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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 …

About 1/4th of adults have high blood pressure which is the single most important risk for death (including heart disease and stroke).There are effective policies that could facilitate people making healthy choices to prevent raised blood pressure, and if fully implemented, could largely prevent hypertension from occurring.Hypertension is easy to screen and treat for BUT only about 50% of adults with hypertension are aware of their condition and only about 1 in 7 is adequately treated.Preventing and controlling high blood pressure is the major mechanism for NCD prevention and control and a model for other NCD risks.Effective lifestyle and drug treatments could prevent and control hypertension in most individuals if systematically applied to the population, simple interventions are feasible in all settings, and can be used to enhance primary care.Urgent sustained action is needed is needed for effective public policies and health system changes to prevent and control hypertension.Cerca de ¼ dos adultos têm hipertensão arterial, que é o fator de risco isolado mais importante para morte (incluídas as mortes por cardiopatia e acidente vascular cerebral).Existem políticas eficazes que poderiam facilitar escolhas pessoais saudáveis para evitar a elevação da pressão arterial e, se plenamente implementadas, podem prevenir a ocorrência da hipertensão arterial.É fácil rastrear e tratar a hipertensão, MAS somente cerca de 50% dos adultos hipertensos estão cientes de sua condição, e apenas cerca de 1 em cada 7 é tratado adequadamente.A prevenção e controle da hipertensão é o principal mecanismo de prevenção e controle das doenças não transmissíveis e um modelo para outros riscos de doenças não transmissíveis.Tratamentos eficazes com mudanças de estilo de vida e medicamentos poderiam prevenir e controlar a hipertensão arterial na maioria das pessoas se aplicados sistematicamente à população; as intervenções simples são viáveis em todos os ambientes e podem melhorar a atenção primária.É necessária a ação continuada e urgente a fim de obter mudanças efetivas nas políticas públicas e no sistema de saúde para prevenir e controlar a hipertensão arterial.

Objective: The study tested the potency of yoga-based intervention on risk reduction of diabetes. Research Design and Methods: This study is an offshoot of a large, 2 group cluster randomized, translational research trial on 11,212 individuals, aged >20 years, with high-risk (>60) for diabetes on IDRS (Indian diabetes risk score) and type 2 diabetes. The present study included a subgroup of 3,366 prediabetes individuals [A1C range of 5.70-6.49% (39-47 mmol/mol)]. Eligible individuals were selected by community-based (rural and urban) screening from 29 states/union Indian territories and were cluster randomized. The wait list control group received lifestyle advice. The experimental group performed a validated yoga-based lifestyle intervention developed by a group of 16 yoga and diabetes experts using the Delphi method. The study outcomes, diabetes incidence/prediabetes remission were obtained by respective A1c values >6.5% (48 mmol/mol) or Results: At 3 months of follow-up, 11.2% of the yoga-intervention group and 21.6% of the control group developed diabetes (p Conclusion: This is the first report on the effectiveness of a yoga-based life style intervention for remission of prediabetes and prevention of diabetes. The intervention was adequately effective for normal and overweight/obese subgroups. The short-term findings demand the need for longer follow-up. We speculate positive long-term outcomes based on the reported effects of yoga on self-control and feeding behavior. Disclosure Raghuram Nagarathna: None. C. Venkata Ram: None. Sasidharan Rajesh: None. Amit Singh: None. Vijaya Majumdar: None. Suchitra Patil: None. Hongasandra Nagendra: None. Funding The Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy; Government of India Ministry of Health and Family Welfare

Autonomic cardiovascular control is impaired in hypertension, leading to a reduction in the parasympathetic tone and to an increase in the sympathetic influences to the heart and peripheral vessels. The sympathetic dysfunction depends on a variety of reflex and nonreflex mechanisms and participates at development and progression of the essential hypertensive state. This has been shown to be the case for borderline hypertension, for moderate and severe high blood pressure, and for resistant hypertension as well. In addition, the adrenergic overdrive participates at the pathophysiology of the complex cardiometabolic alterations, known as "end-organ damage," detectable in the clinical course of hypertensive disease. In the present article, we will review the main features of the adrenergic abnormalities characterizing essential hypertension, the mechanisms potentially involved in this neural abnormality, and its consequences as well. We will also discuss the most recent information achieved in the field and the areas worthy of future investigations.

