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nurse-led vascular care in lowering Hypertension control Rigid stiff arteries enhance blood
vascular risk. Another study3 reported pressure variability and are less
the possible clinical benefit for
and cardiovascular responsive to RAAS blockade than to
early dementia and denied clinical disease other agents such as calcium channel
effectiveness for advanced dementia, blockers. We propose that reduction
which suggests that vascular care On the basis of Omran’s theory of blood pressure variability should
would be useful for prevention rather of epidemiological transition, be added as a seventh strategy to the
than management. Therefore, vascular Jacques Blacher and colleagues (July list of Blacher and colleagues’, which
care might have a more important role 30, p 530)1 provocatively propose could change hypertension therapy.

as a primary prevention of dementia six strategies to reduce the burden FHM has consultant or advisory relationships with
in resource-limited settings, including of hypertensive cardiovascular Daiichi Sankyo, Pfizer, Abbott, Servier, Medtronic,
WebMD, Ipca, American College of Cardiology,
rural areas or developing countries. disease. Notably, missing from their
Menarini, Relypsa, and the University of Utah.
Second, although some previous list are strategies to minimise blood SB has consultant or advisory relationships with
studies3–5 have reported that the pressure variability. In several large Daiichi Sankyo, Pfizer, Abbott, and Merck. UF and
vascular care intervention was effective, randomised trials, such as ALLHAT2 SFR declare no competing interests.

interventions by nurses varied greatly and ASCOT,3 blood pressure variability *Franz H Messerli, Urs Fischer,
across studies, such as in frequency and has been identified as a powerful Stefano F Rimoldi, Sripal Bangalore
targeted health conditions. Comparison independent risk factor for stroke messerli.f@gmail.com
of detailed information of these and cardiovascular events.4–6 Of note, Division of Cardiology, Icahn School of Medicine,
nurse-led vascular cares is worthwhile. not all antihypertensive drugs are Mount Sinai Hospital, New York, NY 10029, USA
Therefore, a comparison of the method equally effective in reducing blood (FHM); Department of Cardiology (SFR) and
Department of Neurology (UF), University of Bern,
of nurse-led care in Moll van Charante pressure variability. The ALLHAT trial5 Bern, Switzerland; and Department of Cardiology,
and colleagues’ study with methods of documented blood pressure variability New York University, New York, NY, USA (SB)
past studies would be useful. reduction to be best with amlodipine, 1 Blacher J, Levy BI, Mourad JJ, Safar ME, Bakris G.
followed by chlorthalidone, whereas From epidemiological transition to modern
We declare no competing interests.
cardiovascular epidemiology: hypertension in
lisinopril was much less efficacious the 21st century. Lancet 2016; 388: 530–32.
*Tomohiro Morita, Asaka Higuchi, than were the other two. Given 2 ALLHAT Collaborative Research Group. Major
Akihiko Ozaki, Yuki Shimada, outcomes in high-risk hypertensive patients
the excessive variability, it is little
Tetsuya Tanimoto randomized to angiotensin-converting
surprise that stroke reduction is left enzyme inhibitor or calcium channel blocker vs
t.morita526@gmail.com diuretic: The Antihypertensive and Lipid-
to be desired in the lisinopril group.
Department of Internal Medicine, Soma Central Lowering Treatment to Prevent Heart Attack
Hospital, Fukushima 976-0016, Japan (TM);
Adjustment for blood pressure Trial (ALLHAT). JAMA 2002; 288: 2981–97.
Department of Hematology, Toranomon Hospital, variability explained the differences 3 Jamerson K, Weber MA, Bakris GL, for the
ACCOMPLISH Trial Investigators. Benazepril
Tokyo, Japan (AH); Department of Surgery (AO) and in stroke and coronary heart disease plus amlodipine or hydrochlorothiazide for
Department of Neurosurgery (YS), Minamisoma
Municipal General Hospital, Fukushima, Japan; and
outcomes between amlodipine- hypertension in high-risk patients. N Engl J Med
based and atenolol-based treatment 2008; 359: 2417–28.
Department of Internal Medicine, Jyoban Hospital of
4 Webb AJ, Fischer U, Mehta Z, Rothwell PM.
Tokiwa Foundation, Fukushima, Japan (TT) in the ASCOT trial.6 Increased residual Effects of antihypertensive-drug class on
1 Moll van Charante EP, Richard E, Eurelings LS, systolic blood pressure variability in interindividual variation in blood pressure and
et al. Effectiveness of a 6-year multidomain risk of stroke: a systematic review and
vascular care intervention to prevent dementia
treated hypertension causes a high meta-analysis. Lancet 2010; 375: 906–15.
(preDIVA): a cluster-randomised controlled risk of vascular events.7 5 Muntner P, Whittle J, Lynch AI, et al.
trial. Lancet 2016; 388: 797–805. Similar to blood pressure variability, Visit-to-visit variability of blood pressure and
2 Greving JP, Kaasjager HA, Vernooij JW, et al. coronary heart disease, stroke, heart failure,
Cost-effectiveness of a nurse-led internet-based LDL cholesterol variability has been and mortality: a cohort study. Ann Intern Med
vascular risk factor management programme: identified as a powerful independent 2015; 163: 329–38.
economic evaluation alongside a randomised 6 Rothwell PM, Howard SC, Dolan E, et al.
controlled clinical trial. BMJ Open 2015;
predictor of death and cardiovascular
Prognostic significance of visit-to-visit
5: e007128. events. 8 Conceivably, the sixth variability, maximum systolic blood pressure,
3 Richard E, Gouw AA, Scheltens P, van Gool WA. strategy of Blacher and colleagues’,1 and episodic hypertension. Lancet 2010;
Vascular care in patients with Alzheimer 375: 895–905.
disease with cerebrovascular lesions slows namely the temporality of 7 Rothwell PM, Howard SC, Dolan E, et al, for the
progression of white matter lesions on MRI: antihypertensive therapy, might also ASCOT-BPLA and MRC Trial Investigators.
the evaluation of vascular care in Alzheimer’s Effects of beta blockers and calcium-channel
disease (EVA) study. Stroke 2010; 41: 554–56.
relate to blood pressure variability.
blockers on within-individual variability in
4 Richard E, Kuiper R, Dijkgraaf M, Van Gool WA. The fact that renin-angiotensin- blood pressure and risk of stroke. Lancet Neurol
Vascular care in patients with Alzheimer’s disease aldosterone system (RAAS) blockers 2010; 9: 469–80.
with cerebrovascular lesions—a randomized 8 Bangalore S, Breazna A, DeMicco DA, Wun CC,
clinical trial. J Am Geriatr Soc 2009; 57: 797–805. and β blockers are less effective with Messerli FH. Visit-to-visit low-density
5 Andrieu S, Coley N, Lovestone S, Aisen PS, increasing age might not be due to lipoprotein cholesterol variability and risk of
Vellas B. Prevention of sporadic Alzheimer’s only diminished RAAS activity, but cardiovascular outcomes: insights from the
disease: lessons learned from clinical trials and TNT trial. J Am Coll Cardiol 2015; 65: 1539–48.
future directions. Lancet Neurol 2015; 14: 926–44. also to increased vascular stiffness.

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