Title: The Evolving Clinical Management of Hypertension
Abstract: The management of hypertension has continued to change during the past 5 decades. We have seen progressive improvements in the number of patients being treated and achieving control of their blood pressure (BP). A large part of this clinical success can be linked to the widening array of effective and inexpensive drugs that are now available to clinicians. In addition, the medical community has become highly knowledgeable about the management of hypertension, although, despite our therapeutic advances, a meaningful number of patients still do not have adequate access to care. The Journal of Clinical Hypertension has become a major resource for practitioners and investigators in the field of hypertension practice, and this brief review will take a look at a small selection of interesting articles published by the Journal last year that addressed this area. One of the major cornerstones in the history of clinical hypertension in the United States was the creation of the National High Blood Pressure Education Program (NHBPEP). In an eloquently written editorial to celebrate the 40th anniversary of the NHBPEP, Dr Marvin Moser and Dr Edward Rochella described the genesis of this remarkable program.1 Among other things, the program was responsible for creating the Joint National Committee (JNC) reports that guided clinical practice over several years and for stimulating efforts by the National Institutes of Health to conduct meaningful clinical trials in the field of hypertension.2 Dr Moser deserves much of the credit for the NHBPEP and remained its champion during many fruitful years of contributing to America's public health. Dr Rochella, a distinguished scientist at the National Heart, Lung, and Blood Institute, played a major role in the activities of the NHBPEP and particularly in the arduous work of producing the JNC reports. Our Journal was delighted to publish this brief article by Drs Moser and Rochella, and we believe that readers will have enjoyed its fascinating insights into the progress of hypertension care in this country. A current area of attention in our field is treatment-resistant hypertension. This condition reflects the fact that some patients, despite being prescribed apparently effective multidrug regimens, continue to have uncontrolled BP. In an editorial, Dr Suzanne Oparil and I reviewed a report that evaluated the emotional responses of patients to this condition.3 Schmieder and colleagues4 had reported that a survey of patients with treatment-resistant hypertension revealed that these individuals had serious emotional consequences associated with their poor BP control. For instance, the patients were fearful of imminent major events such as strokes and heart attacks. They were pessimistic about their future health and in many cases expressed concerns that they might not live long enough to see their children or grandchildren grow up. It is likely that many people with apparent treatment-resistant hypertension may not, in fact, truly have this condition. In some cases, the patients may have high office BP caused by white-coat hypertension; in other cases, there may be hidden or unsuspected secondary hypertension or the use of other drug types that could interfere with hypertension treatment; or, in many cases, there could be a lack of compliance by the patients with their prescribed treatment. One of the major arguments put forward by Dr Oparil and myself was that high BP, regardless of whether an explanation can readily be found, remains a major risk factor for strokes and other serious outcomes. So, without trying to apportion blame for poor treatment results to patient behavior or inadequate clinical management, the overriding need is to identify these patients and find solutions—with traditional or newer modes of treatment—that can bring their BPs into a safer range. There are still deficiencies in the overall management of hypertension in the United States. An article by Dr Adesuwa Olomu and colleagues5 reported on BP control in a Federal Qualified Health Center (FQHC) in Michigan. Although the overall control of BP in the United States has continued to improve during the past several years,6 the findings in Michigan revealed that the patients who qualified for care in this type of facility had lower rates of BP control than the national average. The report indicated that 75% of the patients seen in the center were on Medicaid. Overall, women achieved better BP results than men, but there was no difference between patients categorized as white or black. The control rates in patients with diabetes were particularly poor. The explanation for this result is not easily apparent because it suggests that simply providing standard resources for medical care may not be sufficient. Future strategies may require the introduction of programs to proactively educate and support patients whose BPs are not responding adequately to treatment. Although traditional hypertension guidelines use a BP threshold (typically 140/90 mm Hg) to diagnose hypertension, an