The prevalence of hypertension in chronic kidney disease (CKD) patients exceeds that of the general population. Uncontrolled hypertension plays a significant role in progression to end stage renal disease and results in increased cardiovascular morbidity and mortality. A complex interplay between various pathophysiologic mechanisms is responsible for the development of hypertension in this patient population. The major factors being extracellular volume overload, increased endothelin-1 release and excess renin-angiotensin-aldosterone system and sympathetic nervous system activity. Dietary and lifestyle modifications have synergistic effects to drug therapy in the control of hypertension. There is no single blood pressure target that is optimal for all CKD patients. It is important to individualize the treatment depending on age, the severity of albuminuria, and comorbidities. Drugs blocking the renin-angiotensin-aldosterone system are the recommended first-line antihypertensive agents for most CKD patients. Intradialytic hypertension may be prevented by individualizing the dialysis prescription and using nondialyzable antihypertensives. New onset of hypertension in the elderly or new onset of difficult to control hypertension in a previously well controlled hypertensive patient should prompt the work up for atherosclerotic renal vascular disease.

J-curve can be defined as an increase in event rates when the blood pressure (BP) goes below a particular level. Now that we have safe and powerful drugs available for treatment of hypertension, it has become possible to bring down the BP to very low levels. However, the concept of “lower is better” is now being questioned. Trials looking at J-curve have given conflicting results. Probably, there is no J-curve for systolic BP. J-curve for stroke and renal end points is also debatable. It is in patients with significant obstructive coronary artery disease that there are data for a J curve for diastolic BP. In such patients, we should gradually titrate the dose of drugs, carefully watching for increasing angina. Isolated systolic hypertension (ISH) is another situation wherein care has to be taken when aggressively reducing systolic BP. Even here, there are questions to be answered. The low diastolic BP could be a marker of increased aortic stiffness. Or, the low diastolic BP may be due to other associated comorbid conditions. The fear of J-curve should not lead to undertreatment and thus deny patients the benefit of BP reduction.

Beta-blockers have been used as first-time antihypertensives for decades and such use has also been recommended by guidelines. However, subsequently some meta-analyses questioned this status of beta-blockers by bringing to light their limitation in terms of stroke prevention and their metabolic sideeffects. Following this, several major international hypertension guidelines have removed beta-blockers from the first line of recommended drugs. Some other guidelines, however, have retained them as first-line antihypertensive. Age is an important determinant of choice of antihypertensives and beta-blockers have proven to be very useful in young hypertensives especially if overweight. Amidst these controversies, vasodilatory beta-blockers have emerged with a new promise. They are potent antihypertensives with better reduction of central aortic pressure and a neutral or favorable metabolic profile.

Over the years, clinical and experimental studies have established the pivotal role of neurogenic factors in the genesis, progression, and prognosis of hypertension. It is accepted that sympathetic nervous system dominance over vagal influence is largely responsible for hypertension. Such an imbalance is seen strikingly in resistant hypertension. Lifestyle modifications leading to reduced sympathetic tone and increased vagal tone consistently provide control of hypertension and to some extent reversal or delaying of end-organ damage. However, studies with pharmacological and device-based therapies that aimed to modify autonomic tone to regulate neurogenic factors and to achieve desired blood pressure control have not produced encouraging results. The role of beta-blocker drugs has also been questioned. Catheter-based renal denervation strategy has fallen short of expectation. Understanding thoroughly the mechanisms underlying alterations in the neurogenic factors, the result of abnormal neurogenic milieu at the cellular and molecular levels and methods to identify susceptible individuals either by genetic study or by accurate measures of autonomic tone is expected to help tailor anti-hypertensive therapy and thereby improve outcomes. Keywrods: Anti-natriuresis, Glutamatergic synapse, Vasomotor sympathetic nerve discharge. How to cite this article: Pandurangi UM. Neurogenic Factors and Blood Pressure Regulation. Hypertens J 2016;2(1): 35-38. Source of support: Nil Conflict of interest: None

The sympathetic nervous system (SNS) plays a major role in the pathogenesis of hypertension and contributes to hypertensive target organ complications. Advances in technology over the last three decades have improved the ability to measure sympathetic nerve activity (SNA), thus enabling investigators to probe the role of SNS in the development of cardiovascular diseases. The most direct method of measuring SNA employs the technique of microneurography, which involves recording of postganglionic sympathetic action potential using a subcutaneous electrode inserted into the candidate nerve. This method allows assessment of sympathetic vasoconstrictor discharge to the peripheral circulation in hypertension and provides prognostic information in patients with cardiovascular diseases. However, application of microneurography and other methods of assessment of SNS activity, including norepinephrine spillover and imaging of SNS innervation, in routine clinical practice is limited by availability of the technique and lack of normal reference range established from large population-based data. Nevertheless, these measurements provide further insight into mechanisms of hypertension and effectiveness of various interventions in modifying sympathetic regulation of blood pressure.

Stroke is among the leading causes of death and disability worldwide. Ischemic stroke is 3 to 4 times more common than hemorrhagic stroke. Hypertension is the commonest risk factor for ischemic stroke, in addition to diabetes mellitus, dyslipidemia and smoking. Blood pressure (BP) lowering with appropriate antihypertensive agents would lead to reduction of first ever stroke as well as recurrent strokes. This article discusses the epidemiology of strokes in India, role of hypertension in ischemic stroke causation and its recurrence; BP targets to be achieved, and the preferred antihypertensive agents. In addition, management of hypertension in the setting of acute ischemic stroke is also discussed. Blood pressure lowering is generally avoided within the first 24 hours after acute ischemic stroke. Proper BP management is one of the keys to ensure better outcomes in acute stroke setting.

