The history of clinical medicine shows how advances in scientific knowledge have shaped physician attitudes to disease and treatment objectives.
For these and other reasons, even though epidemiologic studies had shown a direct linear relationship between both BP components and cardiovascular mortality and morbidity,3 the first operative definition of hypertension by the World Health Organization in 1978 included DBP as the most important distinctive element in hypertension and its classification of severity. These concepts strongly influenced physician education in hypertension in the final 30 years of the 20th century. For these reasons, in recent years, SBP control has been promoted as the great challenge in hypertension. In the core trio of hemodynamic values that govern clinical practice (systolic blood pressure [SBP], diastolic blood pressure [DBP], and heart rate), DBP is—to use a fairytale analogy—the less favored princess, the one whose story evokes less interest. There are no data for characterizing the appropriate rate of DBP lowering or target DBP values in patients with coronary heart disease. An important clinical consideration is the relationship between hypothyroidism and hypertension. Conclusion: The differential diagnosis of hypertension comprisesmany syndromes other than essential hypertension that influence DBP.
Meta-analysis of prospective epidemiologic observations in a total of one million adults with no previous vascular disease recorded at baseline has shown an association between an increased risk of vascular mortality, essentially from ischemic heart disease and stroke, and elevation of both diastolic blood pressure (DBP) and systolic blood pressure (SBP).1 Although the average of DBP and SBP is slightly more informative than either alone in predicting vascular mortality from a single blood pressure measurement, the evidence also suggests that risk lies more with SBP than with DBP. Presently, the definition of essential hypertension is based on the level of both DBP and SBP.
Clinical trials in the elderly with predominantly isolated systolic hypertension have shown the benefit of cardiovascular risk reduction by concentrating on the reduction of SBP. Diastolic blood pressure (DBP) increases with age to 55 years, then decreases, whereas systolic blood pressure (SBP) increases steadily with age to at least 80 years. The Veterans Administration and other treatment studies were based on DBP, although SBP may well also have been clearly increased at baseline. Conclusion: An increase in SBP is made more dangerous by either a concomitant increase or concomitant reduction in DBP (especially in the elderly), whereas pure diastolic hypertension may be less harmful. Resolving these issues is methodologically complex, which explains why we still have no conclusive answer about the importance of DBP as a CVR predictor. At present, the levels of evidence for answers to the initial question are low, there are serious gaps in the data available, and many specific issues remain open to debate. Diastolic blood pressure (DBP) came to be considered the most important determinant of cardiovascular risk in the mid-20th century. Reporting the Framingham data in 1971, Kannel et al showed clearly that SBP was more accurate than DBP in predicting cardiovascular risk,2 but it took nearly 20 years before the JNC used SBP in staging hypertension.
In 2008, Williams et al proposed expressing the thresholds for the diagnosis and treatment of hypertension in the single dimension of SBP on the grounds that this is far the more important of the two blood pressure components, especially among the over-50s.3 They argued that with population aging and hence an increase in the number of subjects with systolic hypertension, it was reasonable to classify and treat hypertension solely on the basis of SBP in the over-50s.
In 2008, Kelly et al published a Chinese database comprising 169 871 men and women aged ≥40 years. A 2009 analysis by Franklin et al of the Framingham data in 9557 individuals, all free of cardiovascular events and antihypertensive therapy at baseline, showed the combination of high SBP and low DBP to be a superior predictor of future adverse cardiovascular events. Conclusion: In evaluating, detecting, and treating hypertensive patients, the combination of SBP and DBP remains superior to either component alone in predicting cardiovascular risk.
Furthermore, clinical trials up to the end of the last decade using DBP as the surrogate end point showed clear clinical benefit, in particular for high-risk patients.3 Some may argue that over-reliance on DBP as the surrogate may have contributed to the somewhat attenuated benefits of BP reduction seen in many earlier trials. In clinical practice, we encounter patients whose SBP is controlled, but whose diastolic readings remain suboptimal, particularly among younger patients. Overreliance on SBP control at the expense of diastolic control has the indirect effect of focusing excessive attention on the elderly as the archetypal patients in whom diastolic control is seldom an issue. For these reasons, we should not yet recommend the discarding of DBP as a risk factor and treatment target.We also need DBP for determining proven strong predictors of CV events, such as pulse pressure andmean arterial pressure. Diastolic blood pressure (DBP) was long considered the key determinant of the cardiovascular risk associated with hypertension. The subsequent finding that systolic blood pressure (SBP) correlates better than DBP with coronary heart disease, stroke, and heart failure have challenged this view, suggesting that SBP outweighs DBP as a predictor of cardiovascular morbidity andmortality. Age plays an important role in modifying the relationship between blood pressure components and cardiovascular risk.
