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      Prevention of hypertension in patients with pre-hypertension: protocol for the PREVER-prevention trial

      , 1 , 1 , 1 , 1 , 2 , 3 , 4 , 5 , 5 , 6 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 22 , 23 , 1 , 1 , 1 , 1 , 24


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          Blood pressure (BP) within pre-hypertensive levels confers higher cardiovascular risk and is an intermediate stage for full hypertension, which develops in an annual rate of 7 out of 100 individuals with 40 to 50 years of age. Non-drug interventions to prevent hypertension have had low effectiveness. In individuals with previous cardiovascular disease or diabetes, the use of BP-lowering agents reduces the incidence of major cardiovascular events. In the absence of higher baseline risk, the use of BP agents reduces the incidence of hypertension. The PREVER-prevention trial aims to investigate the efficacy, safety and feasibility of a population-based intervention to prevent the incidence of hypertension and the development of target-organ damage.


          This is a randomized, double-blind, placebo-controlled clinical trial, with participants aged 30 to 70 years, with pre-hypertension. The trial arms will be chlorthalidone 12.5 mg plus amiloride 2.5 mg or identical placebo. The primary outcomes will be the incidence of hypertension, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new sub-clinical atherosclerosis, and sudden death. The study will last 18 months. The sample size was calculated on the basis of an incidence of hypertension of 14% in the control group, a size effect of 40%, power of 85% and P alpha of 5%, resulting in 625 participants per group. The project was approved by the Ethics committee of each participating institution.


          The early use of blood pressure-lowering drugs, particularly diuretics, which act on the main mechanism of blood pressure rising with age, may prevent cardiovascular events and the incidence of hypertension in individuals with hypertension. If this intervention shows to be effective and safe in a population-based perspective, it could be the basis for an innovative public health program to prevent hypertension in Brazil.

          Trial Registration

          Clinical Trials NCT00970931.

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          Most cited references 23

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          Global burden of hypertension: analysis of worldwide data.

          Reliable information about the prevalence of hypertension in different world regions is essential to the development of national and international health policies for prevention and control of this condition. We aimed to pool data from different regions of the world to estimate the overall prevalence and absolute burden of hypertension in 2000, and to estimate the global burden in 2025. We searched the published literature from Jan 1, 1980, to Dec 31, 2002, using MEDLINE, supplemented by a manual search of bibliographies of retrieved articles. We included studies that reported sex-specific and age-specific prevalence of hypertension in representative population samples. All data were obtained independently by two investigators with a standardised protocol and data-collection form. Overall, 26.4% (95% CI 26.0-26.8%) of the adult population in 2000 had hypertension (26.6% of men [26.0-27.2%] and 26.1% of women [25.5-26.6%]), and 29.2% (28.8-29.7%) were projected to have this condition by 2025 (29.0% of men [28.6-29.4%] and 29.5% of women [29.1-29.9%]). The estimated total number of adults with hypertension in 2000 was 972 million (957-987 million); 333 million (329-336 million) in economically developed countries and 639 million (625-654 million) in economically developing countries. The number of adults with hypertension in 2025 was predicted to increase by about 60% to a total of 1.56 billion (1.54-1.58 billion). Hypertension is an important public-health challenge worldwide. Prevention, detection, treatment, and control of this condition should receive high priority.
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            A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group.

            It is known that obesity, sodium intake, and alcohol consumption factors influence blood pressure. In this clinical trial, Dietary Approaches to Stop Hypertension, we assessed the effects of dietary patterns on blood pressure. We enrolled 459 adults with systolic blood pressures of less than 160 mm Hg and diastolic blood pressures of 80 to 95 mm Hg. For three weeks, the subjects were fed a control diet that was low in fruits, vegetables, and dairy products, with a fat content typical of the average diet in the United States. They were then randomly assigned to receive for eight weeks the control diet, a diet rich in fruits and vegetables, or a "combination" diet rich in fruits, vegetables, and low-fat dairy products and with reduced saturated and total fat. Sodium intake and body weight were maintained at constant levels. At base line, the mean (+/-SD) systolic and diastolic blood pressures were 131.3+/-10.8 mm Hg and 84.7+/-4.7 mm Hg, respectively. The combination diet reduced systolic and diastolic blood pressure by 5.5 and 3.0 mm Hg more, respectively, than the control diet (P or =140 mm Hg; diastolic pressure, > or =90 mm Hg; or both), the combination diet reduced systolic and diastolic blood pressure by 11.4 and 5.5 mm Hg more, respectively, than the control diet (P<0.001 for each); among the 326 subjects without hypertension, the corresponding reductions were 3.5 mm Hg (P<0.001) and 2.1 mm Hg (P=0.003). A diet rich in fruits, vegetables, and low-fat dairy foods and with reduced saturated and total fat can substantially lower blood pressure. This diet offers an additional nutritional approach to preventing and treating hypertension.
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              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

