How important is optimal blood pressure control?

Background: Evidence for the cardiovascular benefits of antihypertensive treatment is among the strongest in medicine. Randomized, prospective, unconfounded studies in thousands of people have shown that even small reductions in blood pressure for short periods substantially improve cardiovascular outcomes. Recent evidence has emphasized the importance of optimal blood pressure control, particularly in patients with high cardiovascular risk, such as those with type 2 diabetes mellitus.Objective: This article discusses optimal target blood pressure goals, reviews the effects of antihypertensive treatment in high-risk patients, presents current guidelines for blood pressure control, discusses the failure worldwide to achieve such control, and suggests approaches to improved treatment.Conclusions: In high-risk patients, small improvements in blood pressure control are associated with large reductions in cardiovascular risk. National and international guidelines for the management of hypertension therefore now recommend rigorous blood pressure targets. Despite extensive clinical evidence, the delivery of care for hypertension remains unsatisfactory. Hypertension is underdiagnosed and undertreated, and recommended target blood pressures are rarely achieved. Physicians appear reluctant to make changes to treatment, which would lead to more effective use of antihypertensive drugs. Overwhelming evidence supports the benefit of optimal blood pressure control in patients with hypertension. Several studies have shown that such control can be achieved, but most likely requires combination treatment. Combination treatment is likely to be successful only if drugs are well tolerated and patients are compliant. The angiotensin II receptor antagonists (sartans) have the therapeutic advantage of efficacy, excellent tolerability, and a good record of compliance. Blood pressure control can be more easily accomplished by using sartans early in treatment and by recognizing the benefits of even small reductions in blood pressure.     

Prostanoids and blood pressure: which way is up?

Members of the family of prostanoids, made up of prostaglandins and thromboxanes, are generated via COX-mediated metabolism of arachidonic acid. These lipid mediators exhibit wide-ranging biological actions that include regulating both vasomotor tone and renal sodium excretion. As COX inhibition is often associated with sodium retention leading to edema and hypertension, prostanoids appear to have a role in preventing the development of high blood pressure. On the other hand, prostaglandin E2 (PGE2) and PGI2 have also been implicated as determinants of renin secretion. A new study suggests that PGI2 plays a critical role in stimulating renin release and promoting hypertension following renal artery stenosis.     

ACHC, CHAP, or the joint commission: which one is for you?

Selecting the right accreditation organization is an important decision. This month's column reviews the three nationally recognized accreditation organizations, and examines their standards and survey activities. Factors home care organizations should consider when choosing an accreditation body are presented to facilitate knowledgeable decision making.     

In utero or ex utero cord blood collection: which is better?

BACKGROUND: The relative nucleated cell count of umbilical cord blood (CB) correlates with improved engraftment and survival. This study compares two collection methods to assess CB content, including cell numbers. STUDY DESIGN AND METHODS: The Massachusetts CB bank used trained obstetricians and midwives to collect CB in utero before the delivery of the placenta. The banks in California, Ohio, Oregon, and Minnesota used trained American Red Cross (ARC) personnel who collected CB ex utero after the delivery of the placenta. All banks processed CB by RBC sedimentation and volume reduction. RESULTS: The volume and total nucleated cell count of collected CB before processing, as well as after processing CFU-GM and CD34+ cells, showed no advantage of either method. In utero collections resulted in more rejections of collected units (due to labeling problems, bacterial contamination, clotting, and delay between collection and processing) than ex utero collections. There were fewer medical exclusions after in utero collection. CONCLUSION: CB can be collected successfully using either the in utero or ex utero methods; both methods produce comparable nucleated cell, MNC, CD34+, and CFU-GM numbers. Bacterial contamination, low volume, clotting, and delay until processing are generally higher with in utero collection.     

Should the blood pressure or the blood vessel be the target of therapy?

Measured blood pressure is an insensitive and moderately nonspecific guide to the presence of vascular or cardiac diseases likely to progress to cardiovascular morbid events. Since the goal of the diagnosis and treatment of hypertension is to prevent or forestall such morbid events, blood pressure measurements should be supplemented by studies of the health of the cardiovascular system in defining the syndrome of hypertension and in monitoring its response to therapy.     

Should the blood pressure or the blood vessel be the target of therapy?

Measured blood pressure is an insensitive and moderately nonspecific guide to the presence of vascular or cardiac diseases likely to progress to cardiovascular morbid events. Since the goal of the diagnosis and treatment of hypertension is to prevent or forestall such morbid events, blood pressure measurements should be supplemented by studies of the health of the cardiovascular system in defining the syndrome of hypertension and in monitoring its response to therapy.     

Taking blood pressure: too important to trust to humans?

The measurement of blood pressure in the physician's office is subject to a number of observer errors and also to the "white-coat effect." Automatic devices that measure blood pressure without a human observer in the room can eliminate many of these problems. We argue for greater use of these devices in the physician's office.     

To filter blood or universal leukoreduction: what is the answer?

The safety of the blood supply has been a concern over the past 20-30 years because of the transmission of infectious diseases. Blood is still routinely tested for viruses, and leukoreduction is an effective strategy to reduce the transmission of cell-associated viruses. Clinically, the benefits of leukoreduction include decreases in transfusion reactions, HLA alloimmunization, infections, fever episodes, and antibiotic use. Although leukoreduction will add cost to a unit of blood, projections indicate that leukoreduced blood will become the standard of care.     

Severely elevated blood pressure: when is it an emergency?

High blood pressure is one of the most common chronic medical conditions in this country, occurring in about 1 of every 3 adults. It is not uncommon for nurses to see individuals in the emergency room, hospital, home, or other settings who have severely elevated blood pressure readings. Extremely elevated readings generally evoke considerable concern among healthcare staff. They are faced with deciding whether the individual requires immediate treatment and a higher level of care, such as transport to an emergency department. Severely elevated blood pressure can be a true medical emergency, may require urgent care, or may in fact be a nonemergency. The purpose of this article is to assist nurses in recognizing those situations in which severely elevated blood pressure requires immediate intervention. Current research and best evidence regarding severely elevated blood pressure are presented.