Type 2 diabetes mellitus is a metabolic disorder that occurs due to an interplay of multiple perplexing pathophysiological mechanisms and leads to hyperglycemia. However, till date there has been no single unique molecule that can by itself effectively address all the metabolic abnormalities occurring in type 2 diabetes. Furthermore, type 2 diabetes must be managed with agents that can combat hyperglycemia without causing hypoglycemia and adverse cardiovascular outcomes. Thus, the need of the hour is for a unique molecule that can deliver beyond glycemic control and can in addition address the cardiovascular risk factors that arise in type 2 diabetes. Sodium glucose cotransporter-2 (SGLT-2) inhibitors are the latest of the oral hypoglycemic agents that act by insulin-independent mechanisms and tackle several cardiovascular risk factors that occur in type 2 diabetes. The scope of this article will be to focus primarily on the cardiovascular benefits of SGLT-2 inhibitors and its actions beyond glycemic control in providing a comprehensive care in the management of type 2 diabetes.

Hypertension is a major public health problem and is an impor tant risk factor for stroke, coronary heart disease and renal failure. The blood pressure is not well controlled with drug therapy in large number of individuals, especially in the developing countries. There is a need for less expensive nonpharmacological alternative methods to control blood pressure. Yoga may be such cost-effective alternative. Several uncon trolled and ran do mized control trials have evaluated short- and long-term effects of yoga/meditation-based techniques in prehypertension and mild hypertension. Though, the results are mixed and there are several methodological limitations in reported studies, majority of studies demonstrate a modest decrease in both systolic and diastolic blood pressure. This modest decrease may significantly decrease the stroke mortality and coronary heart disease in general population. A recent scientific statement of American Heart Association also suggests that it is reasonable for all individuals with blood pressure levels more than 120/80 mm Hg to consider alternative approaches like transcendental medication as adjunct method to lower blood pressure.

Hypertension being a common medical condition is resulting in increased hospital admissions worldwide and, moreover, hyper­ tensive emergencies and urgencies have led to an increment in critical care patients. It is, therefore, evident that urgent diag nosis and immediate and appropriate treatment of these con ditions is paramount in reducing mortality and morbidity. Manifestations of the hypertensive emergencies and urgen­ cies may vary depending on the target organ that is affected. Fortunately, more effective and relatively safe drugs are available, nowadays, to lower blood pressure (BP) quickly in these life­ threa tening situations. Critical care physicians should be familiar with all pharmacological and clinical actions of the medications avai lable in treating these hypertensive emer gencies, along with the appropriateness of the choice of medication in any given situation. The purpose of review is to understand the therapeutic inter ventions in treating a hypertensive crisis.

High blood pressure has long been recognized as associated with increased risk of stroke. Basically, the higher the systolic blood pressure, the greater the risk of stroke. The high blood pressure risks are evident in both genders, all ages and all population. Since the 1970s, evidence has been generated deter mining that lowering the blood pressure reduces the risks of stroke. At the population level, the blood pressure distri butions in the United States have shifted to the left, i.e. current population blood pressure levels are lower than previous decades. These lower blood pressures are associated with lower stroke risks. The lower blood pressures are attributed to structured programs implemented specifically to lower blood pressure in the population, clinical guidelines detailed to pharmacologically lower pressures, hypertension prevention efforts and programs, and additional resources devoted to lower blood pressure. These intervention and prevention have been effective in lowering blood pressures and stroke risk reduction. While additional improvements remain to be accomplished globally, the models of lower blood pressures and hypertension should be considered one of the major public health success stories in the past 50 years and a major objective for population risk reduction throughout the world.

Hypertension has a long list of primary as well as secondary causes. Fibromuscular dysplasia is amongst the rare secon­ dary causes of hypertension. Intimal fibroplasia as a pathologic cause occurs in less than 10% of patients with fibromuscular dysplasia. We report a rare case of hypertension due to intimal fibromuscular dysplasia of renal artery, treated successfully with renal angioplasty and stenting. It is important to note that intimal fibromuscular dysplasia mimics atherosclerotic lesions morphologically and on renal angiography.

Hypertension treatment guidelines are intended to provide recom men dations to practitioners on key issues such as diag nostic criteria and blood pressure treatment targets, the optimal use of lifestyle changes as well as drug therapy, and the management of co-existing cardiovascular risk factors. Unfortu nately, despite several major clinical outcomes trials in hypertension, there is still insufficient evidence to allow firm recommendations in important areas. A major uncertainty with potentially large impli cations for stroke and cardiovascular event rates is the systolic blood pressure target in people aged 60 years or more: should it be 150 mm Hg or 140 mm Hg? This commen tary addresses this and other controversial issues and differences of opinion across the several authoritative guidelines published in the last few years.

