Comments on ALLHAT and doxazosin

This commentary has two purposes: to summarize the rationale, design and initial results of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) trial; and to provide a history of the response to ALLHAT that led to a civil action and a Citizens Petition that was the basis for a public hearing by the US Food and Drug Administration, in May 2001. The author concludes that the results of ALLHAT should be widely disseminated. All clinicians must be warned that initial therapy with doxazosin (and possibly other alpha(1) blockers) is definitely inferior to low dose diuretic treatment for patients at high risk for cardiovascular disease, such as those enrolled in ALLHAT

Guidelines, Inertia, and Judgment

There is a general agreement among healthcare providers that hypertension should be controlled, by either lifestyle improvement or antihypertensive drug treatment, for prevention of cardiovascular and renal disease. This agreement has been articulated in published guidelines and widely disseminated in other formats. Control has been defined as reduction of pressure below thresholds of 140/90 mm Hg and, for those with diabetes mellitus or chronic renal disease, 130/80 mm Hg. Population surveys in the United States estimate that control of hypertension remains suboptimal, with ≈50% continuing to have uncontrolled hypertension

Prevalence of Masked Hypertension Among US Adults With Nonelevated Clinic Blood Pressure

Masked hypertension (MHT), defined as nonelevated blood pressure (BP) in the clinic setting and elevated BP assessed by ambulatory monitoring, is associated with increased risk of target organ damage, cardiovascular disease, and mortality. Currently, no estimate of MHT prevalence exists for the general US population. After pooling data from the Masked Hypertension Study (n = 811), a cross-sectional clinical investigation of systematic differences between clinic BP and ambulatory BP (ABP) in a community sample of employed adults in the New York City metropolitan area (2005-2012), and the National Health and Nutrition Examination Survey (NHANES; 2005-2010; n = 9,316), an ongoing nationally representative US survey, we used multiple imputation to impute ABP-defined hypertension status for NHANES participants and estimate MHT prevalence among the 139 million US adults with nonelevated clinic BP, no history of overt cardiovascular disease, and no use of antihypertensive medication. The estimated US prevalence of MHT in 2005-2010 was 12.3% of the adult population (95% confidence interval: 10.0, 14.5)-approximately 17.1 million persons aged ≥21 years. Consistent with prior research, estimated MHT prevalence was higher among older persons, males, and those with prehypertension or diabetes. To our knowledge, this study provides the first estimate of US MHT prevalence-nearly 1 in 8 adults with nonelevated clinic BP-and suggests that millions of US adults may be misclassified as not having hypertension

Hypertension as a Candidate for Disease Management Initiatives: Screening and Diagnosis

Hypertension, i.e. high systemic arterial pressure, is quantitatively related to future cardiovascular and renal insufficiency. Furthermore, treatment of hypertension is beneficial. Hypertension is therefore, one of the most important cardiovascular risk factors accounting for preventable disease. For individual patients, initial diagnostic strategies for hypertension should consider: (i) the need to determine average or usual levels of systolic and diastolic pressure, sometimes by employing the supplemental methods of ambulatory blood pressure monitoring or home blood pressures; (ii) the presence or absence of non-hypertensive reversible cardiovascular risk factors, particularly smoking, elevated serum lipid levels or diabetes mellitus; (iii) the presence or absence of pathological states related to hypertension and the other risk factors affecting the heart, arteries and kidneys; and (iv) the possibility of reversible causes of elevated blood pressure (secondary hypertension). Combining assessments for these factors allows calculation of the absolute cardiovascular risk for each patient and, thus, their likelihood for benefit from various interventions, especially antihypertensive drug therapy. As hypertension is a chronic disorder, comprehensive assessment includes provisions for sustained observation, reassessment and adjustment of both diagnostic and therapeutic approaches. Optimal care of patients with hypertension represents the merging of older concepts of preventive medicine with recently recognised and emerging strategies for ongoing appraisal and intervention.Reviews-on-disease, Hypertension, White-coat-hypertension, Blood-pressure-monitoring, Secondary-hypertension, Pharmacoeconomics, Practice-guideline-commentary