article by Drs Brent Egan and Yumin Zhao7 has drawn attention to the fact that a large number of patients, typically young, are diagnosed with hypertension based on the fact that they have been told on at least two occasions by medical personnel that they have this condition. This is a meaningful consideration because the American Heart Association includes these patients in its statistical reports of cardiovascular conditions.8 The report by Egan and Zhao indicates that when such individuals are included in hypertension statistics they can influence public health policy and reporting since they may have nonhypertensive BPs (<140/90 mm Hg) when re-checked, yet still be counted among the hypertensive population. Of course, it could be argued that for young adults, a value below 140/90 mm Hg (eg, 130/80 mm Hg) might be more appropriate for diagnosis, and indeed this has been suggested as an expert opinion in the hypertension guidelines published by the American Society of Hypertension (ASH)/International Society of Hypertension.9 In a multicultural country it may be important to modify predictors of cardiovascular risk according to ethnicity. For instance, a paper by Dr Nam-Kyoo Lim and colleagues10 based on the Korean General and Epidemiology Study constructed a formula for predicting the probability of patients with a variety of demographic and clinical characteristics to become hypertensive. They compared their Korean-based formula with the Framingham Hypertension Risk Score11 and found that the findings in their own derivative and validated patient sets were clearly more reliable than the Framingham model in identifying Asian patients likely to become hypertensive. It will be interesting to see whether similar risk models can be established for other ethnic groups as well. It is logical to assume that poor adherence or compliance to treatment will increase the risk of uncontrolled hypertension and the probability of adverse cardiovascular outcomes and increased hospitalizations.12 How common is the problem of nonadherence? In a report by Dr Larissa Grigoryan and colleagues,13 120 primary care patients with uncontrolled hypertension were evaluated for drug adherence by electronic monitoring. Of these patients, 74% had at least one day during which their drugs were omitted. Almost 30% of these patients with uncontrolled hypertension had treatment gaps of at least 4 days during the 30-day period of monitoring. Dr Grigoryan and her colleagues speculate that the use of long-acting antihypertensive drugs could help cover the gaps in treatment, but the large number of people who omit their treatment for multiple days at a time would obviously require a different kind of intervention to improve their BP results. It is not always the patient, however, who is responsible for inadequate treatment results. Hypertension is often affected by so-called clinical inertia, a situation in which physicians fail to intensify treatment despite observing that their ongoing therapy is not being effective in achieving the desired results.14 Despite this apparent failure on the part of clinicians, there may at times be good reasons why they do not increase the dosage of drugs or add new ones. In a report by Dr Nayan Desai and colleagues,15 charts were reviewed in 429 patients in an academic chronic kidney disease clinic. Of these patients, 263 had not achieved target BPs. In this uncontrolled group, treatment had been intensified in 81 patients and in another 67, physicians acknowledged the lack of BP control but gave reasons for why they were not adjusting the drug therapy at that time. However, in 115 of the 263 uncontrolled patients, there was no reason offered for a failure to change the therapy, indicating that 44% of patients with inadequate BP control probably represented true therapeutic inertia. Of course, it may still be possible that in these patients there was a plausible reason for not adjusting therapy, but these findings still point out that even among clinicians regarded as experts in BP management there may be excessive caution in upgrading hypertension treatment in appropriate patients. In view of these reports indicating that both patients and clinicians may share responsibility for poor BP results, it is interesting to consider the article by Dr Ivo Abraham and colleagues16 that looked at a meta-analysis of 14,646 patients to evaluate whether physicians or patients might be primarily responsible for inadequate responses to treatment. As already discussed, hypertension is an asymptomatic disease and is particularly susceptible to nonadherence, which has been reported in up to 50% of patients with this condition.17 Using hierarchical modeling of physician and patient characteristics that might be predictive of BP outcomes, Abraham and colleagues found—not surprisingly—that BP control was better in treatment-adherent patients. What was particularly important was that the vigilance by physicians in checking BP and adjusting treatment was clearly a beneficial factor in achieving BP control. Similarly, it was noted that the patients with greatest