Search

Understanding basic medical statistics is important in today’s medical practice, not merely as an academic exercise but to translate medical information into day-to-day patient care. This review article tries to address basics of medical statistics to the end user.

Traditionally, salt intake is linked to hypertension, and salt restriction forms the foundation for “lifestyle” management of hypertension. Despite an increase in incidence of hypertension in the population, data did not show any increase in salt intake over longer time frame. Increased intake of processed food amounts to increase in sugars especially fructose. Rampant and excessive commercial use of high fructose corn syrup in ready-to-eat “fast” food results in hypertension by various mechanisms. This interesting shift of concept of white crystals from salt to sugar is reviewed in this commentary.

Repeated reviews of the evidence to produce recommendations for dietary salt intake have been conducted by independent committees of national and international scientific and governmental organizations. These recommendations support reducing dietary salt to less than 6 gm/day and many to less than 5 gm/day. Nevertheless, there is controversy about recommendations to reduce dietary salt. This commentary discusses low quality research studies and commercial interests as sources of the controversy. Especially, research that assesses usual salt intake in individuals based on a single spontaneously voided (spot) urine sample is discussed as a weak research method prone to erroneous findings. Further, some investigators have altered scientific formula to make their data using spot urine samples appear more robust and made misleading and false statements about evidence relating to dietary salt. Counterintuitive findings based on studies that have used spot urine samples is frequently disregarded in expert committee review given the low quality evidence is incompatible with higher quality evidence which shows direct linear relationships between dietary salt, hypertension and cardiovascular disease in the general population.

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 …

Hypertension is the most important risk factor for global morbidity and mortality. It has assumed epidemic proportions in India with an estimated 100 million patients. In recent decades, the disease is increasing more rapidly in rural than in urban popu lation. Status of hypertension treatment and control is dismal in India with about a third of patients on treatment and only 20% controlled. Innovative system-based strategies using a combination of public health approaches and physician led clinic-based management are required to prevent premature cardio vascular disease burden due to hypertension.

STATEMENTOF PURPOSE: These guidelines have been written to provide a straightforward approach to managing hypertension in the community. We have intended that this brief curriculum and set of recommendations be useful not only for primary care physicians and medical students, but for all professionals who work as hands-on practitioners. We are aware that there is a great variability in access to medical care among communities. Even in so-called wealthy countries, there are sizable communities in which economic, logistic, and geographic issues put constraints on medical care. And, at the same time, we are been reminded that even in countries with highly limited resources, medical leaders have assigned the highest priority to supporting their colleagues in confronting the growing toll of devastating strokes, cardiovascular events, and kidney failure caused by hypertension. Our goal has been to give sufficient information to enable healthcare practitioners, wherever they are located, to provide professional care for people with hypertension. All the same, we recognize that it will often not be possible to carry out all of our suggestions for clinical evaluation, tests, and therapies. Indeed, there are situations in which the most simple and empirical care for hypertension-simply distributing whatever antihypertensive drugs might be available to people with high blood pressure-is better than doing nothing at all. We hope that we have allowed sufficient flexibility in this statement to enable responsible clinicians to devise workable plans for providing the best possible care of hypertension in their communities. We have divided this brief document into the following sections: 1. General introduction, 2. Epidemiology, 3. Special issues with black patients (African ancestry), 4. How is hypertension defined?, 5. How is hypertension classified?, 6. Causes of hypertension, 7. Making the diagnosis of hypertension, 8. Evaluating the patient, 9. Physical examination, 10. Tests, 11. Goals of treating hypertension, 12. Nonpharmacologic treatment of hypertension, 13. Drug treatment of hypertension, 14. Brief comments on drug classes, 15. Treatment-resistant hypertension. Fil: Weber, Michael A.. State University of New York; Estados Unidos Fil: Schiffrin, Ernesto L.. McGill University; Canadá Fil: White, William B.. University of Connecticut; Estados Unidos Fil: Mann, Samuel. Weil Cornell College of Medicine; Estados Unidos Fil: Lindholm, Lars H.. Universidad de Umea; Suecia Fil: Kenerson, John G.. Cardiovascular Associates; Estados Unidos Fil: Flack, John M.. Wayne State University; Estados Unidos Fil: Carter, Barry L.. University of Iowa; Estados Unidos Fil: Materson, Barry J.. University of Miami; Estados Unidos Fil: Ram, C. Venkata S.. MediCiti Institutions; India Fil: Cohen, Debbie L.. University of Pennsylvania; Estados Unidos Fil: Cadet, Jean Claude. State University School of Medicine; Estados Unidos Fil: Jean Charles, Roger R.. Hypertension Center of Haiti; Haití Fil: Taler, Sandra. Mayo Clinic. Department of Medicine; Estados Unidos Fil: Kountz, David. Jersey Shore University Medical Center; Estados Unidos Fil: Townsend, Raymond. University of Pennsylvania; Estados Unidos Fil: Chalmers, John. University of Sydney; Australia Fil: Ramírez, Agustín José. Fundación Favaloro; Argentina. Universidad Favaloro; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Bakris, George L.. University of Chicago; Estados Unidos Fil: Wang, Jiguang. Shanghai Jiaotong University; China Fil: Schutte, Aletta E.. North West University; Sudáfrica Fil: Bisognano, John D.. University of Rochester; Estados Unidos Fil: Touyz, Rhian M.. University of Glasgow; Reino Unido Fil: Sica, Dominic. Virginia Commonwealth University; Estados Unidos Fil: Harrap, Stephen B.. University of Melbourne; Australia

