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Since the first International Society on Hypertension in Blacks consensus statement on the “Management of High Blood Pressure in African American” in 2003, data from additional clinical trials have become available. We reviewed hypertension and cardiovascular disease prevention and treatment guidelines, pharmacological hypertension clinical end point trials, and blood pressure–lowering trials in blacks. Selected trials without significant black representation were considered. In this update, blacks with hypertension are divided into 2 risk strata, primary prevention, where elevated blood pressure without target organ damage, preclinical cardiovascular disease, or overt cardiovascular disease for whom blood pressure consistently 15/10 mm Hg above target, 2-drug therapy is recommended, with either a calcium channel blocker plus a renin-angiotensin system blocker or, alternatively, in edematous and/or volume-overload states, with a thiazide diuretic plus a renin-angiotensin system blocker. Effective multidrug therapeutic combinations through 4 drugs are described. Comprehensive lifestyle modifications should be initiated in blacks when blood pressure is ≥115/75 mm Hg. The updated International Society on Hypertension in Blacks consensus statement on hypertension management in blacks lowers the minimum target blood pressure level for the lowest-risk blacks, emphasizes effective multidrug regimens, and de-emphasizes monotherapy.

Resistant hypertension, secondary hypertension, and hypertensive crises are uncommon but potentially dangerous forms of hypertension that are associated with an increased risk of complications such as myocardial infarction, heart failure, stroke, and renal failure. Appropriate diagnostic screening and selective drug or surgical management can reduce the risk of these complications dramatically. In compliant patients, resistant hypertension occurs most often in obese patients receiving inadequate diuretic therapy. In patients with clinical clues to the diagnosis, the best current screening test for renovascular hypertension is probably the ACE-inhibitor renal scintiscan. Angioplasty is considerably more successful in younger patients with fibrous dysplasia than in older patients with the atherosclerotic variety. Hypertensive crises are divided into BP urgencies and emergencies. In both settings, the reduction in BP should generally be gradual rather than abrupt, with no intent to acutely normalize the BP.

Background The occurrence of kidney stones is disproportionate in the southern region of the United States. Risk factors for the occurrence of kidney stones in this geographic area have not been reported previously. Methods The Women’s Health Initiative (WHI) is an ongoing multicenter clinical investigation of strategies for the prevention of common causes of morbidity and mortality among postmenopausal women. A case-control ancillary study was conducted on 27,410 (white or black) women enrolled in the 9 southern WHI clinical centers. There were 1,179 cases (4.3%) of kidney stones at the baseline evaluation. Risk factors for stone formation were assessed in cases versus age- and race-matched control subjects. Results Risk factors (univariate) included low dietary potassium (2,404 versus 2,500 mg/day, P = 0.006), magnesium (243 versus 253 mg/day, P = 0.003) and oxalate (330 versus 345 mg/day, P = 0.02) intake, as well as increased body mass index (28.5 versus 27.7 kg/m 2 , P = 0.001) and a history of hypertension (42% versus 34%, P = 0.001). A slightly lower dietary calcium intake (683 versus 711 mg/day, P = 0.04) was noted in case subjects versus control subjects, but interpretation was confounded by the study of prevalent rather than incident cases. Supplemental calcium intake > 500 mg/day was inversely associated with stone occurrence. Conclusion Multivariate risk factors for the occurrence of kidney stones in postmenopausal women include a history of hypertension, a low dietary intake of magnesium, and low use of calcium supplements.

