blood pressure

Blood Pressure Monitoring

measurements

accuracy

MeSH

Diagnosis and Management of Resistant Hypertension: A Review

RPR Commentary: Proper measurement technique is essential for accurate BP determination. James W. Mold, MD, MPH

Free full text

View

Do recommended blood pressure (BP) measurement techniques impact the accuracy of readings?

Cuff size, arm position, bladder distention, and leg crossing affect systolic BP (SBP) and diastolic BP (DBP) measurement accuracy (1 mm Hg lower to 20 mm Hg higher). Thin clothing does not impact readings. A 5-minute rest before measurement may give more accurate readings if SBP is 140 mm Hg or higher. Hypertension Canada recommendations are reasonable.

Author/s:

Tony Nickonchuk, Adrienne J. Lindblad, Danielle Perry, Scott Garrison

Diagnosis and Management of Resistant Hypertension: A Review

Megan George — Wed, 29 Apr 2026 21:23:10 +0000

Date Added:

April 29, 2026

Journal/Publication:

JAMA

Publication Date:

March 23, 2026

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2026.1221

Keywords

drug therapy

Drug Resistance

Antihypertensive Agents

Antihypertensive Agents* / therapeutic use

PMID (1):

41870448

MeSH

Blood Pressure Monitoring

Ambulatory

drug resistance, bacterial

drug therapy

Combination

Hypertension* / complications

female

male

Humans

Hypertension* / drug therapy

Hypertension* / epidemiology

Hypertension* / therapy

Recommendations for the diagnosis and management of patients with resistant hypertension. James W. Mold, MD, MPH

View

Importance: Hypertension, defined as office systolic blood pressure (SBP) 130 mm Hg or greater and/or diastolic blood pressure 80 mm Hg or greater, affects 43.9% of women and 49.5% of men in the US. Approximately 19.7% of patients treated for hypertension have apparent resistant hypertension (blood pressure ≥130/80 mm Hg) despite using 3 or more antihypertensive medications, preferably a renin-angiotensin system blocker, a calcium channel blocker, and a thiazide-type diuretic, at maximally tolerated doses.

Observations: Approximately 10% of patients treated for hypertension have true resistant hypertension confirmed with home or 24-hour ambulatory blood pressure monitoring to exclude white-coat hypertension (approximately 37.5% of apparent resistant hypertension) and after excluding medication nonadherence (approximately 50%) and secondary hypertension such as primary aldosteronism (approximately 5%-25%). Conditions associated with resistant hypertension include obesity, diabetes, chronic kidney disease, and sleep apnea. Resistant hypertension is associated with increased risk of cardiovascular death vs controlled blood pressure at 5 years to 10 years (absolute risk increase, 10.3% [95% CI, 8.7%-12.1%]). Lifestyle modifications for resistant hypertension include a low-sodium diet (<1500 mg/d), reducing or avoiding alcohol, 150 min/wk or more of aerobic exercise, and weight loss. Illicit drugs (eg, cocaine) and medications that increase blood pressure (eg, nonsteroid anti-inflammatory drugs, serotonin-norepinephrine reuptake inhibitors) should be avoided. Sleep apnea should be treated when diagnosis is confirmed. Pharmacologic optimization includes use of combination tablets of antihypertensives; intensifying diuretic therapy by using chlorthalidone; and sequential addition of antihypertensive medications using evidence-based algorithms. In a meta-analysis of 20 studies (9 randomized clinical trials [RCTs] and 11 observational studies [331 participants]), use of antihypertensive therapies that combine 2 to 3 medications into a single formulation reduced SBP by -3.99 mm Hg (95% CI, -7.92 to -0.07) vs equivalent doses given separately. For patients with apparent or true resistant hypertension who have an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater and a serum potassium level of 4.5 mmol/L or less, adding spironolactone (25-50 mg/d) compared with placebo lowers office SBP by -13.3 mm Hg (95% CI, -17.89 to -8.72 [4 RCTs]) and 24-hour ambulatory SBP by -8.46 mm Hg (95% CI, -12.54 to -4.38 [2 RCTs]) in a network meta-analysis of 24 RCTs (3485 patients with resistant hypertension). A meta-analysis of 10 RCTs (2478 participants) reported that compared with a sham procedure, catheter-based renal denervation, which disrupts the sympathetic nerves in the renal artery walls, decreased 24-hour ambulatory SBP by -4.4 mm Hg (95% CI, -6.1 to -2.7) and office SBP by -6.6 mm Hg (95% CI, -9.7 to -3.6).

