Public education on hypertension: a new initiative to improve the prevention, treatment and control of hypertension in Canada

High blood pressure is one of the leading risk factors for death. Nevertheless, there is a lack of awareness of hypertension as a risk factor, as well as significant misconceptions about hypertension in the Canadian population. Furthermore, according to the Canadian Heart Health Surveys (1985 to 1992), 42% of hypertensive adult Canadians are unaware of their hypertensive status. A collaboration between Blood Pressure Canada, the Heart and Stroke Foundation of Canada, the Canadian Hypertension Society and the Canadian Hypertension Education Program has been formed to improve public and patient awareness and knowledge of hypertension. The effort will involve the translation of Canadian Hypertension Education Program recommendations for the prevention and management of hypertension to a public level with a broad and evolving dissemination strategy; the training of health professionals to speak to the public and patients on hypertension, coupled with opportunities to speak in forums organized in their local communities; and, media releases and information on hypertension in association with World Hypertension Day and the release of the annually updated public recommendations. Based on higher rates of awareness of hypertension in countries with sustained public education programs on hypertension, it is anticipated that this evolving program will result in improvement in the rates of awareness, treatment and control of hypertension and, ultimately, in lower cardiovascular disease rates in Canada. Public health programs that could reduce the prevalence of hypertension will be integrated into key public recommendations. The program outcomes will be monitored using Statistics Canada national surveys and by specific surveys examining hypertension knowledge in the Canadian population.     

Impact of hypertension in cardiac diseases in Spain. The CARDIOTENS Study 1999

INTRODUCTION AND OBJECTIVES: To analyze the prevalence and control of hypertensive patients with associated cardiac diseases in Spain. METHODS: All the 32,051 outpatients seen the same day by 1,159 primary physicians (79%) and cardiologists (21%) were prospectively included in a database including history of cardiac disease (heart failure, coronary disease or atrial fibrillation), casual blood pressure and ongoing treatments. RESULTS: Hypertension was present in 33% of the whole group and 19% had both hypertension and a cardiac disease. Hypertension was present in 77% of the patients with heart failure, in 66% of those with coronary diseases and in 66% with atrial fibrillation. Less than 60% of the hypertensive patients with heart failure were treated with an angiotensin or a converting enzyme inhibitor. Thirty-two percent of the hypertensive patients with coronary disease received a betablocker and 25% of the hypertensive patients with atrial fibrillation were on oral anticoagulation.Less than 20% of the patients with hypertension and cardiac disease had blood pressure levels under 130/85 mmHg as recommended by international guidelines. Patients seen by primary care physicians were found to be slightly better treated than those under cardiologists' care. CONCLUSIONS: High blood pressure is associated with heart failure, coronary disease and atrial fibrillation in a high percentage of patients. The blood pressure levels recommended by current guidelines for cardiac hypertensives were attained in less than 20% of the cases. The control of blood pressure in these high risk hypertensive patients was low and the use of appropriate pharmacological treatment was poor.     

Management of Older Hypertensive Patients: Is There a Difference in Approach?

Hypertension is the most common reason Americans visit a physician. Recent analyses from the Framingham Heart Study and others have shown that there will be 70 million hypertensive Americans by the year 2020 and that the overwhelming majority of hypertensives will be 65 years of age or older (what we used to call “elderly”). The lifetime risk of Americans who live to age 85 years of becoming hypertensive is approximately 90% for both men and women. These individuals, even if they develop an elevated blood pressure late in life, are at significantly increased risk of the many medical complications attributable to hypertension (coronary artery disease, strokes, heart failure, chronic renal disease, and more). Older hypertensives are more likely to have an elevated systolic blood pressure and a low diastolic blood pressure, both of which are related to a loss of article compliance and have an increase in left ventricular mass and a decrease in peripheral resistance. We now have a substantial body of evidence from well done clinical trials that older hypertensives benefit as much or more than younger patients from antihypertensive therapy, so there is no longer any justification for withholding medication from any hypertensive patient whose competing risk or other medical problems are not a contraindication to treatment. These same studies, and practice‐based analyses, have shown that the major barrier to reaching blood pressure goal is our failure to reduce systolic blood pressure to <140 mm Hg in most patients and to <130 mm Hg in diabetics and those with renal failure. The basis for all antihypertensive therapy, especially in older people, is thiazide diuretics with either angiotensin‐converting enzyme inhibitors, angiotensin receptor blockers, β blockers, or calcium entry blockers as appropriate add‐on treatment. The choice of the second agent depends on other factors, such as comorbidity, lifestyle, and affordability. We must be more aggressive in getting the message out that older hypertensives benefit from treatment and we must overcome the “clinical inertia” that seems to be a factor in the decision of many physicians not to treat an older patient. No older person should suffer a preventable, life‐threatening event or become confined to a wheel chair if attention to lifestyle issues and a few pills a day could avoid that outcome.     