Kutner NG, Brogan D, Hall WD, Haber M, Daniels DS. Functional impairment, depression, and life satisfaction among older hemodialysis patients and age-matched controls: a prospective study. Arch Phys Med Rehabil 2000;81:453-9. Objective: To compare change over time in functional impairment, depression, and life satisfaction among older dialysis patients and age-matched controls. Design: Prospective cohort study over 3 years. Setting: Urban and rural communities throughout Georgia. Subjects: One hundred thirteen prevalent renal failure patients on in-center hemodialysis and 286 controls. Main Outcome Measures: Ordinal functional impairment index and life satisfaction rating, and Center for Epidemiologic Studies Depression Scale. Results: Dialysis patients, compared with controls, reported significantly more functional impairment at baseline, and also at follow-up after adjusting for baseline impairment and covariates. Dialysis patients had higher depression scores at baseline, and also at follow-up after adjusting for baseline depression and covariates. In contrast, dialysis patients reported lower life satisfaction at baseline than did controls, but the two cohorts were not significantly different on reported life satisfaction at follow-up, after adjusting for baseline life satisfaction and race. In both cohorts, functional impairment and depression were significantly related. Conclusion: Older dialysis patients' life satisfaction at a 3-year follow-up, which was similar to life satisfaction among age-matched controls, indicates the value of delivered dialysis care; the value of this care would be increased by reducing excess functional impairment in these patients. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Hypertension is very common in adults >/=60 years of age. Isolated systolic hypertension (ISH) in particular is a good predictor of events associated with elevated blood pressure such as stroke, coronary heart disease, and congestive heart failure. Two large studies, the Systolic Hypertension in the Elderly Program (SHEP) and the Systolic Hypertension in Europe study (Syst-Eur), have demonstrated that antihypertensive drug therapy for elderly patients with ISH reduces the risk of stroke and other major cardiovascular events. SHEP demonstrated that antihypertensive drug treatment with a diuretic-based regimen in patients >/=60 years of age with ISH reduced the incidence of total stroke by 36%. SHEP also demonstrated a 32% reduction in the incidence of cardiovascular events for patients receiving active treatment. The 5-year average systolic blood pressure (SBP) was 155 mm Hg in the placebo group (n = 2371) compared with 143 mm Hg for the active treatment group (n = 2365). Results from the recently completed Syst-Eur study also support the benefits of antihypertensive treatment in patients >/=60 years of age with ISH. Active treatment in Syst-Eur consisted of the calcium channel blocker nitrendipine, with the addition of enalapril and hydrochlorothiazide as needed to reduce SBP to

Hypertension, left ventricular hypertrophy (LVH), hypercreatininemia, and microalbuminuria (MA) are independent risk factors for cardiovascular disease (CVD). Hypertension increases the risk of CVD by two- to three-fold and LVH (especially concentric) is a risk factor for coronary heart disease, heart failure, stroke, and peripheral arterial disease. In people with hypertension, a serum creatinine level of 1.7 mg/dL or more may be an even stronger CVD risk factor than diabetes, smoking, LVH, or systolic blood pressure. Similarly, MA is a strong and independent predictor of CVD morbidity and mortality in people with and without diabetes and/or hypertension. Impaired renal sodium handling and sodium retention are physiological hallmarks of the very early stages of heart failure. Heart failure is a physiologically delicate condition that can decompensate with excess dietary salt intake or over diuresis, or compensate with cautious therapy designed to block the sodium retention and simultaneously interrupt excessively activated neurohumoral mechanisms.

Stroke mortality is higher in the Southeast compared with other regions of the United States. The prevalence of hypertension is also higher (black men = 35%, black women = 37.7%, white men = 26.5%, white women = 21.5%), and the proportion of patients whose hypertension is being controlled is poor, especially in white and black men. The prevalence of hypertension-related complications other than stroke is also higher in the Southeast. The five states with the highest death rates for congestive heart failure are all in the southern region. Of the 15 states with the highest rates of end-stage renal disease, 10 are in the Southeast. Obesity is very prevalent (24% to 28%) in the Southeast. Although Michigan tops the ranking for all states, 6 of the top 15 states are in the Southeast, as are 7 of the 10 states with the highest reported prevalence regarding no leisure-time physical activity. Similar to other areas of the United States, dietary sodium and saturated fat intake are high in the Southeast; dietary potassium intake appears to be relatively low. Other factors that may be associated with the high prevalence, poor control, and excess morbidity and mortality of hypertension-related complications in the Southeast include misperceptions of the seriousness of the problem, the severity of the hypertension, lack of adequate follow-up, reduced access to health care, the cost of treatment, and possibly, low birth weights. The Consortium of Southeastern Hypertension Control (COSEHC) is a nonprofit organization created in 1992 in response to a compelling need to improve the disproportionate hypertension-related morbidity and mortality throughout this region. The purpose of this position paper is to summarize the data that document the problem, the consequences, and possible causative factors.

The Women's Health Trial: Feasibility Study in Minority Populations (WHT:FSMP), a randomized trial of 2208 women, was conducted to investigate three questions. First, can women from minority and low-socioeconomic-status populations be recruited in numbers sufficient to evaluate a dietary intervention designed to lower fat intake. Second, the efficacy of a low fat, increased fruit/vegetable/ grain product intervention for reducing fat consumption. Third, will participation in the intervention lower plasma cholesterol and estradiol levels relative to the controls. The baseline results showed that an adequate number of minority and low SES women could be recruited to test the study hypotheses. A diverse study population of postmenopausal women consuming a high fat diet was recruited: 28% of participants were Black, 16% were Hispanic, 11% had less than a high school level of education, and 15.5% had household incomes of < $15,000.

