Hypertension

This bibliography contains literature on hypertension, as well as commentary from the contributing editor (listed at the bottom of the page). Articles include clinical trials, behavioral, and self-management support literature and are ordered in descending chronological sequence. Links to the articles on the National Library of Medicine (NLM) Web site are given, as available. The NLM site provides direct links to article abstracts, as well as other information. For information regarding the research methodology used to produce this bibliography, see the Bibliography Overview.
 
Articles referencing clinicial guidelines may not reflect current standards.  For up-to-date clinical guidelines, please consult the National Guideline Clearinghouse (NGC), a public resource for evidence-based clinical practice guidelines. NGC is an initiative of the Agency for Healthcare Research and Quality.

Guidelines
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr, Jones DW, Materson BJ, Oparil S, Wright JT, Jr, Roccella EJ. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289(19):2560-72. [Link]

A summary of the 7th edition of the Joint National Committee (JNC) on the Detection, Evaluation and Treatment of High Blood Pressure guidelines for the identification and treatment of hypertension.
 
Medications
Psaty BM, Lumley T, Furberg CD, Schellenbaum G, Pahor M, Alderman MH, Weiss NS. Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA 2003;289:2534-2544. [Link]

A meta-analysis of randomized controlled trials comparing the efficacy and safety of hypertensive medications to decrease cardiovascular morbidity and mortality. Low-dose diuretics are the most effective first-line treatment for preventing the occurrence of cardiovascular disease morbidity and mortality.
 
The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium-channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288:2981-2997. [Link]

33,357 participants aged 55 years or older with hypertension and at least one other CHD risk factor from 623 North American centers were randomized to receive either: chlorthalidone, 12.5 to 25 mg/d; amlodipine, 2.5 to 10 mg/d; or lisinopril, 10 to 40 mg/d. After a mean follow-up of 4.9 years, there were no differences between groups for the primary outcomes of all non-fatal and fatal myocardial infarction. In the analysis of secondary outcomes, chlorthalidone and lisinopril reduced the risk of heart failure compared to amlodipine. Chlorthalidone compared to lisinopril had slightly but significantly lower rates of all cardiovascular outcomes, strokes, and heart failure. Thiazide-type diuretics, in addition to being less costly, were found to be superior in preventing one or more major forms of CVD.
 
SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:3255-3264. [Link]

In persons aged 60 years and over with isolated systolic hypertension, antihypertensive stepped-care drug treatment with low-dose chlorthalidone as step one medication reduced the incidence of total stroke by 36%, with five-year absolute benefit of 30 events per 1000 participants. Major cardiovascular events were reduced by 27%, with five-year absolute benefit of 55 events per 1000.
 
Barriers To Improving The Care of Hypertension
Psaty BM, Manolio TA, Smith, Heckbert SR, Gottdiener JS, Burke GL, Weissfeld J, Enright P, Lumley T, Powe N, Furberg CD. Time trends in high blood pressure control and the use of antihypertensive medications in older adults: the Cardiovascular Health Study. Arch Intern Med 2002; 162(20):2325-32. [Link]

Control of high blood pressure improved in the 1990s, while about half the participants with hypertension had uncontrolled blood pressure (primarily mild to moderate elevations in systolic blood pressure). Low-dose diuretics and beta-blockers -- the preferred agents since 1993, according to the recommendations of the JNC -- remain underused.
 
Hyman DJ, Pavlik VN. Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine. Arch Intern Med 2000; 160(15):2281-6. [Link]

Physicians have higher blood pressure thresholds for the diagnosis and treatment of hypertension than the 140/90 mm Hg criterion recommended by the JNC. 41% of the physicians were not aware of the JNC hypertension guidelines, but those who were used more evidence-based treatments.
 
Berlowitz DR, Ash A, Hickey E, Friedman RH, Glickman M, Kader B, Moskowitz MA. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998; 339:1957-63. [Link]

A discussion of the gaps in the diagnosis and treatment of hypertension in the United States.
 
Primary Care Interventions
Montgomery AA, Fahey T, Peters TJ, MacIntosh C, Sharp DJ. Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial. BMJ 2000; 320(7236):686-90. [Link]

The use of computer-based decision support and a chart-based risk tool did not improve hypertension care. For the patients that were assigned to chart-based risk tools alone, systolic blood pressure was significantly reduced.
 
Hetlevik I, Holmen J, Kruger O. Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system. Scand J Prim Health Care 1999; 17(1):35-40. [Link]

Providing physicians with decision support with hypertension guidelines and feedback on their baseline performance did not improve blood pressure control.
 
Goldberg HI, Wagner EH, Fihn SD, Martin DP, Horowitz CR, Christensen DB, Cheadle AD, Diehr P, Simon G. A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines? Jt Comm J Qual Improv 1998; 24(3):130-42. [Link]

Academic detailing (in clinic training sessions for medical teams) and continuous quality improvement (CQI) were ineffective in improving guideline compliance and clinical outcomes related to hypertension.
 
Mashru M, Lant A. Interpractice audit of diagnosis and management of hypertension in primary care: educational intervention and review of medical records. BMJ 1997; 314(7085):942-6. [Link]

Peer review audit of medical records of hypertensive patients did not lead to improved blood pressure diagnosis or control.
 