Antihypertensive therapy and the concept of total cardiovascular protection

Drug-induced reduction of elevated blood pressure decreases cardiovascular mortality and morbidity in patients with moderate and severe hypertension. Furthermore, antihypertensive drug studies in mild hypertensive subjects (diastolic blood pressure 90 to 104 mm Hg) have shown protection against stroke, left ventricular hypertrophy, congestive heart failure and progression of renal damage, as well as improved patient longevity. The Hypertension Detection and Follow-up Program trial, recently carried out in the U.S., documented reduced coronary artery disease events (fatal and nonfatal) in special drug-treated patients with mild hypertension. From the standpoint of practical management and considering the ubiquity of essential hypertension, a modified stepped-care regimen advocating initial drug therapy with a beta blocker and addition of low-dose thiazide diuretic when necessary constitutes a judicious approach for widespread application. Although there are 8 orally active beta blockers currently approved in the U.S. for clinical use in systemic hypertension, only acebutolol possesses all of the salutary pharmacologic properties of cardioselectivity, intrinsic sympathomimetic activity and hydrophilicity, thereby making this compound an effective and safe beta-blocking agent for first-order management of a broad segment of the hypertensive population.     

Exercise hypertension: an adverse prognosis?

We sought to clarify the prognostic importance of an “exaggerated” or “hypertensive” systolic blood pressure response to exercise during an exercise test. Studies evaluating the prognosis for cardiovascular events and cardiovascular mortality in those with hypertension during exercise testing were systematically reviewed. Fourteen studies were identified. Six studies were of healthy volunteers or hypertensives. Eight studies were in subjects with known or suspected heart disease. Without established heart disease, exercise hypertension predicted cardiovascular events and cardiovascular death. However, two of the six studies included a multivariate analysis; both demonstrated no independent association. Studies in subjects with known or suspected heart disease demonstrated that exercise hypertension predicted fewer cardiac events and lesser mortality or, after multivariate adjustment, no associated risk. In a healthy population, a higher exercise blood pressure may indicate hypertension or prehypertension, instead of normal vascular function, and an associated long-term adverse prognosis. In a population with a high burden of heart disease, the highest risk subjects with the most extensive cardiac disease may not be capable of generating pressure or workload to allow the manifestation of exercise systolic hypertension. By comparison, therefore, those with exercise hypertension have a better prognosis.     

Lack of control of high blood pressure and treatment recommendations in Canada

BACKGROUND: Hypertension is a major risk factor for death that affects many Canadians, but only 16% of hypertensive Canadians are treated and have their hypertension controlled. While the control rate is very low, the 2001 Canadian Hypertension Recommendations do not recommend that low risk hypertensive patients be started on pharmacotherapy, and pharmacotherapy is not recommended for people for whom there is no demonstrable benefit from randomized, controlled trails. OBJECTIVES: To determine the proportion of hypertensive patients who are appropriately managed according to the 2001 Canadian Hypertension Recommendations. METHODS: Data from the Canadian Heart Health Survey, which surveyed a cross-sectional population (n=23,129) between 1986 and 1992, were used to determine the proportion of nondiabetic hypertensive patients who are managed according to the 2001 Canadian Hypertension Recommendations. Hypertensive patients not recommended to receive pharmacotherapy include those without risk factors and target organ damage, with a diastolic blood pressure of 90 to 99 mmHg and a systolic blood pressure of less than 160 mmHg. People with diastolic blood pressures of less than 90 mmHg who have systolic blood pressures of 140 to 159 mmHg are also not recommended to have pharmacotherapy. Patients prescribed antihypertensive therapy who had blood pressure controlled to less than 140/90 mmHg were assessed as having their hypertension managed appropriately, as were those who were not treated and were not recommended to be prescribed treatment. RESULTS: There were 58,813 (1.7%) hypertensive patients who did not have target organ damage or additional risk factors, and had a systolic blood pressure of less than 160 mmHg and a diastolic blood pressure between 90 and 99 mmHg. Twenty four per cent of hypertensive persons (831,787) had a systolic blood pressure of 140 to 160 mmHg and a diastolic blood pressure of less than 90 mmHg. About 25% (23.6%+1.7%) of hypertensive Canadians in the Canadian Heart Health Survey are not recommended to be prescribed antihypertensive therapy according to the 2001 Canadian Hypertension Recommendations. Sixteen per cent of hypertensive patients were treated and had their blood pressures controlled (blood pressure less than 140/90 mmHg). Therefore, about 41% (ie, 16%+25%) of hypertensive patients are appropriately managed according to the 2001 Canadian Hypertension Recommendations. CONCLUSIONS: The results of the Canadian Heart Health survey indicate that there are a striking number of Canadians with untreated high blood pressure (59%) who probably do not have their hypertension managed according to the 2001 Canadian Hypertension Recommendations. Greater efforts are required to identify people with hypertension, and to ensure that they are managed according to the best available evidence.     