A comparative effectiveness analysis of antihypertensive therapy amlodipine (AML) and angiotensin receptor blocker (ARB) fixed- and loose-dose combinations (FDCs and LDCs) in achieving blood pressure (BP) reduction and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) goal attainment was made using retrospective electronic medical record (EMR) data. Treatment goal rates ranged from 35.0% for LDC AML/losartan to 45.7% for FDC AML/olmesartan (OM). FDC AML/OM achieved significantly greater reductions in systolic BP than FDC AML/benazepril (BEN), FDC AML/valsartan (VAL), and LDC AML/ARBs, respectively, and significantly greater reductions in diastolic BP than FDC AML/VAL and LDC therapy, respectively. Compared with patients treated with AML/OM, patients prescribed AML/VAL and LDC AML/ARB were significantly less likely to attain JNC 7 BP goal. Among subpopulations, AML/OM yielded higher rates of goal attainment among both African Americans and obese/overweight patients relative to AML/VAL and combined LDCs. Switchers from monotherapy with AML, OM, or VAL to AML/OM were significantly more likely to attain JNC 7 goals than those switching to AML/VAL or AML/BEN.

Metabolic syndrome (MS) is a cluster of multiple cardio-metabolic risk factors in the same individual. People with MS are at high risk for the development of cardiovascular disease (CVD), chronic kidney disease (CKD), and cerebrovascular disease (CeVD). The excessive presence of MS in South Asians is likely responsible for significant morbidity in this population. This review discusses the scope of MS in South Asians and measures to combat its effects by preventive and therapeutic measures.

J Clin Hypertens (Greenwich). 2011;13:801–812. ©2011 Wiley Periodicals, Inc. The authors examined the comparative effectiveness of 4 angiotensin receptor blockers (ARBs) in patients with hypertension using a large electronic medical record database. Analysis of covariance and logistic multivariate regression models were used to estimate the blood pressure (BP) outcomes of 73,012 patients during 13 months of treatment with olmesartan, losartan, valsartan, and irbesartan. Results were adjusted by baseline BP, starting dose, year, age, sex, race, body mass index, comorbid conditions, and concomitant medications of patients. All ARBs led to sustained reductions in BP, but with significant differences in the magnitude of BP reduction. Raw mean systolic BP/diastolic BP reductions with losartan, valsartan, irbesartan, and olmesartan were 9.3/4.9 mm Hg, 10.4/5.6 mm Hg, 10.1/5.3 mm Hg, and 12.4/6.8 mm Hg, respectively. Adjusting for all covariates, the overall BP reductions with olmesartan were 1.88/0.86 mm Hg, 1.21/0.52 mm Hg, and 0.89/0.51 mm Hg greater than for losartan, valsartan, and irbesartan, respectively, and mean differences were higher for monotherapy: 2.43/1.16mm Hg; 2.18/0.93 mm Hg; 1.44/0.91 mm Hg, respectively (all P values

