Cardiovascular risk factors in a cohort of 30,000 high-risk men and women in the UK: cross-sectional, retrospective and prospective studies of screenees for the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT)

Sympathetic activation in resistant hypertension: theory and therapy

Resistant hypertension defined as requiring 3 or more complementary antihypertensive drugs at maximally tolerated doses accounts for approximately 3% to 4% of all cases of hypertension. Its increased incidence over the past decade is related to the increase in obesity in the Western world. There are a number of dietary factors that affect sympathetic tone including sodium intake apart from increased body mass. This article discusses the mechanisms of sympathetic stimulation and activation in the context of animal models and human studies. In addition, there is a review of clinical trials with and without device therapy that summarizes the clinical findings. Effective management should be based on pathophysiologic principles and a focus on blood pressure reduction to levels well below 150/90 mm Hg because outcome trial evidence and Food and Drug Administration guidance supports this construct. The key to success of device-based therapy depends on identifying the cohort with true resistant hypertension that can benefit from therapies that are adjuncts to pharmacotherapy. Physicians need to concentrate on educating the patient on lifestyle modifications and themselves on use of proper combinations of antihypertensive medications. If this approach fails to result in a safe level of blood pressure then the patient should be referred to a board-certified clinical hypertension specialist.

ACE inhibitors and target organ protection

Lowering the risk of cardiovascular disease (CVD) involves more than treatment of individual risk factors such as hypertension, diabetes, and chronic kidney disease. In this article, Drs Toto, Rinner, and Ram present an evidence-based approach to reducing CVD risk and suggest that optimal treatment with angiotensin-converting enzyme (ACE) inhibitors should be extended to a larger proportion of at-risk patients and in particular to those not previously considered candidates for use of these agents.