The New Hypertension Guidelines

The Canadian Hypertension Education Program (CHEP) has published guidelines annually since 2000. The CHEP guidelines are a model of concise, comprehensive, up‐to‐date, evidence‐rated guidelines for physicians who diagnose and treat hypertension. The guidelines address measurement of blood pressure and the definition of hypertension, secondary hypertension evaluation and treatment, and blood pressure targets and medication choices in patients with and without compelling indications. This review describes CHEP's process for developing guidelines and provides an overview of the 2013 recommendations.     

Hypertension: Where have we gone wrong and how can we fix it?

Hypertension is defined as a disease of elevated systolic and diastolic blood pressure and consequently the goals of treating hypertension have been simply to normalize the blood pressure. However, effective blood pressure control has not resulted in the expected decreases in coronary artery disease. These findings have forced researchers to reexamine the importance of blood pressure in causing coronary artery disease, and to pose the question “Is there more to hypertension than high blood pressure?”Although there are probably several reasons for the poor reduction in the incidence of coronary artery disease in hypertensive patients, one of the most compelling appears to be the realization that hypertension is not simply a disease of numbers, but is a complex inherited syndrome of cardiovascular risk factors, all of which contribute to heart disease in these patients. Included in the hypertension syndrome are abnormalities of lipid profile, insulin resistance, changes in renal function, endocrine changes, obesity, abnormalities of coagulation factors, left ventricular hypertrophy and diastolic dysfunction, and abnormalities of vascular structure and compliance. In many patients, high blood pressure is a late manifestation of this disease process and is preceded by some or all of the associated cardiovascular risk factors.Perhaps where we have gone wrong in the management of hypertension is in the belief that this is simply a disease of numbers. To improve our management, we need to find methods to diagnose these patients early in the course of this disease process, and to treat it as a syndrome rather than as a number.     

How does hypertension affect your eyes?

Hypertension has profound effects on various parts of the eye. Classically, elevated blood pressure results in a series of retinal microvascular changes called hypertensive retinopathy, comprising of generalized and focal retinal arteriolar narrowing, arteriovenous nicking, retinal hemorrhages, microaneurysms and, in severe cases, optic disc and macular edema. Studies have shown that mild hypertensive retinopathy signs are common and seen in nearly 10% of the general adult non-diabetic population. Hypertensive retinopathy signs are associated with other indicators of end-organ damage (for example, left ventricular hypertrophy, renal impairment) and may be a risk marker of future clinical events, such as stroke, congestive heart failure and cardiovascular mortality. Furthermore, hypertension is one of the major risk factors for development and progression of diabetic retinopathy, and control of blood pressure has been shown in large clinical trials to prevent visual loss from diabetic retinopathy. In addition, several retinal diseases such as retinal vascular occlusion (artery and vein occlusion), retinal arteriolar emboli, macroaneurysm, ischemic optic neuropathy and age-related macular degeneration may also be related to hypertension; however, there is as yet no evidence that treatment of hypertension prevents vision loss from these conditions. In management of patients with hypertension, physicians should be aware of the full spectrum of the relationship of blood pressure and the eye.     