Yet despite the findings relating to age, controversy persists over which blood pressure component is the superior predictor of cardiovascular events. Conclusion: We cannot ignore DBP because it has been demonstrated that in patients with isolated diastolic hypertension, who account for 14% of the hypertensive population, cardiovascular risk is twice that in subjects with normal blood pressure.
Lowering of diastolic blood pressure (DBP) has been traditionally considered the main treatment target for almost 30 years. SBP and pulse pressure rise continuously with age due to age-related changes in arterial stiffness. The risks of hypertension were ascribed mainly to DBP until the mid-1980s when SBP also began to be recognized as an important predictor of CV morbidity-mortality. In that case At the first sign of low blood sugar eat the sugar source to raise your blood sugar while you seek medical help. Hi I want to know can be salivary enzymes in saliva can be use as a diagnostic tool Originally Posted by antonyhop Hi I want to know can be salivary enzymes in saliva can be use as a diagnostic tool in type 2 diabetes. Learn more about a career with Canadian Diabetes Association including all recent jobs, hiring trends, salaries, work environment and more. One complication is the J-curve phenomenon, according to which patients with very low DBP are also at increased risk of cardiovascular death.
Blood pressure clinics are typically attended by a mix of young,middle-aged, and elderly.We need tomaintain the DBP parameter in the minds of physicians so that they can offer optimal treatment to these heterogeneous hypertensive populations. The J-curve phenomenon relates to DBP levels in the many hypertensive patients who have coronary artery disease.
We currently stage hypertension using systolic and diastolic values, either separately or in combination.
SBP was assumed to be less important.1 It is not therefore surprising that, in all studies on the prevention of morbidity and mortality by antihypertensive treatment carried out during these years, efficacy should have been evaluated by changes in DBP and that regulatory agencies such as the Food and Drug Administration or the European Medicines Agency use this type of design to the present day.
Normalization of DBP should therefore continue to be a priority, in addition to normalization of SBP. This would produce a J shape for the DBP coronary risk curve, except no such shape has yet been satisfactorily confirmed.
The consensus is that DBP should be lowered continuously, but maintained above 60 mm Hg if the patient has diabetes or is over 60 years of age.4 In older hypertensive patients with a wide pulse pressure, lowering SBP may lower DBP below 60 mm Hg,5 thereby accentuating myocardial ischemia. Many patients with hypothyroidism have DBP elevation, even in the early stages of the disorder, although no relationship between thyroid-stimulating hormone levels and DBP has been found,6 at least in the elderly.
They form an important part of everyday practice in internal medicine, cardiology, and geriatrics.
A particularly large trial, the randomized, double-blind, placebocontrolled Hypertension in the Very Elderly Trial (HYVET), was performed in 3845 patients aged 80 years or above with hypertension defined essentially by SBP (160 mm Hg or higher). The control rate of SBP is about half that achieved with DBP.6 This suggests that control of both would be achieved in more patients if SBP were targeted rather than DBP. Early in the first trimester, active vasodilatation induced by local mediators such as prostacyclin and nitric oxide lowers blood pressure (BP), primarily DBP. In particular, no matter how difficult they may be to design, clinical studies are needed to determine the importance of DBP in determining CVR.
The first three Reports of the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure staged hypertension according to DBP levels.1 DBP was viewed as a better predictor of cardiovascular risk than systolic blood pressure (SBP), which was seen as a natural corollary of aging, while DBP was seen as dependent on peripheral resistance.
However, the 2007 guidelines of the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and European Society of Cardiology stressed the importance of high cardiovascular risk in patients with a high SBP and low DBP, ie, a high pulse pressure.