adherence to therapy were those with a history of prior cardiovascular events, suggesting that adverse cardiovascular outcomes of hypertension provide a strong incentive for more rigorous compliance by patients with prescribed antihypertensive therapy. Although none of these findings could be regarded as unexpected, they nevertheless provide useful information in helping us understand what might underlie good or poor treatment results. A similar look at physician and patient characteristics in determining the outcomes of BP treatment was conducted by Dr Christopher Harle and colleagues.18 Again, this study was motivated by previous evidence that failure by practitioners to increase treatment when BP goals are not met is a major cause of poor results.19 The study comprised an evaluation of 5 years of electronic health records from a multispecialty group practice. The investigators found that 66% of their patients experienced clinical inertia or an inadequate response to unsatisfactory BP control. Interestingly, when evaluating physician performance, only one characteristic appeared to indicate clinical inertia: patient volume. Perhaps it could be speculated that physicians with a long list of patients to see may not have sufficient time to deal with inadequately controlled BP, although making treatment adjustments should not usually be a major time-consuming commitment. Among patients, there were three major predictors of poor results: older age, the absence of a commercial health insurance policy, and obesity. One of the useful results of this work by Dr Harle and colleagues is that by identifying some of the basic explanations for poor results it might be possible to devise strategies to address them. The involvement of skilled clinical pharmacists in the clinical management of hypertension, particularly in a structured collaboration with physicians, has been shown to be highly productive.20 A report by Ziqian Chen and colleagues21 has further evaluated the physician-pharmacist collaboration by studying outcomes based on ambulatory BP monitoring (ABPM). Using the trial design of cluster randomization, three clinics were randomized to be part of the physician-pharmacist collaboration, whereas three other clinics were randomized to serve as a control. All aspects of ABPM favored the physician-pharmacist collaboration. In particular, for the 24-hour systolic BP, there was a mean difference of 11 mm Hg favoring the collaboration; likewise, there was a 12-mm Hg advantage during daytime measurements and a 9-mm Hg advantage at night, confirming the advantages in BP reduction associated with the collaboration. Most meaningfully, in the patients managed by the physician-pharmacist collaboration, there was an average of 2.7 medication changes per patient during the 6-month treatment period, as compared with only 1.1 changes in the control group, indicating the greater commitment to BP control by the pharmacist group. There was also a greater use of diuretics in patients managed by the collaboration. The participation of clinical pharmacists in clinical settings appears to largely eliminate the problem of clinical inertia. Another approach to achieving improved BP outcomes has been reported by Theresa Harrison and colleagues22 from a major staff model health plan. These authors were aware that a variety of strategies have been tested to improve patient care, including sending postcards or using phone reminders to increase patient attendance at scheduled appointments.23 These investigators took this idea one step further and tested the value of active telephone outreach to their patients. Very simply, they compared the results in patients who received a telephone call asking them to come to a clinic for a BP check, with the BPs observed in patients receiving their usual care. The patients responding to the telephone calls achieved clearly better BP control, especially those patients with a background of cardiovascular or kidney disease or diabetes. It was also interesting that predictors of better results were older age and a household income greater than the median. As noted in other reports, these investigators also observed that women achieved better BP results than men. This simple and inexpensive use of telephone contact appears to have produced valuable results. It is recognized that African American patients are more likely to have hypertension and to experience its cardiovascular consequences than people of other ethnicities.24 Therefore, it is imperative to optimize the management of black patients with hypertension and to provide support in helping them achieve control of their BP. In a report by Dr Fadia Shaya and colleagues,25 the potential value of establishing social networks for African American patients was evaluated. These networks were based on patients being clustered into community-based monthly in-person meetings where hypertension education and discussion was offered. Compared with a control group without access to these meetings, the social network patients had significantly greater reductions in their systolic and diastolic