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The First Use of Penicillin in the United States

Jesse J. Waggoner, MD
[+] Article and Author Information

From Duke University School of Medicine, Durham, NC 27710.


Potential Financial Conflicts of Interest: None disclosed.


Ann Intern Med. 2009;150(2):145-146. doi:10.7326/0003-4819-150-2-200901200-00018
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Prehypertension is a true clinical condition
Posted on February 24, 2009
José F Vilela Martin
No Affiliation
Conflict of Interest: None Declared

I would like to make some commentaries about the letter to the editor published on January 20 2009 (1). Blood pressure (BP) is really a continuous variable in mathematical terms, but in practice clinic it means more than that. The true importance of the term "prehypertension" (PHT) defined by the VII Joint National Committee (2) is to call the attention of the primary service doctors, that treat the great majority of the hypertensive and pre-hypertensive patients, for a condition that until then was not observed, and even ignored as risk factor. The evidences show that prehypertensive patients present more probability to progress for high blood pressure (HBP) and increase the cardiovascular diseases risk (CVD), as approached by Pletcher et al. (3). This group of patients needs a stratification of the future risk of cardiovascular events for a best therapeutic decision. In high risk patients, mainly in the high normal BP group (130-139/85-89 mmHg), older, larger abdominal waist, larger body mass index, fasting hyperglycemia, hyperinsulinemia, higher insulin resistance index (HOMA), hypertriglyceridemia and lower HDL cholesterol level than prehypertensive individuals in the normal BP group (120-129/80-84 mmHg) the pharmacological treatment seems to be indicated.

Apparently, candesartan as well as ramipril delay the development of HBP by interfering in the structural and functional processes that precede the disease, such as vascular or neurohumoral causes that elevate the vascular tonus. The critics regarding the anti-hypertensive drugs merchants for the treatment of PHT are not sustained for the scientific evidences published on the progression for established HBP and the target organs damage due to this process. In fact, does not exist a magic limit saying that below such a numeric value of BP the individual is free from CVD risks. However, there are individuals either with associated risk factors (smoking, obesity, family history of CVD, hyperglycemia, dyslipidemia, etc.) or with other established diseases (diabetes, renal failure, coronary heart disease, stroke, etc.) that will prematurely benefit from the use of anti-hypertensive drugs before the organ lesion settles or, if already established, does not develop quickly. However, TROPHY and PHARAO studies (4, 5) did not answer the main question: "Does the treatment of PHT with drugs reduce the cardiovascular morbidity and mortality?" A study of clinical outcomes of long period comparing the relative effectiveness of the lifestyle modifications with pharmacological treatment could answer this question.

References

1. Marshall T. The rise of the term "Prehypertension". Ann Intern Med 2009;150:145.

2. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.

3. Pletcher MJ, Bibbins-Domingo K, Lewis CE, Wei GS, Sidney S, Carr JJ, et al. Prehypertension during young adulthood and coronary calcium later in life. Ann Intern Med 2008;149:91-9.

4. Julius S, Nesbitt SD, Egan BM, Weber MA, Michelson EL, Kaciroti N, et al. Trial of Preventing Hypertension (TROPHY) Study Investigators. Feasibility of treating prehypertension with an angiotensin-receptor blocker. N Engl J Med 2006;354:1685-97.

5. Lüders S, Schrader J, Berger J, Unger T, Zidek W, Böhm M, et al. The PHARAO study: prevention of hypertension with the angiotensin-converting enzyme inhibitor ramipril in patients with high-normal blood pressure: a prospective, randomized, controlled prevention trial of the German Hypertension League. J Hypertens 2008;26:1487-96.

Conflict of Interest:

None declared

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