Although there is considerable evidence to suggest that SBP outperforms DBP in gauging cardiovascular risk in the over-50s, the time has not yet come to jettison DBP.
Although the paradigm has shifted over the last decade with regard to the relative importance of the blood pressure (BP) components, elevated diastolic blood pressure (DBP) does have prognostic implications. Others will say that SBP is not only prognostically more important, it is also more difficult to control and therefore deserves more emphasis. We do not currently have enough evidence to allow us to neglect such cases of isolated diastolic hypertension. This question may seem silly for many, yet profound for those familiar with the epidemiologic data on hypertension and cardiovascular (CV) risk reduction.
On this basis, the guidelines recommend treating everyone with stage 1 and 2 hypertension, and point out that DBP is a stronger CV risk factor than SBP in younger hypertensives.
In the final analysis, blood pressure is just one of the multiple risk factors that influence CV outcome and its treatment should be approached in an individualized manner. Mancia G, De Backer G, Dominiczak A, et al; ESH-ESC Task Force on the Management of Arterial Hypertension. It was documented as such in the early Reports fromthe Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, which defined hypertension and graded its severity in terms of DBP only.
In particular, with increasing age, there is a gradual shift fromDBP to SBP and eventually pulse pressure as predictors of cardiovascular events.
A recent follow-up study of the Framingham data tested the utility of a combination of blood pressure components instead of a single component in predicting cardiovascular risk.4 In a model adjusted for age, sex, and other covariates, the odds of cardiovascular events increased with increasing SBP and DBP, but the relationship between DBP and cardiovascular risk was quadratic and nonlinear.
The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V).
However, in elderly subjects, systolic blood pressure (SBP) has proved a better predictor of CV complications (coronary artery disease, heart failure, stroke), renal failure, and total mortality.
Pulse pressure is also considered an independent and significant predictor of total CV mortality and all-cause mortality.
However, metaanalysis of data from over one million adults in 61 prospective studies indicated that the absolute risk of death from ischemic heart disease at least doubled with every decade, with a line of progression that was similar for both SBP and DBP.1 Data from various trials of antihypertensive treatment showed clear clinical benefit and fewer CV complications as a result of lowering DBP. In younger subjects it depends mainly on peripheral resistance, ie, low DBP means low peripheral resistance. Above this age, and in particular from age 60 onwards, SBP (and pulse pressure) become the more important determinants of total risk. Genetics may play a part in all blood sugar level vitamin d texas houston types of diabetes mellitus.
In this case body cells are resistant to insulin (injections) therefore medications are given orally to lower the blood glucose levels.
If exercise and changes in diet do not help PBRC * of 38 So What a Ketones are acids that build up in the breakfast menu for diabetes type 2 kansas topeka blood.
The two components of blood pressure (BP) move in opposite directions: SBP tends to climb on upwards, while DBP tends to decline. The introduction of ambulatory BP generated a fresh profusion of parameters: daytime BP, nocturnal BP, morning surge BP, average 24-hour BP, and masked hypertension. The first is related mainly to large artery stiffness while the second relates to arteriolar vasoconstriction.
Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous?
Pulse pressure and cardiovascular disease-related mortality: follow-up study of the Multiple Risk Factor Intervention Trial (MRFIT). Single versus combined blood pressure components and risk for cardiovascular disease: the Framingham Heart Study.
An increase in this resistance was considered the fundamental pathophysiological mechanism of hypertension. Thus the Hypertension Optimal Treatment (HOT) study4 was designed to determine the optimal DBP treatment objective, regardless of the SBP levels achieved. Once this objective was achieved it was generally considered that the patient was controlled, regardless of SBP levels.
Secular trends in longterm sustained hypertension, long-term treatment, and cardiovascular mortality.
Effects of intensive blood pressure lowering and low dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.
Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. DBP elevation with a normal SBP is the classic presentation of essential hypertension, progressing to systo-diastolic hypertension if untreated.
In patients with coronary artery disease, hypertension, and left ventricular hypertrophy, DBP levels either above or below the normal range increase myocardial oxygen demand.