BPs and there was also a trend for these patients to achieve a greater rate of BP goal. Using social networks appears to be a good strategy to consider, particularly in communities where setting up these activities—such as in a church or other gathering place—would be feasible and fit into the lifestyles of the patients. A beneficial strategy for improving BP control is the use of home BP monitoring.26 This approach has become far easier to accomplish in recent years as a result of the availability of relatively inexpensive and easy-to-use automated BP devices. It is widely believed within the hypertension community that encouraging patients to become involved in their own care through taking regular home BP measurements will, in turn, lead to better adherence to treatment and better BP results. Dr Jill Tirabassi and colleagues at the Centers for Disease Control and Prevention (CDC) surveyed the attitudes of primary care physicians to the use of home BP monitoring.27 They found that about one third of primary care physicians used home BP monitoring in virtually all their patients. At the other extreme, about one quarter of primary care physicians used this technique in fewer than 40% of their patients. Interestingly, nurse practitioners were more likely than physicians to use home BP measurements. When asked to explain why they were not using home BP monitoring, the most common reason offered by physicians was that patients with low incomes would not easily be able to afford the devices. However, it does appear that home BP measure could be a critical part of improving hypertension care and should be strongly encouraged as a strategy. There is a growing demand on the resources of primary care medicine in this country. Hypertension in particular is now so common that it presents a further burden and it has been suggested that telemedicine may be a good solution for this problem.28 Telemedicine might be particularly valuable for patients in rural areas who find it difficult to keep in-person appointments with their practitioners. In a study by Dr Michael Bowen and colleagues,29 the effects on BP outcomes of using telemedicine during an 18-month period were compared with usual care in patients residing at shorter or longer distances (less than or more than 30 miles) from their usual point of care. These investigators found that there was no difference in BP findings between the telemedicine and the usual care groups, suggesting that telemedicine can be a useful alternative when in-person visits are not practical. This is a useful concept, although those of us who have practiced traditional medicine may remain slightly uncertain as to the long-term benefits of alternatives to personal contact. One of the secrets of effective hypertension management, particularly in the busy primary care setting, is establishing an effective but simple algorithm for treating high BP. In particular, an approach that works for patients across different ages and ethnicities would be highly desirable. There is good evidence that logical combination therapies such as renin angiotensin system blockers plus either diuretics or calcium channel blockers are effective in almost all patients.30 In a strongly written commentary, Dr Joel Handler demonstrated exceptional BP control results in a large staff-model health maintenance organization by the standard use of an angiotensin-converting enzyme (ACE) inhibitor/thiazide diuretic combination.31 This combination starts out at low doses and then is increased to maximum doses over a period of time, if needed, to achieve BP control. If necessary, amlodipine is added, again titrated from a low to a maximum dose and, beyond that, if necessary, either spironolactone or a β-blocker can be added. Of course, this starting regimen of an ACE inhibitor/thiazide cannot be used in patients who are pregnant or potentially might become so. In addition, patients with needs for other drugs—such as β-blockers for patients with a history of myocardial infarction or heart failure—would require different approaches. As well, some of the more recent guidelines9 prefer amlodipine rather than a thiazide to be used in combination with an ACE inhibitor or angiotensin receptor blocker. Recent clinical trials appear to show superiority of this alternative approach in preventing cardiovascular outcomes. There is little argument that renin angiotensin system blockers, amlodipine, and thiazides represent the three drug types that should be regarded as the standards upon which treatment is generally based, and Dr Handler's major success in achieving high control rates is a further recommendation that this combination approach to therapy should be strongly considered. The clinical opinions of hypertension experts are strongly appreciated by readers of this Journal, and a regular feature by Dr Debbie Cohen and Dr Raymond Townsend is an important part of the Journal's offerings. In a recent commentary, these experts evaluated a recent report from the CDC dealing with reasons for poor BP control.32 In brief, the CDC authors reported that 85% of individuals