               M R Law,  J K Morris,  N Wald (2009)
              Objectives To determine the quantitative efficacy of different classes of blood pressure lowering drugs in preventing coronary heart disease (CHD) and stroke, and who should receive treatment. Design Meta-analysis. Data source Medline (1966-2007). Study selection Randomised trials of blood pressure lowering drugs recording CHD events and strokes. 108 trials studied differences in blood pressure between study drug and placebo (or control group not receiving the study drug) (“blood pressure difference trials”), and 46 trials compared drugs (“drug comparison trials”). Seven trials with three randomised groups fell into both categories. The results were interpreted in the context of those expected from the largest published meta-analysis of cohort studies, totalling 958 000 people. Participants 464 000 people defined into three mutually exclusive categories: participants with no history of vascular disease, a history of CHD, or a history of stroke. Results In the blood pressure difference trials β blockers had a special effect over and above that due to blood pressure reduction in preventing recurrent CHD events in people with a history of CHD: risk reduction 29% (95% confidence interval 22% to 34%) compared with 15% (11% to 19%) in trials of other drugs. The extra effect was limited to a few years after myocardial infarction, with a risk reduction of 31% compared with 13% in people with CHD with no recent infarct (P=0.04). In the other blood pressure difference trials (excluding CHD events in trials of β blockers in people with CHD), there was a 22% reduction in CHD events (17% to 27%) and a 41% (33% to 48%) reduction in stroke for a blood pressure reduction of 10 mm Hg systolic or 5 mm Hg diastolic, similar to the reductions of 25% (CHD) and 36% (stroke) expected for the same difference in blood pressure from the cohort study meta-analysis, indicating that the benefit is explained by blood pressure reduction itself. The five main classes of blood pressure lowering drugs (thiazides, β blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers) were similarly effective (within a few percentage points) in preventing CHD events and strokes, with the exception that calcium channel blockers had a greater preventive effect on stroke (relative risk 0.92, 95% confidence interval 0.85 to 0.98). The percentage reductions in CHD events and stroke were similar in people with and without cardiovascular disease and regardless of blood pressure before treatment (down to 110 mm Hg systolic and 70 mm Hg diastolic). Combining our results with those from two other studies (the meta-analyses of blood pressure cohort studies and of trials determining the blood pressure lowering effects of drugs according to dose) showed that in people aged 60-69 with a diastolic blood pressure before treatment of 90 mm Hg, three drugs at half standard dose in combination reduced the risk of CHD by an estimated 46% and of stroke by 62%; one drug at standard dose had about half this effect. The present meta-analysis also showed that drugs other than calcium channel blockers (with the exception of non-cardioselective β blockers) reduced the incidence of heart failure by 24% (19% to 28%) and calcium channel blockers by 19% (6% to 31%). Conclusions With the exception of the extra protective effect of β blockers given shortly after a myocardial infarction and the minor additional effect of calcium channel blockers in preventing stroke, all the classes of blood pressure lowering drugs have a similar effect in reducing CHD events and stroke for a given reduction in blood pressure so excluding material pleiotropic effects. The proportional reduction in cardiovascular disease events was the same or similar regardless of pretreatment blood pressure and the presence or absence of existing cardiovascular disease. Guidelines on the use of blood pressure lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure. Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some.

                Author and article information

                [1 ]Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
                [2 ]Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, Brazil
                [3 ]Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
                [4 ]Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil
                [5 ]Instituto do Coração, Universidade de São Paulo, São Paulo, Brazil
                [6 ]Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo, Ribeirão Preto, Brazil
                [7 ]Faculdade de Medicina São José do Rio Preto, São José do Rio Preto, Brazil
                [8 ]Faculdade de Ciências Médicas, Universidade de Campinas, Campinas, Brazil
                [9 ]Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, Ribeirão Preto, Brazil
                [10 ]Faculdade de Medicina de Botucatu, Universidade Estadual de São Paulo, Botucatu, Brazil
                [11 ]Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
                [12 ]Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
                [13 ]Hospital das Clínicas de Goiânia, Universidade Federal de Goiás, Goiânia, Brazil
                [14 ]Anis Rassi Hospital, Goiânia, Brazil
                [15 ]Hospital Universitário Júlio Muller, Universidade Federal de Mato Grosso, Cuiabá, Brazil
                [16 ]Faculdade de Medicina, Universidade de Ciências da Saúde Alagoas, Maceió, Brazil
                [17 ]Faculdade de Medicina, Universidade Federal de Pernambuco, Recife, Brazil
                [18 ]Instituto de Medicina Integral Prof Fernando Figueira, Recife, Brazil
                [19 ]Hospital Universitário Oswaldo Cruz/PROCAPE, Universidade de Pernambuco, Recife, Brazil
                [20 ]Hospital Universitário Valter Cantídio, Universidade Federal do Ceará, Fortaleza, Brazil
                [21 ]Hospital Universitário, Universidade Federal Maranhão, São Luiz, Brazil
                [22 ]Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, Brazil
                [23 ]Faculdade de Medicina, Universidade Federal de Pelotas, Pelotas, Brazil
                [24 ]Hospital do Coração, São Paulo, Brazil
                BioMed Central
                5 March 2011
                : 12
                : 65
                Copyright ©2011 Fuchs et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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