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The decision to initiate drug therapy is relatively straightforward once hypertension has been unequivocally diagnosed (Table 11 1 and Figure 11 1), but less clear in persons with prehypertension (blood pressure of 120 139/80 89 mm Hg) Some experts have suggested that early blood pressure elevation, and perhaps antecedent metabolic abnormalities, lead to vascular damage that propels further blood pressure elevation in an ever accelerating spiral of progression If so, then interception early in the course might modify the natural history of the disease, leading to diminished requirements for multiple antihypertensive agents and, perhaps, a much more dramatic effect on cardiovascular risk than can be attained with initiation of treatment once hypertension is established In beginning to address this question, the TROPHY study showed that treatment of prehypertension in a population at no particular risk for cardiovascular events only seemed to delay the onset of hypertension, since blood pressure in the treated group increased toward the placebo group when treatment was discontinued The situation is a little clearer in nonhypertensive patients at elevated cardiovascular risk, in whom the HOPE and PROGRESS trials indicated improved outcomes with antihypertensive medication (ACE inhibitor and ACE inhibitor plus diuretic, respectively) These observations have prompted some to think in terms of optimizing blood pressure to a suggested 120/80 mm Hg However, the public health consequences of recommendations to treat prehypertension would be enormous Forty-eight percent of all Americans have hypertension or prehypertension, and much higher proportions fit these categories in a typical family medicine population The JNC 7 guidelines suggest that antihypertensive medications be offered to persons with prehypertension with compelling indications for treatment such as chronic kidney disease or diabetes mellitus (Table 11 4) According to the British Hypertension Society (BHS) recommendations, risk analysis should be used to target treatment to patients with borderline hypertension who are most likely to benefit, particularly individuals at high combined risk of coronary heart or stroke event (> 20 30% within 10 years) (Figure 11 2) Risk is calculated according to Framingham study criteria (calculated from several of the risk factors listed in Table 11 5) A low-risk patient with blood pressure between 120 139/80 89 mm Hg may be advised to make lifestyle.

For overall cardiovascular risk reduction, stop smoking The effects of implementing these modifications are dose and time dependent and could be higher for some individuals BMI, body mass index calculated as weight in kilograms divided by the square of height in meters; BP, blood pressure; DASH, Dietary Approaches to Stop Hypertension Source: Chobanian AV et al The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report JAMA 2003 May 21;289(19):2560 72

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risk factors should be counseled about nonpharmacologic approaches to lowering blood pressure Approaches of proved but modest value include weight reduction, reduced alcohol consumption and, in some patients, reduced salt intake Gradually increasing activity levels should be encouraged in previously sedentary patients, but strenuous exercise training programs in already active individuals may have less benefit Calcium and potassium supplements have been advocated, but their ability to lower blood pressure is limited Smoking cessation will reduce overall cardiovascular risk Overall, the effects of lifestyle modification on blood pressure are modest Although all patients should be urged to modify risk factors,

Table 11 4 Clinical trial and guideline basis for compelling indications for individual drug classes1

High-Risk Conditions with Compelling Indication2 Heart failure Recommended Drugs Diuretic -Blockers ACE Inhibitors ARB CCB Aldosterone Antagonist Clinical Trial Basis ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP2, LIFE, CONVINCE NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK PROGRESS

Post-myocardial infarction High coronary disease risk Diabetes mellitus Chronic kidney disease Recurrent stroke prevention

Sales Documents | Sales Document Header | Define Sales Document Types Select a contract document type and near the bottom of the sales document type you will see a configuration box similar to Figure 4-3, with the following settings: Price procedure condition header and item are pricing procedures, and configured as price procedures However, they do not replace the price procedure used in the contract The standard price procedure determination is used Instead, the values in these fields are used for supplemental price agreements The contract profile is discussed in detail in the next section The billing request is used for service contracts, to bill the customer for a service that was not agreed to in the original service agreement The standard SAP sales document type to perform this billing is LV, which is a debit memo request for service contracts The group reference procedure is used for master contracts to determine which data is to be copied, or proposed, into lower level contracts The referencing procedures are configured with master contracts later in this chapter

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