OBJECTIVE: To evaluate the clinical use and adverse effects of enalapril and lisinopril in elderly hypertensive subjects. DESIGN: A multi-center, retrospective, drug use evaluation survey. SETTING: Ambulatory care clinics at 14 VA and 14 academic medical centers. PATIENTS: 422 elderly (>60 years of age) patients with hypertension and no clinical evidence of congestive heart failure. INTERVENTION: At least 3 consecutive months of anti-hypertensive therapy with either enalapril or lisinopril. MEASUREMENTS: Blood pressure, serum creatinine, serum potassium, concomitant disease states, concurrent medications, and documentation of any adverse event that might be related to ACE inhibitor therapy. RESULTS: There were no significant differences in systolic and diastolic blood pressures, serum creatinine, or serum potassium between enalapril- and lisinopril-treated patients at baseline and after 3 months of therapy. Both treatments resulted in a significant reduction in diastolic blood pressure. There was no significant difference in the incidence of adverse effects between the two treatments. Significantly more patients were dosed on a twice daily regimen of enalapril than lisinopril. CONCLUSION: The data from this retrospective study confirm the safe and effective use of enalapril and lisinopril, two long-acting ACE inhibitors, in elderly hypertensive patients.

In an ancillary study of the Systolic Hypertension in the Elderly Program (SHEP), the effects of diuretics on ventricular ectopic activity were investigated in 186 patients with isolated systolic hypertension. Ventricular premature complexes (VPCs) were examined as the number of VPCs/24 hours, presence of />-1 VPC, presence of ≥10 VPCs/24 hours, and presence of VPC pairs or ventricular tachycardia. Significant changes in VPCs were rat observed either in the 92 patients randomized to chlorthalidone stepped-care (12.5 and 25 mg/day) or in the 94 placebo-treated patients (p >0.1 for all VPC definitions and both groups). Serum potassium decreased from 4.4 ± 0.5 to 4.1 ± 0.5 mEq/liter (p = 0.002) in the chlorthalidone group and did not change (4.4 ± 0.5 to 4.5 ± 0.4 mEq/liter) in the placebo group. Potassium was prescribed routinely for confirmed hypokalemia

This study investigated whether social and/or psychologic factors help to predict older dialysis patients' continued survival. A stratified (by race and sex) random sample of patients aged 60+ years was selected from the ESRD Network census of all patients in that age category residing in a single southeastern state (Georgia) and receiving chronic dialysis as of November 1987; personal interviews with patients were completed in 1988. This analysis includes 287 patients (mean age, 69 years) receiving outpatient hemodialysis for whom primary cause of renal failure and functional status data were complete. Patient tracking and vital statistics data determined that 49% of the sample survived as of October 31, 1990. Study variables included demographic, dialysis, health status, social situation, and psychologic outlook variables reported at the patients' 1988 interviews. Log rank tests showed univariate associations between patients' continued survival and race/gender, recovery time following dialysis treatments, cardiovascular co-morbidity, exercise activity score, freedom from health limitation of daily activity, functional status, leisure activity score, selfrated health status, overall life satisfaction, depression, and public religiosity. The Cox proportional hazards model was fit to the data, with continued survival from the time of the 1988 interview as the dependent variable. There was a significantly increased mortality risk for white men relative to the other race/gender groups and for patients reporting severely impaired functional status at the 1988 interview. With functional status in the model, no other social or psychologic variables were significant predictors of mortality. When patients' vital status as of October 1993 were determined, serum albumin values in the ESRD Network database were significantly related to survival of older black patients, and functional status as of the 1988 interview was significantly related to survival of both blacks and whites. This study, consistent with other research, suggests that continued monitoring of dialysis patients' functional status might help to identify patients who warrant close clinical evaluation.

purpose: This trial was designed to evaluate the efficacy and safety of three different classes of antihypertensive agents in elderly women. patients and methods: The trial had three phases: 4 to 8 weeks of placebo, 6 weeks of titration, and 16 weeks of maintenance. White women between 60 and 80 years old with sitting diastolic blood pressures (DBPs) from 95 through 114 mm Hg treated with placebo were evaluated by history, physical examination, laboratory studies, and quality-of-life interview. After double-blind randomization with low-dose atenolol, enalapril, or isradipine, the dose was increased stepwise and hydrochlorothiazide added as needed to achieve goal DBP (less than 90 mm Hg and greater than 10 mm Hg below baseline). During maintenance, patients not at goal were "stepped up" and patients with uncontrolled DBP at maximum dosage were removed from the study. The pretreatment (baseline) blood pressure of the 315 randomized participants averaged 161100 mm Hg; 92% had been treated previously for hypertension, 15% had diabetes mellitus, 11% smoked, and 38% consumed alcohol. results: For 245 patients completing the trial, the average decrease in blood pressure during treatment was 18.215.6 mm Hg. Antihypertensive efficacy was similar for the monotherapy drug regimens, with 84%, 71%, and 80% of patients receiving atenolol, enalapril, and isradipine, respectively, achieving DBP goal. Of the 70 patients who did not complete the trial, 42 left because of symptoms and 19 because of uncontrolled DBP. No important, unexpected drug-induced changes in symptoms or blood chemistries were noted. Symptom frequency differed little among the three dosage levels, becoming maximal by the second visit at the same dosage level. conclusion: All three drugs lowered DBP comparably, and none produced alarming effects. Thirteen percent of patients left the study because of symptoms.

