In Reply: Drs Berlowitz and Cushman and Mr Glassman are correct in pointing out that improvements were made in blood pressure control among some subgroups during the decade of the 1990s; the VA experience that they cite is a remarkable example. Major systematic efforts were required to achieve these impressive results. Unfortunately, the success of the VA with regard to hypertension control was not mirrored in the community or in the nation as a whole during the 1990s. Data from the nationally representative NHANES samples reveal that, among all patients with hypertension, blood pressure control rates increased from approximately 25% between 1988 and 1991 to only 31% between 1999 and 2000.1 In the Framingham observational cohorts, using the same data set as in our article, we observed statistically significant increases in prevalence of blood pressure control (defined as blood pressure <140 mm Hg/<90 mm Hg) among all patients with hypertension during the 1990s, from 25% to approximately 40% (P<.001). The youngest group of patients with hypertension (those 60 years or younger) had the largest increase in control rates, to levels in excess of 50%, whereas older patients with hypertension had smaller increases, to rates in the 35% to 40% range. We await systematic improvements and greater public health and clinical efforts at blood pressure control in order to reduce the risks associated with hypertension that we reported.
Dr Cheng echoes some of the concerns we enumerated regarding treatment of hypertension in the oldest persons with hypertension, and is correct in reporting that treatment data are derived largely from individuals with stage 2 isolated systolic hypertension.2 - 4 In these trials, treatment was highly effective in reducing risk for stroke and heart failure, 2 critically important causes of death and permanent disability in the elderly. We agree that patients and clinicians need better data to make informed decisions. Treatment trials of stage 1 isolated systolic hypertension in the oldest patients with hypertension would help determine whether and to what extent treatment is beneficial; in the absence of such information, we must rely on indirect evidence from observational studies in conjunction with relevant information from existing clinical trials. For example, a meta-analysis of 1670 patients 80 years and older who were enrolled in clinical trials revealed significant and substantial reductions in stroke and heart failure events associated with antihypertensive therapy, with a small and statistically nonsignificant increase in total mortality.5 The results of the Hypertension in the Very Elderly Trial (HYVET)6 are eagerly awaited, and more studies should be undertaken.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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