Self-Management Support
Boulware LE, Daumit GL, Frick KD, Minkovitz CS, Lawrence RS, Powe NR. An evidence-based review of patient-centered behavioral interventions for hypertension. Am J Prev Med 2001; 21(3):221-32. [Link]

A systematic review of educational, training, and self-management support interventions to improve hypertension care and outcomes.
 
Friedman RH, Kazis LE, Jette A, Smith MB, Stollerman J, Torgerson J, Carey K. A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control. Am J Hypertens 1996; 9(4 Pt 1):285-92. [Link]

Home blood pressure monitoring with telephone linked communications to titrate medications based on blood pressure readings resulted in improved medication adherence and blood pressure control.
 
Interventions To Change Lifestyle Behaviors Associated With Hypertension
Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, Stevens VJ, Vollmer WM, Lin PH, Svetkey LP, Stedman SW, Young DR. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003; 289(16):2083-93. [Link]

Subjects with stage one hypertension or high normal blood pressure assigned to either an “established” lifestyle change intervention or this plus the DASH diet (a diet rich in fruits, vegetables, and low-fat dairy products and reduced in saturated and total fat) significantly lowered their blood pressure and reduced cardiovascular risk compared to those in the “usual advice group”.
 
Mulrow CD, Chiquette E, Angel L, Cornell J, Summerbell C, Anagnostelis B, Brand M, Grimm R Jr. Dieting to reduce body weight for controlling hypertension in adults (Cochrane Review). The Cochrane Library 2002; (Issue 3):Chichester: Wiley. DOI. Oxford: Update Software. [Link]

Weight-reducing diets in overweight hypertensive persons can affect modest weight loss in the range of 3-9% of body weight, and are associated with modest blood pressure decreases of roughly 3 mm Hg systolic and diastolic. Weight reduction diets may decrease dosage requirements of persons taking antihypertensive medications.
 
Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, Roccella EJ, Stout R, Vallbona C, Winston MC, Karimbakas J. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. JAMA 2002; 288(15):1882-8. [Link]

A systematic review of interventions that have proven efficacy for decreasing elevated blood pressure levels for those with high normal blood pressure or hypertension including: engaging in physical activity; maintaining normal body weight; limiting alcohol consumption; reducing sodium intake; maintaining adequate intake of potassium; and consuming a diet rich in fruits, vegetables, and low-fat dairy products and reduced in saturated and total fat.
 
Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002; 136(7):493-503. [Link]

A meta-analysis of 54 randomized, controlled trials (2419 participants) whose intervention and control groups differed only in aerobic exercise. Aerobic exercise was associated with a significant reduction in mean systolic and diastolic blood pressure (-3.84 mm Hg [95% CI, -4.97 to -2.72 mm Hg] and -2.58 mm Hg [CI, -3.35 to -1.81 mm Hg], respectively).
 
Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Engl J Med 2001;344:3-10. [Link]

Reducing sodium intake from the high to the intermediate level reduced the systolic blood pressure by 2.1 mm. As compared with the control diet with a high sodium level, the DASH diet with a low sodium level led to a mean systolic blood pressure that was 7.1 mm Hg lower in participants without hypertension, and 11.5 mm Hg lower in participants with hypertension.
 
Systems of Care
Taylor CT, Byrd DC, Krueger K. Improving primary care in rural Alabama with a pharmacy initiative. Am J Health Syst Pharm. 2003 Jun 1;60(11):1123-9. [Link]

Chronic disease patients receiving care in an underserved rural primary care setting, a medication monitoring and education intervention conducted by a clinical pharmacist improved adherence to a wide range of medication regimens for hypertension, diabetes, dyslipidemia, and anticoagulation therapy.
 
Rogers MA, Small D, Buchan DA, Butch CA, Stewart CM, Krenzer BE, Husovsky HL. Home monitoring services improves mean arterial pressure in patients with essential hypertension. Ann Intern Med 2001; 134:1024-32. [Link]

Home blood pressure monitoring recordings were transmitted to the research assistants, and physicians were given weekly reports resulting in improved blood pressure control over usual care.
 
Soghikian K, Casper SM, Fireman BH, Hunkeler EM, Hurley LB, Tekawa IS, Vogt TM. Home blood pressure monitoring. Effect on use of medical services and medical care costs. Med Care 1992; 30(9):855-65. [Link]

Home blood pressure monitoring recordings were mailed to the research team who transposed these onto a computer algorithm. Intervention subjects had improved blood pressure control, fewer office visits, more telephones, and cost $9.00 less per year (which was not quite statistically significant) than those receiving usual care.
 
Bibliography Editors
Beverly B. Green, M.D., M.P.H.
Dr. Green is Associate Director of the Department of Preventive Care at Group Health, an affiliate scientist at the Group Health Research Institute, and Assistant Professor at the University of Washington. She completed residency training in family medicine, fellowship training in The Robert Wood Johnson Faculty Development Program, and is a practicing family doctor and an epidemiologist. She has over 20 years of experience in the development and implementation of evidence-based clinical guidelines. She worked with the Care Management Institute of Kaiser to develop their national guidelines for hypertension and was a reviewer for the U.S. Preventive Services Task Force Hypertension Guideline. 

Bruce M. Psaty, M.D., Ph.D.
Dr. Psaty is a general internist and cardiovascular disease epidemiologist with interests and expertise in pharmacoepidemiology, pharmacogenetics, and drug safety. He is a senior investigator at the Group Health Research Institute, and a professor of medicine, epidemiology, and health services at the University of Washington.