Ventricular ectopic activity was recorded at baseline in 5.6% of the 12-lead electrocardiograms and 8.2% of the 2-minute rhythm strips of 4674 subjects with isolated systolic hypertension (systolic blood pressure 160 to 219 mm Hg, diastolic blood pressure 10 VPB on the 2-minute rhythm strip. Correlates of VPB presence on the 12-lead ECG were older-age male sex, presence of Q/QS pattern and higher heart rate. Participants with serum potassium < 3.5 mmol/L had a higher prevalence of VPB. Similarly, the number of VPB on the 2-minute rhythm strip was associated with male sex, increasing age, with lower serum potassium, history of palpitations, and presence of Q/QS patterns.

Age-related changes (e.g., decrease in plasma renin activity and total body potassium, increase in plasma catecholamines, volume depletion) need to be taken into account when selecting an antihypertensive agent for the elderly patient. A number of large scale clinical trials (e.g., Systolic Hypertension in the Elderly Program, Veterans Administration Cooperative Study, European Working Party on High Blood Pressure in the Elderly) have demonstrated that antihypertensive therapy with diuretics substantially reduced cardiovascular mortality and stroke incidence. However, since diuretics, even potassium-sparing agents, may induce hypokalemia, newer antihypertensive agents (angiotensin-converting enzyme [ACE] inhibitors and calcium antagonists) may also be appropriate as first-line monotherapy for this patient population. ACE inhibitors are effective antihypertensive agents and are associated with a lower rate of adverse effects than diuretics, beta blockers, and centrally acting agents. Nevertheless, periodic monitoring of serum potassium, creatinine levels, and renal function is advisable. An important feature of calcium antagonists is that they lower blood pressure with no negative effect on serum lipids or glucose metabolism. Typically, they have few side effects, peripheral edema being the most commonly reported. A recent double-blind randomized study comparing a new sustained release nifedipine formulation and the ACE inhibitor lisinopril found the 2 drugs equivalent in efficacy with no differences in the rate of adverse events.

Researchers disagree about the extent to which limited access to health services negatively affects health. In this study, we investigated the association of health status with access to high blood pressure medication among hypertensive respondents drawn from two random household surveys conducted in the state of Georgia during 1981 and 1983. We compared hypertensive respondents reporting difficulties in paying for medication (n = 616) with hypertensive respondents not reporting cost problems (n = 616) who were matched on race, sex, age (±3 years), and per capita family income (±$3,000). Because questions were not identical in the 1981 and 1983 surveys, we compared responses of the matched groups separately for each year in the analysis. In the 1981 comparisons, a significantly higher (P .05). In the 1983 survey, a significantly larger number of those with cost problems (57.4%) reported being in fair or poor health than those without cost problems (43.1%, P

Hypertensive patients with left ventricular hypertrophy (LVH) have increased cardiovascular morbidity and mortality. Experimental studies indicate the importance of both the alpha and beta components of the adrenergic nervous system in the development and reversal of LVH. Therefore labetalol (L), a combined alpha and beta blocker, and propranolol (P), a nonselective beta blocker, were evaluated in a randomized, double-blind study of 35 hypertensive patients with echocardiographic evidence of LVH. Following 2 weeks of placebo, L or P was titrated as needed and tolerated to maximum total daily doses of 1600 mg and 640 mg, respectively. A thiazide diuretic was added if necessary for blood pressure control. M-mode echocardiograms were performed at baseline and after 1, 3, 6 and 12 months of blood pressure control. The echocardiograms were read independently by two blinded observers for end-diastolic dimension and wall thicknesses, and left ventricular mass. Fractional shortening, cardiac output, and peripheral vascular resistance were derived using standard formulas. Both drugs reduced blood pressure significantly and comparably. Significant changes in the echocardiographic measurements were observed as early as 1 month and usually persisted throughout the study. Both drugs decreased posterior wall thickness; however, only the decrease in propranolol group achieved statistical significance. Septal wall thickness was reduced by L at 3 and 12 months. End-diastolic dimension increased significantly in the L-treated group at 3, 6, and 12 months of therapy, whereas P had no effect on this measurement. As a consequence, the calculated left ventricular mass index was reduced by P throughout the study, but remained essentially unchanged by L until the twelfth month. Neither drug adversely affected fractional shortening. Cardiac output was significantly reduced by P, but unchanged by L, despite similar effects on heart rate by both drugs. Thus, despite their similar effects on blood pressure, L and P had different effects on cardiac morphology, which may reflect varying responses to alpha-and beta-adrenergic blockade.