Conclusions and relevance: True resistant hypertension affects 10% of patients treated for hypertension and is diagnosed after excluding white-coat hypertension, medication nonadherence, and secondary hypertension such as primary aldosteronism. First-line treatment includes lifestyle modifications, diuretic therapy with chlorthalidone, and combination tablets of antihypertensives. Spironolactone and renal denervation decrease blood pressure in patients with true resistant hypertension.

Author/s:

Michel Azizi, Wanpen Vongpatanasin, Naomi D. L. Fisher

Management of Orthostatic Hypotension: A Review

Megan George — Thu, 09 Apr 2026 23:15:35 +0000

Date Added:

April 9, 2026

Journal/Publication:

JAMA

Publication Date:

April 6, 2026

URL:

Management of Orthostatic Hypotension: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2026.0284

Keywords

PMID (1):

41941194

MeSH

hypotension

Hypotension, Orthostatic

Dizziness

Diagnosis and Management of Resistant Hypertension: A Review

A review and advice about how to help patients with orthostatic hypotension. James W. Mold, MD, MPH

View

Importance: Orthostatic hypotension is a common but underrecognized condition that increases with age and is associated with a lower quality of life, falls, and increased mortality. The frequent coexistence of supine hypertension and postprandial hypotension with orthostatic hypotension makes it a challenging condition to manage.

Observations: Testing for orthostatic hypotension should be done in patients with orthostatic symptoms (eg, vision changes and dizziness that occur only when upright and improve when seated or lying down), as well as asymptomatic patients in high-risk groups such as adults with frailty who are older than 70 years, individuals with neurodegenerative or autonomic disorders, and patients with unexplained falls. Patients with orthostatic hypotension should be screened for postprandial hypotension and supine hypertension to inform the treatment approach. Nonpharmacological strategies, such as medication review, increased salt and fluid intake, compression garments, and behavioral modifications, serve as fundamental approaches to treat orthostatic hypotension. Midodrine and droxidopa are the only US Food and Drug Administration-approved medications for orthostatic hypotension, but other medications (eg, fludrocortisone, atomoxetine, pyridostigmine) are used off label as part of an individualized treatment plan. Treatment targets in orthostatic hypotension are focused not on blood pressure measurements but on symptom relief and fall prevention.

Conclusions and relevance: All patients with orthostatic symptoms-along with other select patient groups-should be evaluated for orthostatic hypotension. Nonpharmacological treatments are first line, and medication decisions should be tailored based on clinical presentation and relevant comorbidities.

Author/s:

David Moloney, Ayman Youssef, Luis E. Okamoto

Diagnosis and Management of Resistant Hypertension: A Review

Megan George — Tue, 24 Mar 2026 16:14:03 +0000

Date Added:

March 24, 2026

Journal/Publication:

JAMA

Publication Date:

March 23, 2026

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2026.1221

Keywords

Antihypertensive Agents

Resistant Hypertension

Blood Pressure Monitoring

Hyperaldosteronism

Anti-Inflammatory Agents

PMID (1):

41870448

MeSH

Ambulatory

antihypertensive agents

renin-angiotensin system

resistant hypertension

Management of Hypertension in Adults

White Coat Hypertension

Hyperaldosteronism

Anti-Inflammatory Agents

A review of the evaluation and management of patients with resistant hypertension. James W. Mold, MD, MPH

Free full text

View

Author/s:

Michel Azizi, Wanpen Vongpatanasin, Naomi D L Fisher, Felix Mahfoud, Laurence Amar, Ajay J Kirtane