with uncontrolled hypertension had health insurance and 90% of them had regular office medical care. The commentary argues that we are observing a major missed opportunity for primary care physicians to improve hypertension care in the United States.33 Certainly, the data from the CDC support the argument that limited access to care is not the main explanation for poor BP control, particularly when so many of these patients have regular medical access. Clearly, there is an opportunity to improve outcomes by exploiting the availability of medical care. On the other hand, we shouldn't forget that in many countries, particularly in Europe where there is virtually 100% access to health care through universal insurance systems, BP results are still not as good as in the United States! Still, it is impossible to disagree with Drs Cohen and Townsend that greater efforts at the primary care level should be made to further improve outcomes in this country. Most practitioners are aware of recommendations to reduce dietary salt as a means for aiding BP control. The World Health Organization (WHO) together with a Cochrane Collaboration showed that a diet containing <2000 mg of sodium resulted in reduced BP as compared with higher sodium intakes, and it was also demonstrated that increased sodium intake in cohort studies increased the risk of strokes and coronary heart disease.34, 35 In a powerfully argued commentary, Drs Norm Campbell, Daniel Lackland, and Graham MacGregor made the case for universal adoption of the recommendations of the WHO and other authoritative sources for sodium diets below 2000 mg per day.36 It is recognized that controlling sodium on an individual patient basis can be difficult, often because the sodium content in food products is not clearly stated or understood. Therefore, the best methods for reducing excess sodium intake are progressive reductions in the salt content of processed and manufactured foods. This process should be undertaken over a period of years and supported by governmental policies or legislation. There are controversies, of course, in the sodium story, and even some claims that low sodium diets can be harmful! This is probably not a valid argument, and as Dr Campbell and his colleagues point out, one of the main problems in considering the role of sodium in hypertension is that so many studies have been based on flawed methodology. The issue of dietary sodium is a priority for the World Hypertension League (WHL). This Journal—as the official journal of that organization—will be covering this important topic in forthcoming issues. Similar to reducing salt intake, it has long been argued that weight loss in obese or overweight patients would also be beneficial in reducing BP. Indeed, this has been demonstrated, although there have been some concerns that initial BP responses to weight reduction can be attenuated over time.37 Dr Crystal Tyson and her colleagues have reported results from the Weight Loss Maintenance Trial, a 5-year study of the BP effects of reducing body weight.38 Using three different strategies for weight loss, these investigators evaluated the changes in BP in patients classified into three outcomes groups: weight loss, stable weight, or weight gain. They demonstrated that changes in systolic BP (and to a lesser extent diastolic BP) correlated positively with weight changes after 12, 30, and 60 months of follow-up. Briefly, systolic BP rose modestly (by 4.2 mm Hg) in the weight gain group after 5 years, and also rose similarly in the weight stable group. There was no change in BP in the weight loss group. These results suggest that weight loss, even when maintained over a significant period of time, does not appear to reduce BP in a sustained fashion. However, it would be expected that during a 5-year period, the increase in BP associated with aging could at least partly explain these apparently modest long-term effects of weight management on BP. It should also be noted that other cardiovascular risk factors—including type 2 diabetes or lipid abnormalities—would either be prevented or helped by weight loss, thereby providing additional benefits to any BP effects observed in these hypertensive patients. We should still consider weight loss and its maintenance as critical parts of hypertension management. There has been controversy regarding the importance of BP measurements in children, especially regarding the long-term prognostic importance of childhood BPs. A report from the U.S. Preventive Services Task Force concluded that there was no clear evidence that screening for hypertension in children reduces cardiovascular events in adults.39 However, in a very strongly written editorial by Dr Joshua Samuels and colleagues, this conclusion was disputed.40 These experts in pediatric hypertension point out the virtual impossibility of associating childhood hypertension with excessive adult cardiovascular events. To establish such data, it would be necessary to conduct large-scale longitudinal studies lasting for decades, which is clearly a logistic and economic impossibility. However, these