Swiss Hypertension and Risk Factor Program (SHARP): cardiovascular risk factors management in patients with type 2 diabetes in Switzerland

The prevalence of hypertension in type 2 diabetics is high, though there is no published data for Switzerland. This prospective cohort survey determined the frequency of type 2 diabetes mellitus associated with hypertension from medical practitioners in Switzerland, and collected data on the diagnostic and therapeutic work-up for cardiovascular risk patients. The Swiss Hypertension And Risk Factor Program (SHARP) is a two-part survey: The first part, I-SHARP, was a survey among 1040 Swiss physicians to assess what are the target blood pressure (BP) values and preferred treatment for their patients. The second part, SHARP, collected data from 20,956 patients treated on any of 5 consecutive days from 188 participating physicians. In I-SHARP, target BP?135/85 mmHg, as recommended by the Swiss Society of Hypertension, was the goal for 25% of physicians for hypertensives, and for 60% for hypertensive diabetics; values >140/90 mmHg were targeted by 19% for hypertensives, respectively 9% for hypertensive diabetics. In SHARP, 30% of the 20,956 patients enrolled were hypertensive (as defined by the doctors) and 10% were diabetic (67% of whom were also hypertensive). Six per cent of known hypertensive patients and 4% of known hypertensive diabetics did not receive any antihypertensive treatment. Diabetes was not treated pharmacologically in 20% of diabetics. Proteinuria was not screened for in 45% of known hypertensives and in 29% of known hypertensive diabetics. In Switzerland, most physicians set target BP levels higher than recommended in published guidelines. In this country with easy access to medical care, high medical density and few financial constraints, appropriate detection and treatment for cardiovascular risk factors remain highly problematic.     

The Hypertension Management Program: Identifying Opportunities for Improvement

To date, relatively few programs have been evaluated that were designed to affect the clinical practice patterns of primary care physicians who treat patients with hypertension. In particular, studies that have evaluated blood pressure control as a clinical outcome before and after an intervention are lacking. The Hypertension Management Program, developed by Applied Health Outcomes, is a quality improvement program designed to improve the medical management of hypertension in population based health care settings. This program is in the process of continuing to collect baseline data from health maintenance organizations, conducting physician-focused interventions designed for improving clinical care, and collecting postintervention data between 6 and 12 months after the intervention is completed to determine its effect. The authors present the rationale for conducting large-scale hypertension management programs that measure outcomes, as well as preliminary baseline and postintervention data from the Hypertension Management Program, based on a current database of more than 1.9 million individuals enrolled in eight health care plans.     

The Canadian Hypertension Education Program--a unique Canadian initiative

While almost two-thirds of all strokes and one-half of all myocardial infarctions could be prevented if hypertensive individuals had their blood pressures optimally controlled, only a minority of hypertensive individuals (even in publicly funded health care systems with subsidization of medication costs) achieve target blood pressures. Traditional hypertension guidelines have had limited impact on hypertension management and control rates. As a result, the Canadian Hypertension Education Program was developed to address the perceived flaws in the traditional hypertension guideline approach. In the present article, the key features of the Canadian Hypertension Education Program methodology are reviewed, with attention to those factors thought to be critical to the successful translation of recommendations into practice.     

GeogRaphic and socioecoNomic Distribution of real-world Indian data of home blood pressure monitoring (GRAND Study): Study protocol for an observational study in 18 medical centers across India

One-fourth of death in India is attributed to cardiovascular disease (CVD) and more than 80% is related to ischemic heart disease and stroke. The main risk factor for CVD is hypertension. Every third person in India suffers from hypertension and the prevalence increased drastically in the past 20 years, especially among the youngest age group of 20 and 44 years. Regardless of being under anti-hypertension medication, the blood pressure (BP) control rate in the country is still low ranging between 6% and 28% only. Assessing the “true BP control rate” should be performed using both clinic BP measurement and out-of-office BP measurement as the latter shows better prognosis for patients’ hypertension and CVD outcomes. Home blood pressure monitoring (HBPM) shows superiority over ambulatory BP measurement as multiple measurements can be collected at the patient's convenience. Only limited evidence on HBPM in India is available and it's either lacking in hypertension participants or of a small sample size. This study will investigate the real BP control status among 2000 hypertensive patients from 18 centers in 12 states across Pan-India. The outcome of this study will emphasize the value of establishing BP control management practice guidelines suitable for physicians and help policymakers in building proper strategies for hypertension management to reduce the CVD burden on the health situation in India.     

