A 12-week randomized, double-blind, four-arm parallel-group, comparative study was conducted in patients with essential hypertension to evaluate the antihypertensive effect and safety of combination therapy with olmesartan medoxomil (OLM, an angiotensin-receptor blocker) 20 mg plus azelnidipine (AZL, a long-acting dihydropyridine calcium channel blocker (20) and AZL (16) monotherapy groups (À12.1/À6.9 and À12.0/À6.9 mm Hg). The proportion of patients achieving the SeBP goal (o130/85 mm Hg for normal BP or o140/90 mm Hg for high-normal BP) was significantly higher in the O/A (20/16) combination group than in the monotherapy groups. The incidence of adverse events was similar in the O/A combination groups and the monotherapy groups. These results showed that combination therapy with O/A was well tolerated and exerted a stronger antihypertensive effect compared with monotherapy with OLM or AZL in patients with essential hypertension.

Background The effects of pharmacological blood pressure lowering at normal or high-normal blood pressure ranges in people with or without pre-existing cardiovascular disease remains uncertain. We analysed individual participant data from randomised trials to investigate the effects of blood pressure lowering treatment on the risk of major cardiovascular events by baseline levels of systolic blood pressure. MethodsWe did a meta-analysis of individual participant-level data from 48 randomised trials of pharmacological blood pressure lowering medications versus placebo or other classes of blood pressure-lowering medications, or between more versus less intensive treatment regimens, which had at least 1000 persons-years of follow-up in each group. Trials exclusively done with participants with heart failure or short-term interventions in participants with acute myocardial infarction or other acute settings were excluded. Data from 51 studies published between 1972 and 2013 were obtained by the Blood Pressure Lowering Treatment Trialists' Collaboration (Oxford University, Oxford, UK). We pooled the data to investigate the stratified effects of blood pressure-lowering treatment in participants with and without prevalent cardiovascular disease (ie, any reports of stroke, myocardial infarction, or ischaemic heart disease before randomisation), overall and across seven systolic blood pressure categories (ranging from <120 to ≥170 mm Hg). The primary outcome was a major cardiovascular event (defined as a composite of fatal and non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring admission to hospital), analysed as per intention to treat.Findings Data for 344 716 participants from 48 randomised clinical trials were available for this analysis. Pre-randomisation mean systolic/diastolic blood pressures were 146/84 mm Hg in participants with previous cardiovascular disease (n=157 728) and 157/89 mm Hg in participants without previous cardiovascular disease (n=186 988). There was substantial spread in participants' blood pressure at baseline, with 31 239 (19•8%) of participants with previous cardiovascular disease and 14 928 (8•0%) of individuals without previous cardiovascular disease having a systolic blood pressure of less than 130 mm Hg. The relative effects of blood pressure-lowering treatment were proportional to the intensity of systolic blood pressure reduction. After a median 4•15 years' follow-up (Q1-Q3 2•97-4•96), 42 324 participants (12•3%) had at least one major cardiovascular event. In participants without previous cardiovascular disease at baseline, the incidence rate for developing a major cardiovascular event per 1000 person-years was 31•9 (95% CI 31•3-32•5) in the comparator group and 25•9 (25•4-26•4) in the intervention group. In participants with previous cardiovascular disease at baseline, the corresponding rates were 39•7 (95% CI 39•0-40•5) and 36•0 (95% CI 35•3-36•7), in the comparator and intervention groups, respectively. Haz...

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Background The effects of pharmacological blood-pressure-lowering on cardiovascular outcomes in individuals aged 70 years and older, particularly when blood pressure is not substantially increased, is uncertain. We compared the effects of blood-pressure-lowering treatment on the risk of major cardiovascular events in groups of patients stratified by age and blood pressure at baseline. MethodsWe did a meta-analysis using individual participant-level data from randomised controlled trials of pharmacological blood-pressure-lowering versus placebo or other classes of blood-pressure-lowering medications, or between more versus less intensive treatment strategies, which had at least 1000 persons-years of follow-up in each treatment group. Participants with previous history of heart failure were excluded. Data were obtained from the Blood Pressure Lowering Treatment Triallists' Collaboration. We pooled the data and categorised participants into baseline age groups (<55 years, 55-64 years, 65-74 years, 75-84 years, and ≥85 years) and blood pressure categories (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg systolic blood pressure and from <70 mm Hg to ≥110 mm Hg diastolic). We used a fixed effects one-stage approach and applied Cox proportional hazard models, stratified by trial, to analyse the data. The primary outcome was defined as either a composite of fatal or non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring hospital admission. FindingsWe included data from 358 707 participants from 51 randomised clinical trials. The age of participants at randomisation ranged from 21 years to 105 years (median 65 years [IQR 59-75]), with 42 960 (12•0%) participants younger than 55 years, 128 437 (35•8%) aged 55-64 years, 128 506 (35•8%) 65-74 years, 54 016 (15•1%) 75-84 years, and 4788 (1•3%) 85 years and older. The hazard ratios for the risk of major cardiovascular events per 5 mm Hg reduction in systolic blood pressure for each age group were 0•82 (95% CI 0•76-0•88) in individuals younger than 55 years, 0•91 (0•88-0•95) in those aged 55-64 years, 0•91 (0•88-0•95) in those aged 65-74 years, 0•91 (0•87-0•96) in those aged 75-84 years, and 0•99 (0•87-1•12) in those aged 85 years and older (adjusted p interaction =0•050). Similar patterns of proportional risk reductions were observed for a 3 mm Hg reduction in diastolic blood pressure. Absolute risk reductions for major cardiovascular events varied by age and were larger in older groups (adjusted p interaction =0•024). We did not find evidence for any clinically meaningful heterogeneity of relative treatment effects across different baseline blood pressure categories in any age group.Interpretation Pharmacological blood pressure reduction is effective into old age, with no evidence that relative risk reductions for prevention of major cardiovascular events vary by systolic or diastolic blood pressure levels at randomisation, down to less than 120/70 mm Hg. Pharmacological blood pressure reduction ...