The National Cholesterol Education Program defines the metabolic syndrome as three or more of five abnormalities: waist circumference of40 in (102 cm) for men or35 in (88 cm) for women, triglyceride level ofor =150 mg/dL, high-density lipoprotein cholesterol of40 mg/dL in men or50 mg/dL in women, blood pressure ofor =130 oror =85 mm Hg, and fasting glucose ofor =110 mg/dL. It is related to insulin resistance, but the two terms are not synonymous. Both are associated strongly with obesity. The metabolic syndrome is important as an indicator of increased risk of cardiovascular disease (CVD) in patients with and without clinical CVD. The CVD risk of the metabolic syndrome is greater than that conferred by any single CVD risk factor. Since risk factors tend to cluster, if one component of the metabolic syndrome is present, one should assess for other risk factors. The metabolic syndrome is also predictive of new-onset type 2 diabetes. Early diagnosis provides justification for measures that can improve components of the syndrome and reduce CVD risk. The management strategy for metabolic syndrome focuses on overall CVD risk rather than single risk factors; effective therapy includes priority for weight reduction and increased physical activity. Pharmacotherapy is typically needed for control of high blood pressure, hypercoagulability, and increased levels of blood glucose and triglycerides.

A 36-year-old woman had fibrous dysplasia of the left renal artery and an aldosterone-producing adenoma of the right adrenal gland. The patient was evaluated first for secondary hypertension using a renal angiogram that showed fibrous dysplasia with stenosis of the left renal artery; angioplasty was successful. However, 1 month after angioplasty, hypertension recurred. Initially, it was thought that it had restenosed but after a negative angiography, adrenal computed tomography showed a 0.8-cm x 1-cm tumor of the right adrenal gland. The tumor was removed surgically, markedly improving her hypertension.

The Metabolic Syndrome represents a specific clustering of cardiovascular risk factors. One of several recently proposed definitions encompasses 3 or more of the following 5 abnormalities: waist circumference102 cm in men or88 cm in women, serum triglyceride levelor = 150 mg/dL, high-density lipoprotein cholesterol level40 mg/dL in men or50 mg/dL in women, blood pressure (BP)or = 130/or = 85 mm Hg and serum glucoseor = 110 mg/dL. The diagnosis of Metabolic Syndrome allows early recognition of an increased risk of cardiovascular disease. African Americans have the highest coronary heart disease mortality of any ethnic group in the United States. African-American women and Hispanic men and women have the highest prevalence of the Metabolic Syndrome. This phenomenon is attributable mainly to the disproportionate occurrence of elevated BP, obesity, and diabetes in African Americans, and the high prevalence of obesity and diabetes in Hispanics. Management of the Metabolic Syndrome consists primarily of modification or reversal of the root causes and direct therapy of the risk factors. The first strategy involves weight reduction and increased physical activity, both of which can improve all components of the syndrome. The second strategy often involves drug treatment of the individual risk factors to further improve BP, lipids, and glucose thereby decreasing the risk of cardiovascular disease. This comprehensive review is provided as part of the educational activities of the African-American Lipid and Cardiovascular Council (AALCC).

The Women's Health Trial: Feasibility Study in Minority Populations (WHT: FSMP) documented that a low-fat diet was associated with a reduced fat intake in older women of diverse ethnic backgrounds. The purpose of the current study was to examine the effect of the low-fat diet on anthropometric and biochemical variables.Randomized clinical trial in 2,208 postmenopausal women, 50 to 79 years of age.The decrease in fat intake correlated directly with a decrease in body weight (r=.22, P.001). After 6 months, the intervention group had an average weight loss of 1.8 kg. Body mass index decreased 0.7 kg/m2. Waist circumference decreased 1.8 cm. All of these changes were statistically significant, compared to changes in the control group (P.01). Changes in systolic (-3.1 mm Hg) and diastolic (-1.1 mm Hg) blood pressures (BP) occurred in the intervention group. The decrease in systolic BP reached statistical significance (P=.02), relative to the control group. Decreases in plasma glucose were small (-0.2 mmol/L) in the intervention group, although there was a trend for difference from the control group (P=.11). Decreases in serum insulin levels were small (-0.5 microIU/mL) in the intervention group, although there was, again, a trend for difference from the control group.In older White, Black, and Hispanic women, a long-term low-fat dietary intervention was accompanied by modest, but statistically significant, decreases in body weight and anthropometric indices, without any particular attempt being made to reduce calories. Changes in glucose and insulin were small. The long-term biological significance of the glucose and insulin changes is unknown.