The eye in hypertension

Hypertension has a range of effects on the eye. Hypertensive retinopathy refers to retinal microvascular signs that develop in response to raised blood pressure. Signs of hypertensive retinopathy are frequently seen in adults 40 years and older, and are predictive of incident stroke, congestive heart failure, and cardiovascular mortality--independently of traditional risk factors. Hypertension is also a major risk factor for the development of other retinal vascular diseases, such as retinal vein and artery occlusion, and ischaemic optic neuropathy. High blood pressure increases the risk of both development of diabetic retinopathy and its progression. Adequate control of blood pressure has been proven in randomised clinical trials to reduce vision loss associated with diabetic retinopathy. Finally, hypertension has been implicated in the pathogenesis of glaucoma and age-related macular degeneration. Recognition of the ocular effects of blood pressure could allow physicians to better manage patients with hypertension, and to monitor its end-organ effects.     

Implementing standardized performance indicators to improve hypertension control at both the population and healthcare organization levels

The ability to reliably evaluate the impact of interventions and changes in hypertension prevalence and control is critical if the burden of hypertension‐related disease is to be reduced. Previously, a World Hypertension League Expert Committee made recommendations to standardize the reporting of population blood pressure surveys. We have added to those recommendations and also provide modified recommendations from a Pan American Health Organization expert meeting for “performance indicators” to be used to evaluate clinical practices. Core indicators for population surveys are recommended to include: (1) mean systolic blood pressure and (2) mean diastolic blood pressure, and the prevalences of: (3) hypertension, (4) awareness of hypertension, (5) drug‐treated hypertension, and (6) drug‐treated and controlled hypertension. Core indicators for clinical registries are recommended to include: (1) the prevalence of diagnosed hypertension and (2) the ratio of diagnosed hypertension to that expected by population surveys, and the prevalences of: (3) controlled hypertension, (4) lack of blood pressure measurement within a year in people diagnosed with hypertension, and (5) missed visits by people with hypertension. Definitions and additional indicators are provided. Widespread adoption of standardized population and clinical hypertension performance indicators could represent a major step forward in the effort to control hypertension.     

The potential anti-inflammatory benefits of improving physical fitness in hypertension

Hypertension is associated with an increased risk of stroke and atherosclerosis. In addition to elevated blood pressure, hypertension is characterized by neuroendocrine and immune activation, including elevated levels of C-reactive protein, inflammatory cytokines, and soluble adhesion molecules, which are predictive of morbidity and mortality outcomes. Pharmacological treatment for hypertension reduces blood pressure, but has limited effectiveness in reducing the accompanying inflammation and its associated morbidity and mortality. Exercise and diet interventions regularly show reductions in blood pressure in hypertensive individuals. Similar interventions in other populations show reductions in many inflammatory markers, but these effects have not been routinely examined in hypertensive individuals. The mechanisms through which exercise might exert an anti-inflammatory action include the sympathetic nervous system, the hypothalamic-pituitary-adrenal axis, as well as direct effects of blood pressure. Here, exercise is promoted as a potentially effective treatment for both the elevated blood pressure and chronic inflammation found in hypertension.     

Does rapidity of blood pressure lowering affect outcomes in hypertension treatment?

Hypertension affects more than 65 million Americans and is inadequately controlled in most of them. The presence of uncontrolled hypertension confers increased rates of cardiovascular mortality. The benefits of blood pressure reduction have been clearly demonstrated in many large placebo-controlled trials. Even small differences in blood pressure can reduce the number of major cardiovascular events. Data from the Study on Cognition and Prognosis in the Elderly (SCOPE), Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) study, and Systolic Hypertension in Europe (Syst-Eur) trial demonstrate that the achievement of early blood pressure reduction has long-term benefits on cardiovascular outcomes. VALUE demonstrated that blood pressure control within the first month of treatment was independently linked to cardiovascular outcomes. Similar results were obtained in the SCOPE and Syst-Eur trials when hypertensive therapy was delayed from 3 months to 2 years. The early achievement of blood pressure control should be of paramount importance both for physicians and their patients.     