Management of Hypertension in Adults

Megan George — Tue, 24 Mar 2026 16:08:23 +0000

Date Added:

March 24, 2026

Journal/Publication:

JAMA

Publication Date:

March 23, 2026

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2026.1132

Keywords

primary aldosteronism

Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial

Hypokalemia

PMID (1):

41870440

MeSH

Hypertension, Pulmonary

Guidelines for management of patients with hypertension from the American College of Cardiology and the American Heart Association. James W. Mold, MD, MPH

Commercial full text (fees may apply)

View

Hypertension is the leading modifiable risk factor worldwide for ASCVD, and approximately half of US adults have hypertension.1 Uncontrolled BP contributes to heart failure, stroke, atrial fibrillation, and sudden cardiac death and is associated with development of kidney failure and dementia.2 This guideline was designed to provide clinicians with a risk stratification approach to managing BP. This synopsis highlights key guideline recommendations.

Author/s:

Amber E Johnson, Christopher D Jackson, Jason T Alexander

Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial

Alex Haga — Wed, 23 Oct 2024 15:12:08 +0000

Date Added:

October 23, 2024

Journal/Publication:

JAMA Internal Medicine

Publication Date:

October 7, 2024

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2024.5213

Keywords

arm position

Garlic lowers blood pressure in hypertensive subjects, improves arterial stiffness and gut microbiota: A review and meta-analysis

measurements

PMID (1):

39373998

MeSH

Arm position has a significant effect on BP measurements. James W. Mold, MD, MPH

Free full text

View

Importance: Guidelines for blood pressure (BP) measurement recommend arm support on a desk with the midcuff positioned at heart level. Still, nonstandard positions are used in clinical practice (eg, with arm resting on the lap or unsupported on the side).

Objective: To determine the effect of different arm positions on BP readings.

Design, setting, and participants: This crossover randomized clinical trial recruited adults between the ages of 18 and 80 years in Baltimore, Maryland, from August 9, 2022, to June 1, 2023.

Intervention: Participants were randomly assigned to sets of triplicate BP measurements with the arm positioned in 3 ways: (1) supported on a desk (desk 1; reference), (2) hand supported on lap (lap), and (3) arm unsupported at the side (side). To account for intrinsic BP variability, all participants underwent a fourth set of BP measurements with the arm supported on a desk (desk 2).

Main outcomes and measures: The primary outcomes were the difference in differences in mean systolic BP (SBP) and diastolic BP (DBP) between the reference BP (desk 1) and the 2 arm support positions (lap and side): (lap or side - desk 1) - (desk 2 - desk 1). Results were also stratified by hypertensive status, age, obesity status, and access to health care within the past year.

Results: The trial enrolled 133 participants (mean [SD] age, 57 [17] years; 70 [53%] female); 48 participants (36%) had SBP of 130 mm Hg or higher, and 55 participants (41%) had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher. Lap and side positions resulted in statistically significant higher BP readings than desk positions, with the difference in differences as follows: lap, SBP Δ 3.9 (95% CI, 2.5-5.2) mm Hg and DBP Δ 4.0 (95% CI, 3.1-5.0) mm Hg; and side, SBP Δ 6.5 (95% CI, 5.1-7.9) mm Hg and DBP Δ 4.4 (95% CI, 3.4-5.4) mm Hg. The patterns were generally consistent across subgroups.

Conclusion and relevance: This crossover randomized clinical trial showed that commonly used arm positions (lap or side) resulted in substantial overestimation of BP readings and may lead to misdiagnosis and overestimation of hypertension.