The safety and efficacy of an amlodipine/olmesartan medoxomil (OM)-based titration regimen was assessed in patients with type 2 diabetes mellitus and hypertension. After a 2- to 3-week placebo run-in period, 207 patients received amlodipine 5 mg and were uptitrated to amlodipine/OM 5/20, 5/40, and 10/40 mg and then amlodipine/OM 10/40 mg plus hydrochlorothiazide 12.5 and 25 mg in a step-wise manner at 3-week intervals if the seated blood pressure (BP) remained ≥120/70 mm Hg. The primary end point was the change from baseline in the mean 24-hour ambulatory systolic BP after 12 weeks of treatment. The baseline mean ± SD seated cuff systolic/diastolic BP was 158.8 ± 13.1/89.1 ± 10.1 mm Hg and the mean ± SD 24-hour ambulatory systolic/diastolic BP was 144.4 ± 11.7/81.6 ± 9.8 mm Hg. At week 12, the change from baseline in the mean ± SEM 24-hour ambulatory systolic/diastolic BP was -19.9 ± 0.8/-11.2 ± 0.5 mm Hg (p0.0001 vs baseline), and 70% of patients had achieved a 24-hour ambulatory BP target of130/80 mm Hg. At the end of 18 weeks of active treatment in patients uptitrated to amlodipine/OM 10/40 mg plus hydrochlorothiazide 25 mg, the change from baseline in the mean ± SEM seated BP was -28.0 ± 1.5/-13.7 ± 1.0 mm Hg (p0.0001 vs baseline), with 62% of patients reaching the guideline-recommended seated BP goal of130/80 mm Hg. Drug-related treatment-emergent adverse events occurred in 19.3% of patients. The most frequent events were peripheral edema (6%), dizziness (3%), and hypotension (2%). In conclusion, this amlodipine/OM-based titration regimen was well tolerated and effectively lowered BP throughout the 24-hour dosing interval in patients with hypertension and type 2 diabetes.

Systemic hypertension is an important risk factor for premature cardiovascular disease. Hypertension also contributes to excessive morbidity and mortality. Whereas excellent therapeutic options are available to treat hypertension, there is an unsettled issue about the very definition of hypertension. At what level of blood pressure should we treat hypertension? Does the definition of hypertension change in the presence of co-morbid conditions? This article covers in detail the evolving concepts in the diagnosis and management of hypertension.

Although systemic hypertension is a common clinical condition, hypertensive emergencies are unusual in clinical practice. There are some situations, however, that qualify as hypertensive emergencies or urgencies. It is important, therefore, to diagnose these acute conditions, in which immediate treatment of hypertension is indicated. The diagnosis of hypertensive emergencies depends on consideration of the clinical manifestations as well as the absolute level of blood pressure. Manifestations of hypertensive emergencies can be quite profound, but they vary depending on the target organ that is affected. Thus, an accurate clinical diagnosis is necessary to render appropriate therapy. Fortunately, effective drug therapy is available to lower the blood pressure quickly in hypertensive emergencies. Physicians should be familiar with the pharmacologic and clinical actions of drugs in treating hypertensive emergencies. With proper clinical diagnosis, hypertensive emergencies can be successfully treated, and complications can be largely prevented with timely intervention.

Despite the last three decades of progress in improving cardiovascular outcomes via renin–angiotensin–aldosterone system (RAAS) blockade in hypertensive patients, substantial residual morbidity/mortality remains. Attempts to improve clinical outcomes by combining angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have yielded mixed results. Adverse effects of RAAS blockade with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may relate to compensatory increases in plasma renin activity (PRA). The first-in-class direct renin inhibitor, aliskiren, blocks the RAAS at its point-of-activation, suppressing PRA and attenuating increases associated with other antihypertensives. Aliskiren (with or without other agents) provides significant and prolonged blood pressure reductions in a broad range of hypertensive patients and is well tolerated. Initial results from organ-protection studies are promising. Long-term outcomes studies should yield valuable information regarding the significance of direct renin inhibition in clinical practice.

