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Abstract-In this prospective, randomized, open-label, blinded end point study, we aimed to establish whether strict blood pressure control (Ͻ140 mm Hg) is superior to moderate blood pressure control (Ն140 mm Hg to Ͻ150 mm Hg) in reducing cardiovascular mortality and morbidity in elderly patients with isolated systolic hypertension. We divided 3260 patients aged 70 to 84 years with isolated systolic hypertension (sitting blood pressure 160 to 199 mm Hg) into 2 groups, according to strict or moderate blood pressure treatment. A composite of cardiovascular events was evaluated for Ն2 years. The strict control (1545 patients) and moderate control (1534 patients) groups were well matched (mean age: 76.1 years; mean blood pressure: 169.5/81.5 mm Hg). Median follow-up was 3.07 years. At 3 years, blood pressure reached 136.6/74.8 mm Hg and 142.0/76.5 mm Hg, respectively. The blood pressure difference between the 2 groups was 5.4/1.7 mm Hg. The overall rate of the primary composite end point was 10.6 per 1000 patient-years in the strict control group and 12.0 per 1000 patient-years in the moderate control group (hazard ratio: 0.89; [95% CI: 0.60 to 1.34]; Pϭ0.38). In summary, blood pressure targets of Ͻ140 mm Hg are safely achievable in relatively healthy patients Ն70 years of age with isolated systolic hypertension, although our trial was underpowered to definitively determine whether strict control was superior to less stringent blood pressure targets. Key Words: isolated systolic hypertension Ⅲ elderly Ⅲ blood pressure Ⅲ prognosis Ⅲ valsartan H igh blood pressure (BP) is well known to be a major risk factor for cardiovascular events, such as stroke and myocardial infarction, 1 and linear relationships between cardiovascular risk and both systolic and diastolic BPs, unrelated to age, have also been reported based on a meta-analysis of large cohort studies conducted worldwide. 2 In particular, systolic BP predominantly affects cardiovascular events in elderly people. 3 Numerous large clinical trials, such as the Systolic Hypertension in the Elderly Program, 4 Swedish Trial in Old Patients, 5 Medical Research Council, 6 Systolic Hypertension in Europe, 7 and Systolic Hypertension in China, 8 have provided evidence of the benefits of reducing BP in the elderly. Meta-analysis of clinical trials showed that treatment of hypertension in older adults is as beneficial as that in younger adults. 9 A recent study performed in hypertensive patients aged Ն80 years of age, the Hypertension in the Very Elderly Trial, showed that antihypertensive treatment is beneficial to reduce the risks of death from stroke, death from any cause, and heart failure. 10 These observations indicate that antihypertensive treatment is beneficial even in very elderly patients.To reduce cardiovascular risks, in general BP should be kept as low as possible based on evidence from numerous clinical trials and epidemiological data. 11 On the other hand, several epidemiological studies in the elderly, such as Vantaa and Leinden 85-Plus, reported a poor progno...

These findings show the difference in nocturnal fall in blood pressure between the non-sodium sensitive and sodium-sensitive types of essential hypertension. The diminished nocturnal fall, recognized in the sodium-sensitive type, is restored by sodium restriction, indicating that the circadian rhythm of blood pressure shifted from a nondipper to a dipper pattern. On the other hand, the nocturnal fall is not affected by sodium restriction in the non-sodium sensitive type, and the circadian rhythm remains of the dipper variety.

Background-Recently, we found that sodium restriction shifted the circadian rhythm of blood pressure from nondipper to dipper in patients with the sodium-sensitive essential hypertension. This study examined whether diuretics can transform the circadian rhythm of blood pressure from nondipper to dipper. Methods and Results-We studied 21 patients with essential hypertension during both a baseline period and a period of treatment with hydrochlorothiazide (25 mg daily). The periods lasted 4 weeks each. Twenty-four hour ambulatory blood pressures were measured on the same day of the week at the end of the each period. In nondippers (nϭ11), but not in dippers (nϭ10), a significant interaction existed between diuretic therapy and nocturnal fall in systolic and diastolic blood pressure, which indicated that the degree of nocturnal blood pressure fall was affected by diuretic therapy. Nocturnal fall, which was diminished in nondippers, was restored by diuretic therapy with hydrochlorothiazide, indicating that the circadian rhythm of blood pressure shifted from nondipper to dipper patterns. Conclusions-The present study demonstrated that diuretics can restore nocturnal blood pressure decline in a manner similar to sodium restriction, which suggests that the kidneys and sodium metabolism may play important roles in the genesis of the circadian rhythm of blood pressure. Diuretic-based treatment may have an additional therapeutic advantage of reducing the risk for cardiovascular complications by transforming the circadian rhythm of blood pressure.

Decreases in some HRV measures, particularly those reflecting long-term variability, are independent predictors of cardiac death in chronic haemodialysis patients.

Our results show that as renal function deteriorates in glomerulopathy the nocturnal dip in blood pressure is lost, resulting in enhanced urinary sodium and protein excretions during night. These findings are compatible with our proposal that impaired natriuresis during daytime makes nocturnal blood pressure elevated to compensate for diminished natriuresis by pressure natriuresis. We speculate that nocturnal glomerular capillary hypertension contributes, at least in part, to enhanced urinary sodium and protein excretions during night.