Author/s:

Hairong Liu, Di Zhao, Ahmed Sabit

Garlic lowers blood pressure in hypertensive subjects, improves arterial stiffness and gut microbiota: A review and meta-analysis

Aubrey Delammermore — Wed, 18 Jan 2023 06:00:00 +0000

Date Added:

January 18, 2023

Journal/Publication:

Experimental and Therapeutic Medicine

Publisher:

Spandidos

Publication Date:

February 1, 2020

Issue:

Volume:

Pages:

1473-1478

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3892/etm.2019.8374

Keywords

PMID (1):

32010325

MeSH

antihypertensive agents

Supplementation with garlic reduces systolic BP by an average of 5 mmHg with very few adverse effects. A typical regimen would be aged garlic extract 600 to1200 mg twice a day. It appears to act by increasing endothelial cell nitric oxide and inhibiting angiotensin II. James W. Mold, MD, MPH

Free full text

View

Garlic supplements have shown effectiveness in reducing blood pressure in hypertensive patients, similarly to first-line standard anti-hypertensive medications. Kyolic garlic has also shown promise in improving cardiovascular health by reducing arterial stiffness, elevated cholesterol levels and blood ‘stickiness’. In addition, the prebiotic properties in garlic increase gut microbial richness and diversity. This article systematically reviews previously published trials investigating the effects of garlic on blood pressure, and provides an updated meta-analysis of hypertensive participants. In addition, we summarise the findings of recent clinical trials investigating the effects of Kyolic aged garlic extract on arterial stiffness, and gut microbiota in hypertensive subjects. We searched online electronic databases, including PubMed and Google Scholar for randomised controlled trials (RCTs) published between 1955 and December, 2018 examining the effects of garlic on high blood pressure. The meta-analysis of 12 trials and 553 hypertensive participants confirmed that garlic supplements lower systolic blood pressure (SBP) by an average of 8.3±1.9 mmHg and diastolic blood pressure (DBP, n=8 trials, n=374 subjects) by 5.5±1.9 mmHg, similarly to standard anti-hypertensive medications. This reduction in blood pressure was associated with a 16–40% reduction in the risk of suffering from cardiovascular events. Additionally, this review summarises new evidence for the vitamin B12 status playing an important role in the responsiveness of blood pressure to garlic. Furthermore, Kyolic aged garlic extract significantly lowered central blood pressure, pulse pressure, pulse wave velocity and arterial stiffness, and improved the gut microbiota, evidenced by higher microbial richness and diversity, with a marked increase in the numbers of Lactobacillus and Clostridia species found following 3 months of supplementation. Thus, Kyolic aged garlic extract is considered to be highly tolerable with a high safety profile either as a stand-alone or adjunctive anti-hypertensive treatment, with multiple benefits for cardiovascular health.

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis

Aubrey Delammermore — Thu, 08 Sep 2022 05:00:00 +0000

Date Added:

September 8, 2022

Journal/Publication:

Heart

Publisher:

BMJ Publishing Group

Publication Date:

August 9, 2022

Pages:

1-8

URL:

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1136/heartjnl-2022-321332

Keywords

PMID (1):

35945000

MeSH

Randomized Controlled Trials as Topic

Odds Ratio

body mass index

Salt substitutes, when compared to use of regular salt, reduce BP, CV mortality, and all-cause mortality.

Free full text

View

Objectives The Salt Substitute and Stroke Study (SSaSS) recently reported blood pressure-mediated benefits of a potassium-enriched salt substitute on cardiovascular outcomes and death. This study assessed the effects of salt substitutes on a breadth of outcomes to quantify the consistency of the findings and understand the likely generalisability of the SSaSS results.

Methods We searched PubMed, Embase and the Cochrane Library up to 31 August 2021. Parallel group, step-wedge or cluster randomised controlled trials reporting the effect of salt substitute on blood pressure or clinical outcomes were included. Meta-analyses and metaregressions were used to define the consistency of findings across trials, geographies and patient groups.

Results There were 21 trials and 31 949 participants included, with 19 reporting effects on blood pressure and 5 reporting effects on clinical outcomes. Overall reduction of systolic blood pressure (SBP) was −4.61 mm Hg (95% CI −6.07 to −3.14) and of diastolic blood pressure (DBP) was −1.61 mm Hg (95% CI −2.42 to −0.79). Reductions in blood pressure appeared to be consistent across geographical regions and population subgroups defined by age, sex, history of hypertension, body mass index, baseline blood pressure, baseline 24-hour urinary sodium and baseline 24-hour urinary potassium (all p homogeneity >0.05). Metaregression showed that each 10% lower proportion of sodium choloride in the salt substitute was associated with a −1.53 mm Hg (95% CI −3.02 to −0.03, p=0.045) greater reduction in SBP and a −0.95 mm Hg (95% CI −1.78 to −0.12, p=0.025) greater reduction in DBP. There were clear protective effects of salt substitute on total mortality (risk ratio (RR) 0.89, 95% CI 0.85 to 0.94), cardiovascular mortality (RR 0.87, 95% CI 0. 81 to 0.94) and cardiovascular events (RR 0.89, 95% CI 0.85 to 0.94).