Most patients with hypertension require more than one drug to attain recommended blood pressure (BP) targets. Initiating therapy with two agents is recommended for patients at high risk of a cardiovascular event or with a BP20/10 mmHg above goal. Combination therapy is effective when comprised of agents with complementary mechanisms of action, such as calcium channel blockers (CCBs) and angiotensin II-receptor blockers (ARBs). Two fixed-dose CCB/ARB combinations are approved in the US: amlodipine/valsartan (AML/VAL) and amlodipine/olmesartan medoxomil (AML/OM).To review and describe the efficacy of AML/VAL and AML/OM combinations by discussing similarly designed clinical trials.Three 8-week, randomized, double-blind, placebo-controlled, parallel-group factorial-design studies were examined (two AML/VAL; one AML/OM). The study endpoints presented in this review were: change from baseline in least-squares mean seated diastolic BP (SeDBP) and least-squares mean seated systolic BP (SeSBP). In addition to the efficacies of AML/VAL and AML/OM combinations, the efficacies of AML, VAL and OM administered as monotherapy are presented. Placebo-subtracted BP reductions were calculated for this review.Patient demographics were similar but mean baseline SeBP was higher in the OM study (163.8/101.6 mmHg) than in the VAL studies (152.8/99.3 and 156.7/99.1 mmHg), possibly suggesting that the OM study included a more difficult-to-treat patient population. AML/ARB combinations consistently produced greater mean SeBP reductions than monotherapy. Least squares (LS) mean SeDBP reductions were 19.4 mmHg (AML/OM 10/40 mg; placebo-corrected: 15.9 mmHg) and 18.6 mmHg (AML/VAL 10/320 mg; placebo-corrected: 9.8 mmHg). LS mean SeSBP reductions were 28.5 mmHg (AML/OM 10/40 mg; placebo-corrected: 25.7 mmHg) and 28.4 mmHg (AML/VAL 10/320 mg; placebo-corrected: 15.5 mmHg).This review of published factorial-design studies showed that the maximal marketed doses of an amlodipine/olmesartan medoxomil combination (10/40 mg) and an amlodipine/valsartan combination (10/320 mg) produced large reductions in BP from baseline. Limitations of this review include the small number of studies analyzed and the inherent heterogeneity between patient populations. Further research is warranted to directly compare the efficacy of these combinations in a randomized, controlled trial, or additional published clinical trials are required to provide larger data sets for robust meta-analyses and to overcome heterogeneity observed within these studies.

Angiotensin receptor blockers (ARBs), through their physiological blockade of the renin-angiotensin system, reduce morbidity and mortality associated with hypertension, heart failure, myocardial infarction, stroke, diabetic nephropathy, and chronic kidney disease. Among many attributes, excellent tolerability, and their ability to control hypertension for 24 hours with a positive effect on renal function position them as a useful choice for hypertension and related conditions. Because of the widespread actions of the renin-angiotensin system on critical tissues, treatment with ARBs may be beneficial in special populations. Ongoing and future studies will be needed to conclusively determine if ARBs also improve outcomes in patients with heart failure and preserved systolic function, atrial fibrillation, cognitive dysfunction, and kidney transplant recipients. Preliminary clinical data also suggest that combining ARBs and angiotensin-converting enzyme inhibitors may provide a more optimal blockade of the renin-angiotensin system and, therefore, may offer greater cardio- and nephroprotection. Future data will help delineate which ARBs and angiotensin-converting enzyme inhibitors are best combined and which patient populations might benefit from the dual blockade of the renin-angiotensin system.

