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Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indication is managed in parallel with the blood pressure 2 Conditions for which clinical trials demonstrate benefit of specific classes of antihypertensive drugs AASK, African American Study of Kidney Disease and Hypertension; ACC/AHA, American College of Cardiology/American Heart Association; ACE, angiotensin converting enzyme; AIRE, Acute Infarction Ramipril Efficacy; ALLHAT, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; ANBP2, Second Australian National Blood Pressure Study; ARB, angiotensin receptor blocker; BHAT, -Blocker Heart Attack Trial; CCB, calcium channel blocker; CIBIS, Cardiac Insufficiency Bisoprolol Study; CONVINCE, Controlled Onset Verapamil Investigation of Cardiovascular End Points; COPERNICUS, Carvedilol Prospective Randomized Cumulative Survival Study; EPHESUS, Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study; HOPE, Heart Outcomes Prevention Evaluation Study; IDNT, Irbesartan Diabetic Nephropathy Trial; LIFE, Losartan Intervention For Endpoint Reduction in Hypertension Study; MERIT-HF, Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure; NKF-ADA, National Kidney Foundation American Diabetes Association; PROGRESS, Perindopril Protection Against Recurrent Stroke Study; RALES, Randomized Aldactone Evaluation Study; REIN, Ramipril Efficacy in Nephropathy Study; RENAAL, Reduction of Endpoints in Non-Insulin-Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan Study; SAVE, Survival and Ventricular Enlargement Study; SOLVD, Studies of Left Ventricular Dysfunction; TRACE, Trandolapril Cardiac Evaluation Study; UKPDS, United Kingdom Prospective Diabetes Study; ValHEFT, Valsartan Heart Failure Trial 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

modifications (Table 11 3) and be monitored without receiving an absolute diagnosis of prehypertension A risk calculation tool can be downloaded from http://www bhsocorg/ Cardiovascular_ Risk_Charts_and_Calculatorshtm (in using this tool, convert serum cholesterol from mg/dL to mmol/L by dividing by 387) A free PDA-based coronary heart disease risk calculator is available at http://wwwstatcodercom/ cholesterolhtm In general, 20% total cardiovascular risk (which includes stroke) is equivalent to 15% coronary heart disease risk

Treatment should ideally be offered to all persons in whom blood pressure reduction, irrespective of initial blood pressure levels, will reduce overall cardiovascular risk (see above) Blood pressure targets for hypertensive patients at the greatest risk for cardiovascular events, particularly patients with diabetes and those with chronic kidney disease, should be lower (< 130/80 mm Hg) than for individuals at lower total cardiovascular risk (< 140/90 mm Hg) However, since there does not seem to be a blood pressure

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level below which risk plateaus, these recommendations should be taken as reasonable goals pending further information on optimal targets, which may be even lower On the other hand, lower may not always be better The association between cognitive decline and lower blood pressure in the elderly has led to the proposal that hypertension in mid-life gives rise to cerebrovascular small vessel disease that predisposes to hypoperfusion of subcortical white matter and cognitive decline later in life Several studies in older persons with predominantly systolic hypertension have confirmed that antihypertensive therapy prevents fatal and nonfatal myocardial infarction and overall cardiovascular mortality These trials have also placed the focus on control of systolic blood pressure in contrast to the historical emphasis on diastolic blood pressures There is no clear consensus on blood pressure goals in the management of prehypertension, but pressure should still be treated until it is < 130/80 mm Hg in prehypertensive patients with diabetes or chronic kidney disease and perhaps also in those at high risk for a cardiovascular event Large-scale trials in hypertension have focused on discrete end points occurring over relatively short intervals,

Thresholds for intervention Initial blood pressure (mm Hg)

> 180/110

160 179 100 109

FIGURE 4-3

140 159 90 99

130 139 85 89

< 130/85

If cardiovascular complications, target organ damage, or diabetes is present, confirm over 3 4 weeks then treat; if absent, re-measure weekly and treat if blood pressure persists at these levels over 4 12 weeks

If cardiovascular complications, target organ damage or diabetes is present, confirm over 12 weeks then treat; if absent, re-measure monthly and treat if these levels are maintained and if estimated 10-year CVD risk is 20%

160/100

140 159 90 99

4:

< 140/90

Target organ damage or cardiovascular complications or diabetes or 10-year CVD riska 20%

No target organ damage and no cardiovascular complications and no diabetes and 10-year CVD riska < 20%

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