Although morning surge in blood pressure has been shown to be associated with the occurrence of myocardial ischemic events and stroke, few studies have been done regarding its pathogenesis, probably because of a lack of method for the quantitative assessment of awakening time. We conducted an echocardiographic study and ambulatory blood pressure monitoring in 23 elderly hypertensive patients to evaluate the relationship between the hypertensive cardiac change and morning surge in blood pressure. Of note was that the time of arising from bed was assessed quantitatively by an activetracer equipped with an internal acceleration sensor to monitor the physical activity. The change in systolic blood pressure after arising from bed was correlated significantly with the left ventricular mass index (r = 0.51, P < .02) and the A/E ratio, which represents the diastolic function (r = 0.70, P < .01). In contrast, the change in systolic blood pressure before rising from bed was not correlated with any echocardiographic parameters. We conclude that the magnitude of morning surge in blood pressure after arising from bed was related with the severity of hypertensive target organ damage.

To evaluate the morphological and functional characteristics of the heart in elderly patients with white coat hypertension, we performed an echocardiographic study in 67 elderly individuals older than 60 years: 17 patients with white coat hypertension, 34 patients with true hypertension, and 16 normotensive control subjects. White coat hypertension was defined as a mean 24-hour ambulatory systolic blood pressure of less than 140 mm Hg associated with office hypertension. Cardiac responses to an isometric handgrip exercise test were used to evaluate left ventricular functional reserve. Left atrial dimension and left ventricular mass index were significantly greater in the white coat hypertension group than in the normotension group (P<.05) but were similar to values in the true hypertension group. Left ventricular diastolic function, expressed by peak late-early filling ratio of diastolic mitral flow, showed increasing impairment in the order of the normotension, white coat hypertension, and true hypertension groups (analysis of variance, /*<.O5); the ratio in the white coat hypertension group tended to be higher than that in the normotension group (unpaired I test, P=.O54). The relation between fractional shortening and end-systolic stress did not shift downward after handgrip exercise in the white coat hypertension group, indicating that functional reserve in the left ventricle was maintained. Thus, patients with white coat hypertension had a moderately increased left atrial dimension and left ventricular mass in association with a tendency for disturbed diastolic function, although systolic functional reserve remained the same. These findings suggest that white coat hypertension in the elderly may not be innocent (Hypertension. 1993^2:826-831 have been studied by many investigators. For the clinician, perhaps one of the most important applications of ambulatory recording techniques is the detection of white coat hypertension, which can be defined as an elevated clinic BP in association with a normal 24-hour or daytime ambulatory BP. The prevalence of white coat hypertension has been reported to range from 21% to 56% among hypertensive patients depending on the cutoff point used.'-4 Despite the wide prevalence and important clinical implications of white coat hypertension, only a few studies are available with respect to the prognosis or severity of target-organ damage in such patients. Accordingly, it remains unclear whether or not white coat hypertension should be treated like sustained hypertension.Recent reports 56 indicate that white coat hypertension is common not only in the younger population but Received January 5, 1993; accepted in revised form July 26, 1993.From the Division of Cardiology, Tokyo (Japan) Metropolitan Geriatric Hospital.Correspondence to Iwao Kuwajima, MD, Division of Cardiology, Tokyo Metropolitan Geriatric Hospital, 35-2, Sakaecho, Itabashi-ku, Tokyo 173, Japan. also among the elderly. A high prevalence in the elderly is understandable because of the high variability of BP in that ...

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By studying 3,408 consecutive autopsied elderly patients, we found that two thirds of the 132 massive cerebral infarctions (86) were embolic, of cardiac origin. Embolic infarction associated with nonvalvular atrial fibrillation was seen in 48 cases (36%), half due to the first stroke. Embolic infarction associated with heart diseases other than nonvalvular atrial fibrillation was seen in 23 cases (17%), and that from nonbacterial thrombotic endocarditis was seen in 15 cases (11%). Thrombotic infarction or infarction of nonembolic cardiac origin was found in only 39 cases (30%). Of 56 patients with fatal massive cerebral infarction who died <2 weeks after their stroke, 25 (45%) had embolic strokes associated with nonvalvular atrial fibrillation. Our study shows that nonvalvular atrial fibrillation is a very important cause of fatal massive cerebral infarction in the elderly. (Stroke 1989;20:1653-1656