UNLABELLED Despite successful therapies for chronic hypertension, hospital admissions for hypertensive emergency more than tripled between 1983 and 1992. OBJECTIVE To examine the safety and efficacy of fenoldopam, the first antihypertensive with selective and specific action on vascular dopamine (DA1) receptors, in a clinical trial involving emergency department patients with true hypertensive emergencies. METHODS Patients with a sustained diastolic blood pressure (DBP) of > or =120 mm Hg and evidence of target organ compromise were randomized in a double-blinded manner to one of four fixed doses of intravenous fenoldopam (0.01, 0.03, 0.1, or 0.3 microg/kg/min) for 24 hours. The primary endpoint was the magnitude of DBP reduction in each of the three higher-dose groups after four hours of fenoldopam treatment compared with the lowest-dose group. RESULTS One hundred seven participants from 21 centers were enrolled, and 94 patients received fenoldopam. Evidence of acute target-organ damage included new renal dysfunction or hematuria (50%), acute congestive heart failure or myocardial ischemia (48%), and papilledema or grade III-IV hypertensive retinopathy (34%). The DBP decreased in a dose-dependent fashion, with significant differences between the 0.1- and 0.3-microg/kg/min groups compared with the lowest-dose group. Treatment was well tolerated, and there were no deaths or serious adverse events during follow-up, up to 48 hours. All patients were successfully transitioned to oral or transdermal antihypertensives with maintenance of blood pressure control. CONCLUSIONS Fenoldopam safely and effectively lowers blood pressure in a dose-dependent manner in patients with hypertensive emergencies. Observations supporting potential risk factors for hypertensive emergency are discussed.

It is clear that the renin-angiotensin system (RAS) and the sympathetic nervous system (SNS) play key roles in sustaining elevated blood pressure, subsequently resulting in increased risks of cardiovascular (CV), cerebrovascular and kidney disease. Modifying these systems with antihypertensive agents has led to the discovery that their effects may indeed extend beyond controlling blood pressure. Within blood vessels, angiotensin II type 1 receptor blockers (ARBs) inhibit postsynaptic angiotensin II type 1 receptors (AT1). The ARB eprosartan, in contrast to other ARBs, also inhibits prejunctional AT1 receptors, which regulate noradrenaline release. The positive effects of eprosartan on blood pressure have been studied extensively, and are due to modulation of both the RAS and the SNS (through stimulation of the angiotensin II type 2 [AT2] receptor). Of importance to isolated systolic hypertension, trough sitting systolic blood pressure (SBP) is also significantly reduced with eprosartan. In addition, many studies have shown how the benefits of eprosartan go beyond that of blood pressure control alone. Eprosartan has shown positive effects on vascular inflammation and resistance to oxidation and/or modification of low-density lipoprotein. A wealth of other positive actions are associated with eprosartan treatment, including effects on platelet aggregation, kidney function and structure, progressive left ventricular dysfunction and central SBP. Clinical studies have clearly demonstrated the benefits of RAS blockade alongside the additional effects beyond blood pressure control with eprosartan treatment. These data place eprosartan as an effective agent to prevent CV, cerebrovascular and renal complications associated with high blood pressure.

Hypertension is a common condition associated with considerable morbidity and mortality. Antihypertensive drugs reduce the risk of cardiovascular and cerebrovascular events, and may also be associated with reductions in cognitive decline. Eprosartan is an angiotensin II type 1 receptor antagonist with a unique dual mechanism of action that is approved for the treatment of essential hypertension. In clinical trials, eprosartan has been shown to significantly reduce systolic blood pressure and to be associated with significant reductions in pulse pressure in elderly patients with isolated systolic hypertension. Data suggest that blood pressure reductions achieved with eprosartan in elderly hypertensive patients are also associated with improvements in cognitive function. Eprosartan compares favorably with other classes of antihypertensive agents in terms of reductions in mortality, cardiovascular and cerebrovascular events, and stroke recurrence. Evidence suggests that eprosartan may represent a useful addition to combination drug strategies for the management of hypertensive patients with elevated cardiovascular and cerebrovascular risk.

Despite the prevalence of hypertension, blood pressure (BP) can be controlled with effective therapy in most patients. However, in a small percentage of the hypertensive population, BP remains refractory to therapeutic measures. In such patients who have so-called "resistant" hypertension, proper evaluation and assessment have to be undertaken to improve the BP control. There are some situations or factors that may make hypertension control difficult in some patients. Therefore, it is necessary to identify possible reasons for the loss of BP control and rectify them to achieve normotension. In addition to indicated work-up for secondary causes, aggressive treatment (nonpharmacologic and pharmacologic) of hypertension is required to prevent excessive morbidity and mortality in this special population.

