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In This Issue of JAMA |

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JAMA. 2014;311(5):439-441. doi:10.1001/jama.2013.279304.
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Elevated blood pressure is common during acute ischemic stroke. In a multicenter randomized clinical trial involving 4071 patients with acute ischemic stroke and elevated systolic blood pressure, He and colleagues assessed the effect of immediate blood pressure reduction on mortality and major disability. The authors found that compared with discontinuation of antihypertensive medications during hospitalization, antihypertensive treatment to lower blood pressure did not reduce the likelihood of death and major disability at 14 days or at hospital discharge. In an Editorial, Saver discusses blood pressure management in early ischemic stroke.

Related Editorial

In an analysis of data from a longitudinal cohort study of 4681 individuals aged 18 to 30 years at baseline and followed up for 25 years, Allen and colleagues examined the association between blood pressure trajectories throughout early adulthood and the presence of coronary artery calcification during middle age. The authors identified 5 distinct blood pressure trajectories—low-stable, moderate-stable, moderate-increasing, elevated-stable, and elevated-increasing—and found that trajectories with elevated blood pressure levels were associated with an increased risk of coronary artery calcification in middle age. In an Editorial, Sarafidis and Bakris discuss the association of blood pressure change with subclinical coronary heart disease.

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Left atrial fibrosis is common in patients with atrial fibrillation (AF), and extensive fibrosis has been associated with poor outcomes of rhythm-control strategies such as catheter ablation. In a multicenter prospective study that enrolled 329 patients with a history of AF who were scheduled to undergo a first ablation procedure, Marrouche and colleagues assessed the association of quantification of atrial fibrosis using delayed enhancement magnetic resonance imaging (DE-MRI) with subsequent outcomes of AF catheter ablation. The authors report that atrial tissue fibrosis estimated by DE-MRI was independently associated with the likelihood of recurrent arrhythmia.

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CLINICAL REVIEW & EDUCATION

In this JAMA article, James and colleagues—panel members appointed to the Eighth Joint National Committee (JNC 8)—present an executive summary of their evidence-based guideline for the management of high blood pressure in adults. The guideline draws on evidence from randomized clinical trials to address 3 clinical questions relating to high blood pressure management and clinical outcomes: the threshold to initiate antihypertensive pharmacologic treatment, blood pressure goals for pharmacologic treatment, and comparative benefits and harms of antihypertension medications. The authors describe the evidence review and guideline development process; report their recommendations for blood pressure goals and treatment and the level of evidence supporting the recommendations; and highlight differences from the previous JNC 7 report. Three editorials address important issues in guideline development and review and discuss implications for patient care and health policy.

Related Editorials 1, 2, and 3

Splitting drug tablets to achieve an intermediate dose or to economize when a higher strength tablet costs the same as a desired lower dose. This Medical Letter article summarizes data on active drug uniformity and drug content in split tablets; factors that influence accuracy in tablet splitting; and contraindications to splitting. Ultimately, while splitting tablets may not have adverse clinical consequences and may reduce costs for patients and institutions, using a whole tablet is the safest way to ensure accurate dosing.

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