Thyroxine replacement lowers both SBP and DBP in hypertensive patients with hypothyroidism, including during the subclinical (or oligosymptomatic) phase of disorder. Effect of intensive blood pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial.
AHA scientific statement: the treatment of hypertension in the prevention and management of ischemic heart disease. DBP was initially required to be between 90 and 109 mm Hg, but this was subsequently relaxed to include any value below 110 mm Hg, allowing the inclusion of many patients with isolated SBP. Presently, physicians and patients are expected to monitor two parameters of blood pressure.
Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Predominance of isolated systolic hypertension among middle aged and elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES III). A drop of 10 mm Hg is usual by 13 to 20 weeks, reaching a nadir at 20 to 24 weeks; fluctuation is similar in both normotensive and hypertensive women.
However, for over 30 years the Framingham investigators have been telling us that SBP is the more important component.
Central PP as assessed from the augmentation index is significantly related to cardiovascular events.5 However, more large-scale observational and interventional studies are required to confirm the prognostic role of central as opposed to peripheral BP. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Pulsatile versus steady component of blood pressure: a cross-sectional analysis and a prospective analysis of cardiovascular mortality. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes: principal results of the Conduit Artery Function valuation (CAFE) study.
Central or peripheral systolic or pulse pressure: which best relates to target organs and future mortality? Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials.
Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES) III. Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction. While these viewpoints have merits, it does not mean that they should be pursued at the expense of neglecting diastolic control. On the contrary, forgetting that their DBP remains suboptimal is likely to expose such patients to higher than acceptable long-term risk. Prognosis of isolated systolic and isolated diastolic hypertension as assessed by self-measurement of blood pressure at home: the Ohasama study.
Association between blood pressure level and the risk of myocardial infarct, stroke and total mortality.
Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. This is not the message that the data are giving us: an elevated DBP is a predictor of CV events.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the Management of Arterial Hypertension. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Isolated diastolic hypertension, pulse pressure, and mean arterial pressure as predictors of mortality during a follow-up of up to 32 years.
Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. The concept was derived from the knowledge that DBP represents the resistance that the heart has to overcome in order to pump blood into the systemic circulation and also from the strong relationship between diastole and coronary perfusion.
Under 50 years of age, DBP is a stronger predictor of cardiovascular risk than SBP or pulse pressure. Thus for any given SBP value greater than 120 mm Hg, the odds of cardiovascular events are increased at both the high and low extremes of DBP.
It was also the best predictor of coronary and cerebrovascular events in the Cardiovascular Health Study in subjects 65 years or older. More intensive DBP lowering also translated into clear benefit (especially in diabetics) in the Hypertension Optimal Treatment trial. Age-specific relevance of usual blood pressure to vascular mortality: a metaanalysis of individual data for one million adults in 61 prospective studies. Ambulatory blood pressure in the hypertensive population: patterns and prevalence of hypertensive sub-forms. My son Ben has been diagnosed with type 1 and we are seeing his symptoms reverse with raw foods and green smoothies! If you are unsure or if you are not feeding this product for weight loss ask your veterinarian.
The resulting increase in pulse pressure (PP) has attracted attention as a risk factor in its own right. These were supplemented by central BP, pulse wave velocity, augmentation pressure, and augmentation index.
Thus no cost saving is involved in concentrating on a single parameter; indeed, there may be wastage in ignoring the free contribution of DBP. In addition, in clinic or home blood pressure (BP) measurements, DBPwasmuchmore stable and reproducible than SBP. The underlying hemodynamic abnormality is the elevation of systemic vascular resistance and hence of mean arterial pressure, with no corresponding increase in cardiac output. This is why the burden of elevated cardiovascular risk rests more with SBP than it does with DBP. It would be simpler and more practical for all concerned to base management decisions on a single parameter.
Three large placebo- controlled interventional studies—Systolic Hypertension in the Elderly Program (SHEP), Systolic Hypertension in Europe (Syst-Eur), and Systolic Hypertension in China (Syst- China)—reinforced this idea during the 1990s, showing that drug treatment of isolated systolic hypertension reduced cardiovascular events in elderly patients.