A number of controlled clinical trials provide evidence that angiotensin-receptor blockers improve the prognosis in a variety of conditions that place patients at high cardiovascular risk. The effect is more than one would expect from the effect of these agents on blood pressure alone. The results of some of these trials have expanded the indications for these drugs.

Hypertension is an important and widely prevalent risk factor for the development of chronic kidney disease (CKD), which unfortunately may progress to end-stage renal disease. CKD is a progressive condition that causes significant morbidity and mortality. Diabetes is the leading cause of end-stage renal disease in the Western world. Both hypertension and diabetes are the causative factors for the occurrence of CKD and its consequences. Aggressive control of hypertension and diabetes is indicated to reduce the risk for kidney disease in the community. Certainly, effective control of hypertension is a proven modality to prevent renal disease. The concept of decreasing the systemic blood pressure as well as the intraglomerular pressure has led to the application of rational therapeutic options in patients with renal insufficiency. Although treatment of hypertension alone is critical, drugs that block the renin-angiotensin system have been shown to have special renal (and cardiovascular) benefits. Early detection and treatment of microalbuminuria is an integral part of disease management. This article reviews the pathophysiologic and therapeutic implications of the link between hypertension and the kidney.

Although systemic hypertension is a common clinical condition, hypertensive emergencies are distinctly unusual in clinical practice. There are some situations, however, that qualify as hypertensive emergencies or urgencies. It is important, therefore, to diagnose these conditions because immediate treatment of severe hypertension is indicated. The diagnosis of hypertensive emergencies depends on the consideration of the clinical manifestations as well as the absolute level of blood pressure. Depending on the target organ that is affected, manifestations of hypertensive emergencies can be quite profound, yet variable. Thus, the physician has to make an accurate clinical diagnosis properly to render appropriate therapy. Fortunately, effective drug therapy is available to decrease blood pressure quickly in hypertensive emergencies. Physicians should be familiar with the pharmacologic and clinical actions of drugs that are used in the treatment of hypertensive emergencies. With proper clinical diagnosis, hypertensive emergencies can be treated successfully and the complications can be prevented with timely intervention. This review discusses the treatment of hypertensive emergencies in general and the therapeutic role of fenoldopam in particular.