Cardiovascular risk factor control in communities--update from the ASH Carolinas-Georgia Chapter, the Hypertension Initiative, and the Community Physicians' Network

The prevalence of hypertension dictates that blood pressure must be managed effectively in primary care. The American Society of Hypertension (ASH) regional chapters and clinical hypertension specialists represent a positive response by ASH to the growing problems of hypertension and metabolic syndrome-related risks and disease. To have a significant public health effect, the impact of clinical hypertension specialists must be leveraged. Key activities in the community include educating other providers locally, delivering care for complex referral patients, and fostering growth of a practice network with a central database in collaboration with academic partners. The database supports practice audit and feedback reports to enhance quality improvement, identify continuing medical education topics, and facilitate clinical trials to test new therapeutic and best-practice approaches to risk factor management. The ASH regional chapters serve as a forum for community and academic hypertension specialists to collaborate with like-minded individuals and organizations. The collaboration among the ASH Carolinas-Georgia chapter, the Hypertension Initiative, and the Community Physicians' Network provides a model for other ASH chapters and health delivery groups to partner in delivering continuing medical education programs focused on cardiovascular risk factor management, recruiting practices into the network, and developing and maintaining a centralized patient database. Evidence suggests that this collaboration is facilitating application of evidence-based medicine and risk factor control.     

中国心血管内科医师高血压情况和心血管病发病风险

目的 了解中国心血管内科医师高血压患病、治疗和控制情况,评估心血管内科医师心血管疾病发病的风险,为制定干预策略、促进人群健康提供依据.方法 对中国内地31个省、自治区、直辖市,共386家综合性医院心血管内科共4032名心血管内科医师进行高血压患病率、知晓率、治疗率和控制率的流行病学调查,并对冠心病和缺血性心血管疾病的发病风险进行评估.结果 我国心血管内科医师的高血压患病率为13.1%.心血管内科医师的高血压知晓率为81.7%,治疗率为69.6%,控制率44.6%.心血管内科医师55岁之前高血压患病率男性高于女性,55岁以后两性之间差异无统计学意义.高血压组Framinham冠心病风险量表的10年冠心病风险平均为0.08,非高血压组平均为0.03.国人10年缺血性心血管病风险量表的10年绝对风险高血压组平均为0.03,非高血压组平均为0.01.结论 中国心血管内科医师高血压的知晓率、治疗率、控制率均不够理想.患高血压医师的心血管疾病风险较高,有必要提倡其对血压情况的自我监测.

Abstract：

Objective To observe the prevalence, awareness, treatment and control rate of hypertension and to evaluate the 10-year absolute risk of coronary heart disease (CHD) and ischemic cardiovascular disease (ICVD) in Chinese cardiovascular physicians. Methods A total of 4032cardiovascular physicians (28 to 79 years old) from 386 hospitals in 31 provinces, autonomous regions and municipalities were randomly selected and received an epidemiologic survey of prevalence, awareness, and control of hypertension and evaluations of CHD and ICVD risk. Results The prevalence of hypertension in Chinese cardiovascular physicians was 13.1%. The awareness rate of hypertension in Chinese cardiovascular physicians was 81.7%. Hypertension treatment rate was 69. 6% and blood pressure control rate was 44. 6%. The prevalence of hypertension was higher in male physicians than in female physicians before the age of 55 years old. Ten-year absolute risk of CHD and ICVD was 0. 08 and 0. 03 in hypertensive physicians compared to 0. 03 and 0. 01 in non-hypertensive physicians. Conclusions The results show suboptimal awareness, treatment and control rate in Chinese cardiovascular physicians for their own hypertension status. Physicians suffering from hypertension face higher risk for cardiovascular disease. It is therefore necessary to improve the self-monitoring of blood pressure in Chinese cardiovascular physicians.     

The Role of Stress and the Sympathetic Nervous System in Hypertension and Ischemic Heart Disease: Advantages of Therapy with β-Receptor Blockers

Human and animal studies link social and environmental factors to hypertension and ischemic heart disease. Job stress and undesirable life events may precede the development of raised blood pressure. Hypertension and ischemic heart disease vanquished many of the survivors of the seige of Leningrad.

Specific behavior patterns of some patients with ischemic heart disease and the pschological ambience of others with hypertension have been associated with raised neural tone as reflected by levels of plasma norepinephrine and epinephrine. Sympathoneural hypertonicity is a factor in left ventricular hypertrophy and the latter has been a prophet for sudden cardiac death. Sympathoadrenal surges may contribute to both reduced coronary reserve in hypertensives and increased vulnerabily to ventricular dysrhythmia.

The “coronary epidemic” of our modern times appears related in part to outdated survival mechanisms, not suitable to human behavior in our urban milieu. Beta receptor blocking agents are effective antidotes providing protection from adrenomedullary overdrive and even perhaps, modification of that behavior. Stress and the sympathetic nervous system are important co-conspirators in hypertension and sudden cardiac death.