This randomized clinical trial examined the feasibility of low-fat dietary interventions among postmenopausal women of diverse backgrounds. During 1992-1994, 2,208 women aged 50-79 years, 28% of whom were black and 16% Hispanic, enrolled at clinics in Atlanta, Georgia, Birmingham, Alabama, and Miami, Florida. Intervention/support groups met periodically with a nutritionist to reduce fat intake to 20% of energy and to make other diet modifications. At 6 months postrandomization, the intervention group reduced fat intake from 39.7% of energy at baseline to 26.4%, a reduction of 13.3% of energy, compared with 2.3% among controls. Saturated fatty acid and cholesterol intakes were reduced, but intakes of fruits and vegetables, but not grain products, increased. Similar effects were observed at 12 and 18 months. Black and non-Hispanic white women had similar levels of reduction in fat, but the decrease in Hispanic women was less. Changes did not vary significantly by education. While bias in self-reported intakes may have resulted in somewhat overestimated changes in fat intake, the reported reduction was similar to the approximately 10% of energy decrease found in most trials and suggests that large changes in fat consumption can be attained in diverse study populations and in many subgroups.

In an in-depth examination to better define the renal effects of mild hypertension, we used urinary proteins to indicate damage to the glomerulus (albumin), tubular reabsorption capability (retinol-binding protein), and turnover of tubular tissue (alanine aminopeptidase and N-acetyl-beta-D-glucosaminidase) in a group of 18 people with mild hypertension not associated with diabetes and a control group (n = 12). The participants' activity was controlled on a high normal salt diet for 3 days followed by a low salt diet for 4 days. Two distinct patterns of albumin excretion were evident in the hypertensive group: 22% had elevated, highly variable excretion patterns, and the rest had tightly grouped values below 16 mg/g creatinine, 16 micrograms/min, or 16 mg/L, with the lowest within-person biological variability given by albumin calculated as a ratio to creatinine. Albumin and NAG excretion primarily correlated with systolic blood pressure and the best correlations were given by ratios to creatinine. A marked decrease in salt excretion of 71% (to 50.8 mEq/day) resulted in significant (P.0005) decreases in systolic (13.9 mm Hg), diastolic (6.4 mm Hg), and mean arterial pressures (8.9 mm Hg) only in the group with mild hypertension. However, albumin excretion did not decrease when dietary salt content was lowered. The group with hypertension also had higher urinary excretion of lysosomal N-acetyl-beta-D-glucosaminidase (P.01), and whites in the group had a higher excretion of retinol-binding protein than did whites in the control group (P.02). Retinol-binding protein values, however, were within the normal range, indicating that the elevated albumin values were the result of changes in selectivity of the glomerulus.

Renal and electrolyte complications occur commonly in elderly patients with heart disease. Renal function declines with age. A seemingly normal serum creatinine level in the geriatric patient often represents a creatinine clearance of 60 ml/min or less. It is important to measure or estimate the creatinine clearance in an older patient with a borderline high or elevated serum creatinine level before administering renally excreted drugs. The Cockcroft and Gault formula is recommended for estimating the creatinine clearance in such patients. Impaired renal function can also predispose to drug-induced hyperkalemia in geriatric patients; the most common offending drugs are potassium chloride supplements, potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, digoxin, and nonsteroidal anti-inflammatory drugs. Elderly patients should be evaluated for renal artery stenosis if they have worsening of previously stable hypertension, new-onset hypertension, or progressive renal impairment on angiotensin-converting enzyme inhibitors. Risk factors and management guidelines for radiocontrast nephropathy in the elderly are also discussed.

