors mediate cardiovascular and renal disease. A greater level of oxidative stress could contribute to higher rates of hypertension and related cardiovascular and renal complications in African Americans than in white Americans. The objective of this study was to compare oxidative stress induced by a standardized episode of acute hyperlipidemia in the two groups. Fifteen African Americans (37 +/- 1 years, 9 women/6 men, body mass index 30 +/- 2 kg/m(2)) and 15 whites (38 +/- 2 years, 9 women/6 men, body mass index 27 +/- 1 kg/m(2)) were evaluated. Acute hyperlipidemia was induced by a 4-h long infusion of Intralipid and heparin. Blood samples were drawn at baseline and after 2 and 4 h of acute hyperlipidemia for nonesterified fatty acids, triglycerides, and F2-isoprostanes, a biomarker of oxidative stress. Plasma nonesterified fatty acids and triglycerides increased significantly and similarly in African Americans and whites after 2 and 4 h of the Intralipid and heparin infusion. Although baseline plasma F2-isoprostanes did not differ between groups, F2-isoprostanes increased more in African Americans than in whites at 2 h (12.2 +/- 2.6 v 5.0 +/- 2.9 pg/mL, P