Background Whether the treatment of patients with hypertension who are 80 years of age or older is beneficial is unclear. It has been suggested that antihypertensive therapy may reduce the risk of stroke, despite possibly increasing the risk of death. Methods We randomly assigned 3845 patients from Europe, China, Australasia, and Tunisia who were 80 years of age or older and had a sustained systolic blood pressure of 160 mm Hg or more to receive either the diuretic indapamide (sustained release, 1.5 mg) or matching placebo. The angiotensin-converting-enzyme inhibitor perindopril (2 or 4 mg), or matching placebo, was added if necessary to achieve the target blood pressure of 150/80 mm Hg. The primary end point was fatal or nonfatal stroke. Results The active-treatment group (1933 patients) and the placebo group (1912 patients) were well matched (mean age, 83.6 years; mean blood pressure while sitting, 173.0/90.8 mm Hg); 11.8% had a history of cardiovascular disease. Median follow-up was 1.8 years. At 2 years, the mean blood pressure while sitting was 15.0/6.1 mm Hg lower in the active-treatment group than in the placebo group. In an intention-totreat analysis, active treatment was associated with a 30% reduction in the rate of fatal or nonfatal stroke (95% confidence interval [CI], −1 to 51; P = 0.06), a 39% reduction in the rate of death from stroke (95% CI, 1 to 62; P = 0.05), a 21% reduction in the rate of death from any cause (95% CI, 4 to 35; P = 0.02), a 23% reduction in the rate of death from cardiovascular causes (95% CI, −1 to 40; P = 0.06), and a 64% reduction in the rate of heart failure (95% CI, 42 to 78; P<0.001). Fewer serious adverse events were reported in the active-treatment group (358, vs. 448 in the placebo group; P = 0.001). Conclusions The results provide evidence that antihypertensive treatment with indapamide (sustained release), with or without perindopril, in persons 80 years of age or older is beneficial.

In this population-based cohort, systolic blood pressure, but not diastolic pressure, changes over time aligned with change in sodium excretion, but this association did not translate into a higher risk of hypertension or CVD complications. Lower sodium excretion was associated with higher CVD mortality.

Abstract-In previous studies, of which several were underpowered, the relation between cardiovascular outcome and blood pressure (BP) variability was inconsistent. We followed health outcomes in 8938 subjects (mean age: 53.0 years; 46.8% women) randomly recruited from 11 populations. At baseline, we assessed BP variability from the SD and average real variability in 24-hour ambulatory BP recordings. We computed standardized hazard ratios (HRs) while stratifying by cohort and adjusting for 24-hour BP and other risk factors. Over 11.3 years (median), 1242 deaths (487 cardiovascular) occurred, and 1049, 577, 421, and 457 participants experienced a fatal or nonfatal cardiovascular, cardiac, or coronary event or a stroke.Higher diastolic average real variability in 24-hour ambulatory BP recordings predicted (PՅ0.03) total (HR: 1.14) and cardiovascular (HR: 1.21) mortality and all types of fatal combined with nonfatal end points (HR: Ն1.07) with the exception of cardiac and coronary events (HR: Յ1.02; PՆ0.58). Higher systolic average real variability in 24-hour ambulatory BP recordings predicted (PϽ0.05) total (HR: 1.11) and cardiovascular (HR: 1.16) mortality and all fatal combined with nonfatal end points (HR: Ն1.07), with the exception of cardiac and coronary events (HR: Յ1.03; PՆ0.54). SD predicted only total and cardiovascular mortality. While accounting for the 24-hour BP level, average real variability in 24-hour ambulatory BP recordings added Ͻ1% to the prediction of a cardiovascular event. Sensitivity analyses considering ethnicity, sex, age, previous cardiovascular disease, antihypertensive treatment, number of BP readings per recording, or the night:day BP ratio were confirmatory. In conclusion, in a large population cohort, which provided sufficient statistical power, BP variability assessed from 24-hour ambulatory recordings did not contribute much to risk stratification over and beyond 24-hour BP. (Hypertension. 2010;55:1049-1057.)Key Words: blood pressure variability Ⅲ ambulatory blood pressure Ⅲ population science Ⅲ risk factors Ⅲ epidemiology A mbulatory blood pressure monitoring not only provides information on the blood pressure level but on the diurnal changes in blood pressure as well. Blood pressure variability includes both short-term and circadian components, which can be estimated by the SD of the blood pressure values over a defined period of the day or by the night:day blood pressure ratio, respectively. We recently reported in Ͼ7000 subjects recruited from 6 populations on the prognos- Although the aforementioned analyses shed light on the association between outcome and long-term blood pressure variability, the predictive value of short-term reading-toreading blood pressure variability remains uncertain. Possible limitations of previous studies were a lack of statistical power, 2-5 selection of specific groups of patients, 5-7 categorization of variability by arbitrary cutoff points, 2,4,7-9 and sole reliance on fatal end points. 10,11 Moreover, various parameters can capture short-term b...

INH predicts cardiovascular outcome in patients who are normotensive on office or on ambulatory daytime BP measurement.

Abstract-Previous studies on the prognostic significance of the morning blood pressure surge (MS) produced inconsistent results. Using the International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcome, we analyzed 5645 subjects (mean age: 53.0 years; 54.0% women) randomly recruited in 8 countries. The sleep-through and the preawakening MS were the differences in the morning blood pressure with the lowest nighttime blood pressure and the preawakening blood pressure, respectively. We computed multivariable-adjusted hazard ratios comparing the risk in ethnic-and sex-specific deciles of the MS relative to the average risk in the whole study population. During follow-up (median: 11.4 years), 785 deaths and 611 fatal and nonfatal cardiovascular events occurred. While accounting for covariables and the night:day ratio of systolic pressure, the hazard ratio of all-cause mortality was 1. Key Words: ambulatory blood pressure Ⅲ blood pressure measurement Ⅲ morning surge Ⅲ epidemiology Ⅲ population science S everal studies showed that the incidence of cardiovascular complications peaks in the morning. 1,2 For instance, in the Multicenter Investigation of Limitation of Infarct Size Study 1 and in the Thrombolysis in Myocardial Infarction Phase II Trial, 2 the incidence of myocardial infarction was highest between 6:00 AM and 12:00 AM. Blood pressure also follows a circadian pattern, generally characterized by a fall during sleep and a sharp rise on awakening. 3 This observation gave rise to the hypothesis that an exaggerated morning surge of blood pressure might predict cardiovascular outcome. However, previous studies of populations 4 and hypertensive patients 5-7 produced contradictory results, possibly because of the small number of events and the lack of statistical power. A further issue complicating the interpretation of previous studies is the varying definitions of the morning surge in blood pressure. 8Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.

The international database of ambulatory blood pressure in relation to cardiovascular outcome will provide a shared resource to investigate risk stratification by ambulatory blood pressure monitoring to an extent not possible in any earlier individual study.

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Quality assurance and control should be planned at the design stage of a project involving BP measurement and implemented from its very beginnings until the end. The procedures of quality assurance set up in the EPOGH study for the BP measurements resulted in a well-defined BP phenotype, which was consistent across centres.