As a group, elderly hypertensive individuals exhibit volume depletion, a decrease in plasma renin activity, a decrease in total body potassium, and an increase in plasma catecholamines. These factors should be considered when selecting an antihypertensive agent. Large-scale clinical trials in the el

In a prospective study, 32 hypertensive patients with echocardiographic evidence of left ventricular hypertrophy were treated with methyldopa, hydrochlorothiazide, or methyldopa and hydrochlorothiazide combined. Echocardiograms and electrocardiograms were obtained in each of the 32 patients before treatment, at the point of initial blood pressure control, and then one, three, and six months thereafter; in 27 patients these studies were also obtained after 12 and 18 months. Left ventricular end-diastolic posterior wall thickness decreased in seven patients whose blood pressure was controlled with methyldopa alone (p less than 0.01) and in 17 patients whose blood pressure was controlled with methyldopa and hydrochlorothiazide combined (p less than 0.01); in both groups, the reduction in left ventricular posterior wall thickness at end-diastole was apparent one month after blood pressure control was established (p less than 0.05). In contrast, no significant reduction in left ventricular posterior wall thickness at end-diastole was observed in eight patients who had equivalent control of blood pressure with hydrochlorothiazide alone (p = 0.34). During the 18-month follow-up period, ventricular septal thickness at end-diastole decreased in the group treated with methyldopa and hydrochlorothiazide combined (p = 0.03); whereas, ventricular septal thickness at end-diastole appeared to increase in the group treated with hydrochlorothiazide alone (p less than 0.01). These results suggest that evidence of regression of left ventricular hypertrophy may be detected as early as one month after blood pressure is controlled with methyldopa or methyldopa and hydrochlorothiazide combined; whereas, long-term control of hypertension with hydrochlorothiazide alone was not associated with evidence of regression of left ventricular hypertrophy. Although the patient number are small, these data suggest that there are differences in the long-term effects of diuretics and sympatholytic drugs on left ventricular anatomy, which may, in part, relate to divergent effects on the sympathetic nervous system.

Computer systems for clinical consulting on patient management operate on descriptions of medical expertise derived from repositories of systematized knowledge of medicine (textbooks and/or panels of experts) or from empirical situations embedded in medical records. The paper describes MARIS, a conversational system of the latter category, designed to provide relatively powerful consulting services for the management of patients in internal medicine.

The level of the "Beaumont" protein present in serum was measured by a population of 223 black and 76 Caucasian women with different exposures to oral contraceptives (OCs). No differences were found in the values in nonusers, past users, current users, or new users of OCs. The values were higher in black nonusers and users than in comparable Caucasian groups, suggesting a racial difference. A group of 55 thrombotic women were subclassified by type of thrombosis and exposure to OC therapy. No significant difference was seen between the values in thrombotic women exposed or not exposed to OCs. A similar result was obtained when the types of thrombosis (arterial or venous) were compared. These results do not confirm Beaumont's hypothesis that antibodies are induced by contraceptive steroids in a subgroup of women on OC therapy.

Blood pressure and body weight were carefully measured in 119 young black women before and after 6 to 24 months of contraceptive therapy with oral progestational agents (minipills). Results are compared with 673 women followed during continued use of nonhormonal contraceptive methods. Minipill therapy (0.35 mg of norethisterone) was associated with no significant (p > 0.05) increase in either systolic or diastolic blood pressure means. Minipill users did not develop diastolic blood pressures of 90 mm Hg or more during the study period. Substantial weight gain occurred as a side effect.

Isolated systolic hypertension is a prevalent condition among elderly U.S. residents of all age, sex, and race groups. In a population-based survey conducted on 4,672 adult residents of Georgia in 1981, prevalence rates were considerably below those noted in earlier surveys, such as Baldwin County, Georgia (1962), National Health Examination Series I (1960-1962), Evans County, Georgia (1967-1969), National Health and Nutrition Examination Survey I (1971-1974) and/or II (1976-1980). The lower 1981 prevalence of isolated systolic hypertension in Georgia was observed in association with a much greater likelihood of anti-hypertensive therapy in adult and elderly patients. The overall trend for early and more aggressive therapy of diastolic hypertension might account for less arterial rigidity and occurrence of isolated systolic hypertension in later life.

Reductions in left ventricular (LV) mass have been reported after antihypertensive therapy with certain sympatholytic agents and converting enzyme inhibitors, but little or no improvement has been noted after vasodilator therapy. In this study we evaluated the effect of the calcium channel blocker nitrendipine on echocardiographic LV mass. During a 12-month period, nitrendipine was used as monotherapy in 30 patients and in combination with propranolol or a diuretic in an additional 28 patients. Nitrendipine monotherapy lowered supine blood pressure from 148/97 to 136/83 mm Hg, but LV mass did not change significantly. Supine blood pressure decreased from 155/103 to 134/86 mm Hg in patients receiving combination therapy but, again, changes in LV mass were not significant. These data suggest that nitrendipine is effective in lowering blood pressure, but this is not associated with a significant decrease in LV mass in patients with mild hypertension. Clinical Pharmacology and Therapeutics (1986) 40, 679–685; doi:10.1038/clpt.1986.244