Admittedly, we also have no hard evidence of clinical benefit from lowering DBP in this category of patient, but there is epidemiologic evidence that neglecting their DBP could expose them to unnecessary risk. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). The majority (approximately 75%) of hypertensive patients are over 50 years of age and have predominantly systolic hypertension.
The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Chronic Complication Of Diabetes Mellitus Ppt Ut Salt Lake City i’m always looking for a more natural approach to treating my diabetes. Consequently, it was good news to hear that international hypertension experts wanted to simplify life for the practicing physician. Taking DBP into account enhances the view of overall risk when combined with SBP, improves hypertensive care, and does so at no extra charge. The result is an isolated increase in DBP.2,3 Such diastolic hypertensives are frequently obese and exhibit higher sympathetic and reninangiotensin- aldosterone system activation.
This is particularly important because despite treatment, about a third of all patients fail to achieve long-term blood pressure control. It must also be remembered that in contrast to the case with DBP, there have never been any outcome trials examining the benefits of lowering SBP to different pressure levels. From age 60 years on, when considered together with SBP, DBP becomes inversely related to cardiovascular risk and pulse pressure emerges as the best predictor. The evidence suggests that this J-curve relationship between DBP and coronary risk applies mainly to older subjects with isolated systolic hypertension. Diabetes affects approximately 26 million people in the United States and a very large percentage of these patients experience problems with their feet.
Though they are not healthy to eat all of the time, they do help to take the edge off of your diabetic diet. The condition has been characterized as prehypertension, but is unfortunately rarely picked up in everyday practice.
Perhaps the time has now come to jettison DBP in the day to day management of essential hypertension, and focus our energies on the control of SBP alone. PP was first reported as a cardiovascular risk marker in 1989 and confirmed as such in several epidemiologic studies.3 It is associated with other risk factors for atherosclerotic vascular disease, such as obesity, inflammation, the micro- and macrovascular complications of type 2 diabetes, and plasma natriuretic peptide levels.
Indeed, recent trials have shown that aggressive BP lowering in high-risk patients is more likely to optimize DBP than SBP. For a start, the absolute difference in untreated SBP between hypertensive and control groups exceeds that in DBP. The fact that SBP and DBP both predict risk in the under-50s confirms the concept that increased peripheral resistance is dominant in determining cardiovascular risk in young hypertensives.
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Understanding insulin can be confusing because there are so many types some of the names sounds Diabetes is treated with meal planning exercise medication and blood glucose monitoring. There are several theoretical reasons for considering PP an excellent indicator of cardiovascular and mortality risk. In the largest available meta-analysis of observational data (61 studies in one million subjects, 70% from Europe, without overt cardiovascular disease), both SBP and DBP were independently and similarly predictive of stroke and coronary mortality. In cohort studies most (but not all) patients were already being treated for hypertension before enrolment and classification into different risk categories. These complications type 2 diabetes definition ada oregon portland include damage to the heart the kidneys the nerves the skin the eyes and many more. Tom Hanks says he has had to rule out roles which require drastic weight gain following his diagnosis with Type 2 diabetes. Mouth-watering potatoes seasoned to perfection are better tasting than ever with 80 Calorie per serving Betty Crocker Pouch Potatoes These tasty potatoes are ready in Mainly used in treating obesity, diabetes mellitus. Nevertheless, patients still clearly benefited, as shown by the improved clinical outcomes. It can be plausibly argued that this was due at least in part to achieving the target DBP level with 5 mm Hg to spare, despite the mean end of study SBP remaining suboptimal.
This further reduces the absolute difference in DBP while maintaining a relatively high difference in SBP. Diabetics can eat the same foods as anyone else; they just need to watch their portion sizes to keep their carbohydrate intake at the recommended levels, which are usually 45 to 60 grams per meal.
Naturally, those with uncontrolled SBP will remain at high risk for the entire duration of observation. The same is true in randomized placebo-controlled trials; we see big differences in SBP and small differences in DBP. In addition,many trials (except those in isolated systolic hypertension) had an inclusion criterion for DBP (eg, >95 mm Hg), but no threshold for SBP. As expected, large falls in SBP were paralleled by much smaller falls in DBP (eg, 30 mm Hg SBP vs 11 mm Hg DBP).
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