Conclusions The beneficial effects of salt substitutes on blood pressure across geographies and populations were consistent. Blood pressure-mediated protective effects on clinical outcomes are likely to be generalisable across population subgroups and to countries worldwide.

Author/s:

Yin, X., Rodgers, A., Perkovic, A., Huang, L., Li, K., Yu, J., Wu, Y., Wu, J. H. Y., Marklund, M., Huffman, M. D., Miranda, J. J., Di Tanna, G. L., Labarthe, D., Elliott, P., Tian, M., Neal, B.

To Treat or Not to Treat? Effect of Urate-Lowering Therapy on Renal Function, Blood Pressure and Safety in Patients with Asymptomatic Hyperuricemia: A Systematic Review and Network Meta-Analysis

Saige Blanchard — Tue, 10 May 2022 05:00:00 +0000

Date Added:

May 10, 2022

Journal/Publication:

Journal of the American Board of Family Medicine

Publisher:

Journal of the American Board of Family Medicine

Publication Date:

January 16, 2022

Issue:

Volume:

Pages:

140-151

URL:

To Treat or Not to Treat? Effect of Urate-Lowering Therapy on Renal Function, Blood Pressure and Safety in Patients with Asymptomatic Hyperuricemia: A Systematic Review and Network Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3122/jabfm.2022.01.210273

Keywords

Asymptomatic Hyperuricemia

Milestones in Heart Failure: How Far We Have Come and How Far We Have Left to Go

Disease Management

family medicine

Network Meta-Analysis

PMID (1):

35039419

MeSH

Lowering uric acid levels in patients with asymptomatic hyperuricemia appears to have beneficial effects on renal function and/or blood pressure, depending upon the medication used, with very few significant adverse effects. James W. Mold, MD, MPH

Free full text

View

Purpose: Hyperuricemia is associated with increased cardiovascular risk. Because patients with asymptomatic hyperuricemia (AH) experience no immediate discomfort and there are possible side effects of urate-lowering drugs, treatment for AH is controversial. We aimed to perform a network meta-analysis (NMA) to investigate the effects of different urate-lowering therapies (ULTs) on serum uric acid level, renal function, blood pressure (BP), and safety in AH patients.

Methods: This NMA focused on AH patients. The intervention group (patients receiving urate-lowering drugs) was compared with others using other types of drugs, placebo, or usual care. We undertook a NMA under the frequentist framework by R.

Results: Thirteen eligible trials were identified. The interventions included allopurinol, febuxostat, and benzbromarone, which are not approved in the United States. Benzbromarone and allopurinol had the best efficacy on lowering serum uric acid level in short-term and long-term follow-up (mean difference [MD] = -3.05; 95% CI, -5.19 to -0.91 vs MD = -3.17; 95% CI, -5.19 to -1.15). Patients using allopurinol had significantly higher eGFR than using placebo in both short-term and long-term follow-up (MD = 3.07; 95% CI, 0.18 to 5.95 vs MD = 4.10; 95% CI, 2.66 to 5.54). No difference in BP was found between groups, except for febuxostat to diastolic BP after long-term treatment (MD = -1.47; 95% CI, -2.91 to -0.04). No statistically increased odds of safety events were found with the use of ULT.

Conclusions: Our result showed that in AH patients, allopurinol has a renoprotective effect. Febuxostat has a significant impact in lowering diastolic BP. ULT does not result in a higher risk of safety events.

Author/s:

Tien, Y., Shih, M., Tien, C., Huang, H., Tu, Y.