SummaryHypertension is a common problem with advancing age, approaching or exceeding a 50% prevalence in the aging population. When blood pressure consistently exceeds 140/90 mm Hg, it should be treated. Patients with borderline isolated systolic hypertension should have their blood pressure measured at 6 month intervals. Risk of isolated systolic hypertension is sufficient to justify cautiously administering drug therapy if nonpharmacologic therapy fails to bring the systolic pressure

The purpose of this research was to evaluate the effectiveness of hypertension (HBP) education within a population of sixth grade students (n = 1204) and their parents (n = 1446). The "3Rs and HBP" curriculum attempts to diffuse the HBP information from teachers, to pupils and then to parents using the sixth grade son/daughter as a "health messenger." This curriculum was tested with and without a home blood pressure measurement component versus controls in 21 schools randomly assigned to the three conditions. Postintervention data were collected from students at school and from their parents at home interviews. Students were compared for knowledge, blood pressure measurement skill, and home diffusion activities. Parents were compared for knowledge, risk factor reduction, blood pressure, care-seeking, and compliance behaviors. Student self-esteem and family interactions were investigated as possible intervening variables in the diffusion process. Student knowledge, BP measurement skills, and diffusion to parents was increased by the 3Rs and HBP curriculum with the home component. Parental effects beyond the diffusion process were limited to knowledge improvement in certain groups. Family interaction (level and style) was found to be a significant intervening variable in the diffusion process.

Data concerning ethinylestradiol (EE) blood levels among 93 healthy women using oral contraceptives are presented. Seventy-two per cent of the observed variation in EE blood levels was unexplainable on the basis of time since ingestion of the last oral contraceptive, day of menstrual cycle, race, age, weight, height, blood pressure, cigarette consumption, alcohol consumption, diurnal variation, or lifetime use of oral contraceptives.This 2-fold investigation studied 1) the extent to which women vary in blood levels of ethinylestradiol (EE) after ingesting oral contraceptives (OCs) containing similar amounts of EE or mestranol (ME), which is metabolized to EE; and 2) whatever variations might be accountable on the basis of physical, behavioral, or other characteristics. 93 healthy OC users were given either OCs with 50 mcg of ME (84 subjects) of 50 mcg of EE (9 subjects). Linear regression was used to determine relevance of variation in EE blood levels based on hours since pill ingestion, day of menstrual cycle, or any other variables. Hours since OC showed the strongest relationship to log EE, accounting for 25% of the variation. Another 3% could be accounted for by day of menstrual cycle. The remaining 72% of observed variation in EE levels could not be explained in terms of time since ingestion of last OC, day of menstrual cycle, race, age, weight, height, or use-duration of OCs.

The effect of enalapril, an antihypertensive inhibitor of angiotensin-converting enzyme, on plasma catecholamine levels and plasma volume (PV) has not been well established. In a randomized, double-blind study, 29 subjects (28 blacks and one white) received one of the following dosing regimens: hydrochlorothiazide (HCTZ), 25 mg twice a day (group 1; n = 12); enalapril, 10 mg twice a day (group 2; n = 12); or enalapril, 10 mg twice a day, with HCTZ, 25 mg twice a day (group 3; n = 5). Dosages were doubled after 4 wk if diastolic blood pressure was ≥90 mm Hg. After 8 wk of therapy, supine blood pressure decreased by 24.1/16.0 mm Hg (systolic/diastolic) in group 1, by 10.8/4.0 mm Hg in group 2, and by 48.0/27.8 mm Hg in group 3. Mean values of supine plasma levels of norepinephrine, epinephrine, and dopamine did not change with therapy. PV fell 7.9% in group 1, 1.3% in group 2, and 5.0% in group 3. There were no correlations between changes in PV and blood pressure, but a decrease in PV correlated with an increase in plasma norepinephrine levels in the group treated with HCTZ alone (r = −0.65) and in all 29 subjects combined (r = −0.45). Enalapril alone was not very effective in lowering blood pressure in these subjects, but the combination of enalapril with HCTZ was very effective. There was no evidence of a direct effect of enalapril on the sympathetic nervous system or on PV. Clinical Pharmacology and Therapeutics (1984) 36, 731–737; doi:10.1038/clpt.1984.250

One hundred fifty children with impetigo were studied over a two-year period. Group A β-hemolytic streptococci were isolated from the skin lesions of the majority (75%) of patients. The streptococcal pyoderma strains were further classified by agglutination reactions with T-antisera, the most frequent patterns being 25/Imp.19, T-12, and 3/B3264. No predominant staphylococcal pyoderma strains were noted by phage typing. Treatment with cleansing and local application of antibiotics were effective in healing the lesions within one to three weeks. Follow-up clinical examination and urinalyses revealed one patient who developed significant hematuria of acute glomerulonephritis, an attack rate of approximately 1%.