experts point out that we already have good evidence for BP tracking, such that higher BPs in children tend to be carried into adulthood and to identify adults more likely to have hypertension at an earlier age. As well, the editorial points out that even in children it is possible to find early evidence for target organ changes, including left ventricular hypertrophy, indicating that high BP in children should be regarded as a potentially important cardiovascular finding. The main conclusion from these authors' findings, therefore, was that screening for hypertension in children is very important and should be performed on a regular basis. BP in children can be variable, so multiple readings have been recommended to ensure an accurate classification of their BPs.41 Dr Lauren Becton and colleagues42 studied data from 1725 adolescents from the National Health and Nutrition Examination Survey (NHANES). Interestingly, 91% of these young patients maintained their original BP classification (normal, prehypertension, or hypertension) when their BPs were re-checked. Of the patients who changed their classification, the presence of obesity appeared to be a major factor in this variability. Therefore, it is recommended that children who are overweight have their BP checked with increased frequency to ensure an accurate estimate of their BP status. Because it is more convenient, there has been interest in using automated oscillometric BP devices as an alternative to traditional auscultatory methods for measuring BP in children.43 Dr Sigridur Eliasdottir and colleagues have carefully compared the use of an aneroid and an oscillometric device for measuring BP in children.44 They found that the two methods did not correlate very closely, particularly as far as diastolic BPs were concerned. Their conclusion is that a hypertensive reading should definitely be confirmed on several occasions before a diagnosis of hypertension is made. In an accompanying commentary, Dr Joseph Flynn45 also argued that oscillometric devices, despite their apparent convenience, may give rather variable BP results. It should be noted that in young people the diastolic BP is of meaningful importance (perhaps in contrast to the elderly), and it is a characteristic of oscillometric methods that diastolic BPs are calculated by proprietary algorithms that are unique to each manufacturer's device. Dr Flynn, therefore, recommends that if a high BP in a child is observed with an oscillometric device that this finding be confirmed using an auscultatory device. In addition, Dr Flynn provides a useful clinical algorithm for establishing the presence of high BP in children.45 To measure the prevalence of hypertension in a pediatric population, Dr Corinna Koebnick and colleagues46 performed a cross-sectional study of 237,248 children aged 6 to 17 years followed in a large prepaid health plan. Using standard diagnostic criteria from pediatric hypertension guidelines,47 they found that 31% of these young people had prehypertension (BP >90th percentile of age, sex, and height base measurements) and 2.1% had hypertension (three BP readings >95th percentile). However, these investigators noted that 4.8% of this large cohort had two of their three BP readings above the 95th percentile. Thus, in all likelihood, a total of 6.9% of this pediatric population had established, or very close to established, evidence for hypertension. This appears to be a remarkable prevalence of hypertension in this very young population and draws attention to the importance of measuring BP in children and continuing to follow them on a long-term basis. In a further study, Dr Koebnick and her colleagues48 used the same database of pediatric patients to explore the association of hypertension with obesity. This was an interesting issue to pursue because previous research also indicated an association between hypertension and obesity in children.49 Using the power of their health plan's very large patient numbers, these investigators compared the prevalence of hypertension in individuals classified as having normal weight, overweight, moderate obesity (body mass index 30–35), or extreme obesity (body mass index >35). (It should be noted that definitions of obesity in children vary by age and other factors and a detailed description of this classification is given in the article. Dr Koebnick and colleagues found that, compared with children of normal weight, the prevalence of hypertension was 2.4-fold higher in overweight individuals, was 4.4-fold higher in patients with moderate obesity, and 10.8-fold higher in patients with extreme obesity. Their conclusion, very appropriately, was that all obese children should be checked frequently for hypertension. Needless to say, strategies for managing their obesity would also be an important part of managing these children. One of the interesting issues in hypertension in America is the high rate of strokes in the southeastern states, sometimes referred to as the “Stroke Belt.” It is probable that uncontrolled hypertension plays a major part in this excess stroke rate, and