Milestones in Heart Failure: How Far We Have Come and How Far We Have Left to Go

Saige Blanchard — Mon, 03 Jan 2022 06:00:00 +0000

Date Added:

January 3, 2022

Journal/Publication:

Cureus Journal of Medical Science

Publication Date:

December 12, 2021

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7759/cureus.20359

Keywords

MeSH

Angiotensin Receptor Antagonists

heart failure

Disease Progression

A nice summary of what we currently know about the pharmacologic treatment of congestive heart failure. James W. Mold, MD, MPH

Free full text

View

Heart failure is a clinically complex syndrome that results due to the failure of the ventricles to function as pump and oxygenate end organs. The repercussions of inadequate perfusion are seen in the form of sympathetic overactivation and third spacing, leading to clinical signs of increased blood pressure, dyspnea, fatigue, palpitations, etc. This article provided a brief overview of the clinical syndrome of heart failure; its epidemiology, risk factors, symptoms, and staging; and the mechanisms involved in disease progression. This article also described several landmark trials in heart failure that tested the efficacy of first-line drugs such as beta-blockers, angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and the latest drugs in the field of heart failure: angiotensin receptor neprilysin inhibitors. Most studies described in this article were guideline-setting trials that revolutionized the practice of medicine and cardiology.

Author/s:

H., Kela, I., Kakarlala, C., Hassan, M., Belavadi, R., Gudigopuram, S. V. R., Raguthu, C., Modi, S., Sange, I.

Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice Guideline

Saige Blanchard — Wed, 23 Jun 2021 05:00:00 +0000

Date Added:

June 23, 2021

Journal/Publication:

Annals of Internal Medicine

Publisher:

American College of Physicians

Publication Date:

June 22, 2021

URL:

Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice Guideline

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7326/M21-0834

Keywords

PMID (1):

34152826

MeSH

Renal Replacement Therapy

renal dialysis

referral and consultation

risk assessment

renal insufficiency, chronic

Eleven guideline recommendations for management of elevated BP in patients with CKD from the Kidney Disease: Improving Global Outcomes (KDIGO). James W. Mold, MD, MPH

Free full text

View

Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of blood pressure (BP) in patients with chronic kidney disease (CKD) not receiving dialysis is an update of the KDIGO 2012 guideline on the same topic and reflects new evidence on the risks and benefits of BP-lowering therapy among patients with CKD. It is intended to support shared decision making by health care professionals working with patients with CKD worldwide. This article is a synopsis of the full guideline.

Methods: The KDIGO leadership commissioned 2 co-chairs to convene an international Work Group of researchers and clinicians. After a Controversies Conference in September 2017, the Work Group defined the scope of the evidence review, which was undertaken by an evidence review team between October 2017 and April 2020. Evidence reviews were done according to the Cochrane Handbook. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to guide the development of the recommendations and rate the strength and quality of the evidence. Practice points were included to provide guidance when evidence was insufficient to make a graded recommendation. The guideline was revised after public consultation between January and March 2020.

Recommendations: The updated guideline comprises 11 recommendations and 20 practice points. This synopsis summarizes key recommendations pertinent to the diagnosis and management of high BP in adults with CKD, excluding those receiving kidney replacement therapy. In particular, the synopsis focuses on recommendations for standardized BP measurement and a target systolic BP of less than 120 mm Hg, because these recommendations differ from some other guidelines.

Author/s:

Tomson, C. R. V., Cheung, A. K., Mann, J. F. E., Chang, T. I., Cushman, W. C., Furth, S. L., Hou, F. F., Knoll, G. A., Muntner, P., Pecoits-Filho, R., Tobe, S. W., Lytvyn, L, Craig, J. C., Tunnicliffe, D. J., Howell, M., Tonelli, M., Cheung, M., Earley, A., Ix, J. H., Sarnak, M. J.

Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review

Devin Evans — Fri, 19 Mar 2021 05:00:00 +0000

Date Added:

March 19, 2021

Journal/Publication:

Journal of the American Medical Association

Publication Date:

March 16, 2021

Issue:

Volume:

325

Pages:

1088-1098

URL:

Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2020.26867

Keywords

transient ischemic attack

Acute Ischemic Stroke

PMID (1):

33724327

MeSH

Tissue Plasminogen Activator

Platelet Aggregation Inhibitors

ischemic attack, transient

Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial

A non-systematic review of the diagnosis and management of patients with transient ischemic attack and acute stroke. James W. Mold, MD, MPH

Free full text

View

Importance: Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually.

Observations: Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic resonance diffusion or computed tomography perfusion imaging (modified Rankin Scale score 0-2: 53% vs 18%; OR, 4.92 [95% CI, 2.87-8.44]).

Conclusions and relevance: Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.

Author/s:

Mendelson, Scott J., Prabhakaran, Shyam

Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial

Brian Desmarais — Thu, 24 Oct 2019 17:04:27 +0000

Date Added:

April 3, 2020

Journal/Publication:

European Heart Journal

Publication Date:

October 22, 2019

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1093/eurheartj/ehz754

Keywords

Perhaps once a day antihypertensives should be taken at night rather than in the AM. James W. Mold, MD, MPH

Free full text

View

AIMS:

The Hygia Chronotherapy Trial, conducted within the clinical primary care setting, was designed to test whether bedtime in comparison to usual upon awakening hypertension therapy exerts better cardiovascular disease (CVD) risk reduction.

METHODS AND RESULTS:

In this multicentre, controlled, prospective endpoint trial, 19 084 hypertensive patients (10 614 men/8470 women, 60.5 ± 13.7 years of age) were assigned (1:1) to ingest the entire daily dose of ≥1 hypertension medications at bedtime (n = 9552) or all of them upon awakening (n = 9532). At inclusion and at every scheduled clinic visit (at least annually) throughout follow-up, ambulatory blood pressure (ABP) monitoring was performed for 48 h. During the 6.3-year median patient follow-up, 1752 participants experienced the primary CVD outcome (CVD death, myocardial infarction, coronary revascularization, heart failure, or stroke). Patients of the bedtime, compared with the upon-waking, treatment-time regimen showed significantly lower hazard ratio-adjusted for significant influential characteristics of age, sex, type 2 diabetes, chronic kidney disease, smoking, HDL cholesterol, asleep systolic blood pressure (BP) mean, sleep-time relative systolic BP decline, and previous CVD event-of the primary CVD outcome [0.55 (95% CI 0.50-0.61), P < 0.001] and each of its single components (P < 0.001 in all cases), i.e. CVD death [0.44 (0.34-0.56)], myocardial infarction [0.66 (0.52-0.84)], coronary revascularization [0.60 (0.47-0.75)], heart failure [0.58 (0.49-0.70)], and stroke [0.51 (0.41-0.63)].

CONCLUSION:

Routine ingestion by hypertensive patients of ≥1 prescribed BP-lowering medications at bedtime, as opposed to upon waking, results in improved ABP control (significantly enhanced decrease in asleep BP and increased sleep-time relative BP decline, i.e. BP dipping) and, most importantly, markedly diminished occurrence of major CVD events.

TRIAL REGISTRATION:

ClinicalTrials.gov, number NCT00741585.

Author/s:

Hermida, R.C., Crespo, J.J., Domínguez-Sardiña, M, Otero, A., Moyá, A., Ríos, M.T., Sineiro, E., Castiñeira, M.C., Callejas, P.A., Pousa, L., Salgado, J.L., Durán, C., Sánchez, J.J., Fernández, J.R., Mojón, A., Ayala, D.E., Hygia Project Investigators

Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis

Brian Desmarais — Wed, 12 Jun 2019 01:48:41 +0000

Date Added:

June 11, 2019

Journal/Publication:

Annals of Internal Medicine

Publication Date:

June 11, 2019

URL:

Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7326/M19-0223

Keywords

cardiovascular

MeSH

White Coat Hypertension

Blood Pressure Determination

cardiovascular diseases

Research Personnel

National Institutes of Health (U.S.)