Primary hypertension is the most common form of hypertension in clinical practice, and it is recognized more often in adolescents and adults than in younger children. The pathogenesis of essential hypertension is likely multifactorial. Obesity, insulin resistance, inappropriate activation of sympathetic nervous system, alterations in sodium hemostasis, renin angiotensin system, vascular smooth muscle structure and function, genetic factors and fetal programming have all been implicated in this circulatory disorder.1 The role of genetics in the development of hypertension has been demonstrated in twin studies that show a stronger correlation among identical twins than non-identical twins. Furthermore, genetic factors also influence certain behavioral traits, which might lead to the development of hypertension. For example, a tendency toward obesity or alcoholism is influenced by both genetic and environmental factors. Elevated blood pressure in childhood is associated with early markers of cardiovascular abnormalities such as left ventricular hypertrophy (LVH) and atherosclerosis. Hence, there has been an increasing focus on the identification, prevention, and treatment of children and adolescents with sustained hypertension.2 Systemic hypertension in children is defined as an arterial blood pressure ≥the 95th percentile for age, height, and gender. Therefore standard nomograms based on the above factors are necessary to define normal or elevated blood pressures. Hypertension in children is presumed to be rare and is thereby often missed. Screening studies for essential hypertension among school-going children in India show a prevalence distribution of 0.46–11.7%.3 A study reported by Mohan and Kumar in Ludhiana found a high incidence of hypertension in the urban areas, particularly in obese children.4 Raj also showed that childhood obesity showed an increasing trend in short period, and hypertension, not surprisingly, was common in overweight children.1 The prevalence of pre-hypertension in both rural and urban areas is significant in the younger age groups.5 The worldwide prevalence of pre-hypertension and hypertension is 17.3%; in Brazil, 7.4%; in Canada, 12.3–15.1%; in Greece, 10.1%; in India, 7.7%; in Iran, 10.1%; in Italy, 9.1–10%; in Seychelles, 1–11.4%; in South Africa, 12.2%; in South Asia/Taiwan, 12.9%. In USA, a study by Feber et al showed a prevalence of 13.8% in children aged 4–17 years.6 Concurrently, the National Health and Nutritional Examination Surveys (NHANES) demonstrated childhood blood pressure levels are increasing steadily. The study reported by Arun K De and co-workers in this issue of IHJ shows that primary hypertension is common among healthy school children of Kolkata in the age group of 5–15 years; they show a prevalence of hypertension to be 0.38% with the male to female ratio of 62:38.7 Children in height group of 141–160 cm and weight group of 41–45 kg had the highest number of hypertension cases. Obesity among these hypertensive children was 13.5%. All obese children incidentally were boys. ‘Tracking’ the tendency of individuals to maintain their blood pressure level compared with their peers is another important factor in determining the ultimate development of hypertension.8 The Bogalusa heart study showed that more than 40% of adults with hypertension had a history of blood pressure higher than the 80th percentile during childhood.9 Similarly, the Muscatine study showed that more than 45% of young adults with high systolic blood pressure had atleast one systolic measurement greater than 90th percentile during childhood; 40% of those with elevated diastolic blood pressure also had a history of elevated blood pressure during childhood.10 On the basis of emerging evidence, it is now apparent that primary hypertension is detectable in the young and that it occurs commonly. The long-term health risks for hypertensive children and adolescents can be substantial. Therefore, it is important that clinical measures be taken to reduce the cardiovascular risk in children. The assessment and management of hypertension in children differs from those in adults in several important ways. Hypertension in children and adolescents is defined by normative values for blood pressure according to gender, age and height which are published in fourth report of NHBPEP. Hypertension is defined as average systolic or diastolic BP >95th percentile for gender, age and height measured on three separate occasions. JNC 7 guidelines state that BP levels between 90th and 95th percentile are considered pre-hypertensive. According to the NHBPEP recommendation, children three years of age or older should have their blood pressure measured when seen at a medical facility. While it is important to screen children to prevent development of hypertension, the USPSTF states that there is insufficient evidence to recommend for or against routine screening for childhood hypertension to reduce the risk of CAD. The preferred method for BP measurement in children is by auscultation. Accurate blood pressure measurement is critical for diagnosis, evaluation, and management of hypertension in children. All subsequent measurements should be done in the same arm and position. Aneroid manometers are accurate when calibrated on atleast a semi-annual basis. Correct measurement of blood pressure in children requires use of a cuff that is appropriate to the size of the child's upper right arm, the preferred side because of the rare possibility of decreased pressure in the left arm caused by coarctation of aorta. By convention, an appropriate cuff size is one with an inflatable bladder width that is atleast 40% of the arm circumference at a point midway between the olecranon and acromion. The cuff bladder length should cover 80–100% of arm circumference. An oversized cuff can underestimate the blood pressure level, whereas the undersize cuff can overestimate blood pressure and all the measurements should be taken in a controlled environment after 5 min of rest in sitting position with the right arm supported at heart level. If the blood pressure >90th percentile, the blood pressure measurement should be repeated at the same office time to test the validity of reading. Ambulatory blood pressure monitoring is helpful in ruling out white coat hypertension, episodic hypertension, autonomic dysfunction and have role in differentiating primary from secondary hypertension and in identifying patients likely to have hypertension induced end organ damage.11 (How does it help identify these pts? This is not clear. May be can be taken out.) Secondary hypertension is more common in children than in adults. The possibility that some underlying disorder may be the cause of hypertension should be considered in every child or adolescent with elevated blood pressure levels. Very young children, children with stage 2 hypertension, and children or adolescents with clinical signs that suggest the presence of systemic conditions associated with hypertension should be evaluated more aggressively.

Recognition of the role of the renin-angiotensin-aldosterone system (RAAS) in initiating and maintaining hypertension prompted the development of drugs that disrupt the RAAS, notably the angiotensin-converting enzyme (ACE) inhibitors and, more recently, the angiotensin II receptor blockers (ARBs). This article focuses on the use of ARBs in hypertension management and reviews evidence emerging from clinical trials that ARBs offer target organ protection over and above their antihypertensive activity.