particularly so in older people.50 Dr Gaurav Dave and colleagues51 have reported data from their Community Initiative to Eliminate Stroke. In this Stroke Belt risk factor screening and prevention project, these investigators obtained data on 2663 patients. They observed that 44% of this cohort had uncontrolled systolic BP and 23% had uncontrolled diastolic BP. The control rates were lower in African American patients than whites, consistent with the general observation that African American patients have a disproportionate risk of stroke, particularly in the Stroke Belt. Further analysis of the data showed, not surprisingly, that the two factors that predicted uncontrolled hypertension in this older cohort of patients were race (African American) and nonadherence to treatment. These findings clearly help set an agenda for further work in communities in this region of the United States. In another study focusing on African American patients with hypertension, Dr Jane Harman and her colleagues52 reported results from the Jackson Heart Study. They reported findings in 2415 treated African Americans, noting that the target BP of <140/90 mm Hg was achieved by 66% and 70% of patients at the two milestone examinations during this study. Typical for many other trials, the control of BP in men was poorer than in women. The investigators noted that the use of thiazide diuretics appeared to be associated with the best results in these patients, consistent with previous observations that thiazides are effective in reducing BP in African American patients.53 Recent guidelines have suggested that when their recommended strategies for controlling hypertension are not fully successful, practitioners should consider referring their patients to practitioners who are specialists in hypertension. Dr Matthew Denker and his colleagues54 at the University of Pennsylvania reported on BP control results 1 year after patients were referred to their institution because of uncontrolled hypertension. These investigators—who are a well-recognized group of hypertension specialists—performed a chart review of 158 patients in whom they had 1 year of follow-up data. Remarkably, the average BP in these patients was reduced during this period from 149/87 mm Hg to 129/78 mm Hg. Beyond that, this result was achieved without, on average, using a greater number of medications than were already in use at the time of patient referral. How did these hypertension specialists achieve such a good result without using greater numbers of antihypertensive agents? Their primary strategy was to utilize the lessons of renin profiling, a volume/vasoconstriction concept originally developed by Dr John Laragh.55 This concept allows for a more rational method of combining drugs to address the pathophysiologic abnormalities of hypertension, and it is of interest that these academic hypertension experts used measurements of plasma renin and aldosterone to help guide them in assembling the most effective treatment combinations for their patients. This is a fascinating report, and should be taken into consideration as algorithms for treating hypertension—particularly in hard-to-control patients—are developed to guide clinical practice in the community. Several years ago, ASH created a new medical specialty, credentialing clinicians who had satisfied appropriate training criteria and successfully passed an examination as “ASH Hypertension Specialists.” Specialists are expected to have many skills, among them the ability to deal with resistant hypertension, one of the most common and serious issues in primary care clinical practice.56 Hypertension specialists should also be effective in teaching colleagues best practices in achieving BP control as a critical part of preventing the expense, both in human terms and financially, of strokes, myocardial infarctions, heart failure, and dialysis. Dr William Elliott and a group of other leaders of ASH have put forward an argument to justify why hypertension specialists should now be regarded as a vital part of the cardiovascular prevention team, and why funding to optimize their participation in advancing better care of hypertension should be made available.57 Cardiovascular research and teaching now place emphasis on the importance of good hypertension control, and it is to be hoped that increasing numbers of clinicians interested in hypertension—which, after all, is probably the most common chronic condition in medical practice—will consider becoming qualified as ASH Hypertension Specialists. Overall, it has been most gratifying to see in just this small selection of papers extracted from last year's publications of this Journal such thoughtful and imaginative strategies for the management of hypertension. Let me stress that what has been discussed in this very brief overview is truly only a small sample of the wide range of information published in the pages of this Journal. I strongly recommend reviewing our full list of contents. Our published articles are readily available online at: http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291751-7176.