India has become the capital of all communicable diseases and noncommunicable diseases like hypertension and diabetes. Vitamin D deficiency is also very high in the Indian subcontinent (as high as 80–90%). Therefore, it is possible that these issues are interrelated, or we should look for possible relations. The landmark study by us suggested the cause of vitamin D deficiency as poor dietary intake or in other words due to malnu trition. Vitamin D deficiency is multifactorial in etiology; the etiological factors vary from place to place and person to person. The three primary reasons for the deficiency are: lack of balanced diet, reduced sunlight exposure and increased melanin in the skin. Even if, by chance, someone gets adequate vitamin D from diet and sunlight, its activation in the liver and kidneys is defective due to increasing prevalence of liver and kidney diseases. Liver diseases are on the increase due to overeating with consequent obesity and nonalcoholic liver disease, or due to alcohol intake and exposure to hepatotoxic agents or infections. Subclinical liver disease is now widely prevalent in the people with consequent poor activation of vitamin D. Increasing renal diseases due to several reasons and the lack of vegetables and fruits consumption with consequent hypomagnesemia contribute to poor 1-hydroxylation in the kidneys. Lack of intake of balanced diet, lack of outdoor exercises and eating more food are all lifestyle issues, and the same are the causes for diseases, like hypertension, diabetes, ischemic heart disease (IHD), strokes and cancers and, therefore, the link between vitamin D deficiency and these diseases become very obvious. It is only natural that we see vitamin D deficiency in all the diseases, or supplementation of vitamin D benefits all the patients. To tackle the problem of vitamin D deficiency in India, we need to address all the healthcare issues simultaneously and empower the people for regular intake of balanced diet, doing regular exercise and exposure to sunlight through systematic and meticulous social, educational, agricultural and financial reforms. Therefore, all disease control programs in India should focus on empowering the people, by the necessary social reforms and its implementation. As an interim measure, fortification of foodstuffs like oil or wheat-flour also may be tried till such time that all sections of the society are empowered for taking balanced diet regularly.

Treadmill exercise testing is the most common noninvasive test to assess patients with suspected or known cardiovascular disease. Measurement of blood pressure (BP) during exercise stress is cumbersome due to patient motion and hemodynamic changes during exercise. Different population studies give differing levels for abnormal BP response to exercise and there is no unanimity about the level of BP at which exercise test is contraindicated or terminated. However, studies uniformly associate abnormal BP responses to exercise not only with risk of future hypertension but also with cardiovascular events, stroke and mortality. The present article provides a brief account of common precautions in BP measurement, the diagnostic and prognostic significance of different BP responses during exercise stress testing.

Arterial stiffness is a pathological manifestation of cumulative vascular damage resulting from various known and unknown vascular risk factors. Central aortic pressure and pulse wave velocity are the two most commonly used and the most informative non-invasive measures of arterial stiffness. Numerous studies have documented incremental value of these measures in a variety of clinical conditions, most notably, hypertension. In hypertensive subjects, assessment of arterial stiffness not only provides incremental information about vascular risk, it also helps in guiding therapeutic decision making and serves as a tool for monitoring response to antihypertensive therapy.

Ambulatory blood pressure measurement (ABPM) gives better prediction of cardiovascular morbidity and mortality, and endorgan damage associated with hypertension (HTN) than clinic or casual blood pressure measurements, since the diurnal blood pressure profile and nocturnal blood pressure levels are not ascertained by the later. 1 Although the technology has been available for more than three decades, its role in the evaluation and management of hypertension has been well established only in the past decade. Ambulatory blood pressure measurement is indicated to identify ‘white coat’ effect/hypertension, masked hypertension, to evaluate drug-resistant hypertension, and to assess adequacy of control in patients at high-risk of cardiovascular disease. The various blood pressure categorizations afforded by ambulatory blood pressure monitoring are valuable for clinical management of high blood pressure and prevention of cardiovascular events. This review summarizes the utility of ambulatory blood pressure monitoring in the manage ment of hypertension and its practical importance.

Old age is defined variably in medical parlor. Blood pressure (BP) increases with age as a continuous variable. Hypertension is the single most attributable risk factor for death worldwide and accounts for considerable morbidity. Control of BP reverses this process. However, when to treat the elderly and how, is sometimes a confusing area. Due to high rates of comor bidities and drug adverse effects, often the elderly are undertreated. But, it should be made clear that the benefit of treatment of BP in the elderly is very high and if treatment is provided with reasonable standard of care, the benefit far outweighs the risk.