Displaying publications 81 - 100 of 149 in total

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  1. Fulltext Diversity of and initiatives for hypertension management in Asia-Why we need the HOPE Asia Network
    Kario K, Chia YC, Sukonthasarn A, Turana Y, Shin J, Chen CH, et al.
    J Clin Hypertens (Greenwich), 2020 Mar;22(3):331-343.
    PMID: 31773883 DOI: 10.1111/jch.13733
    The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was set up to improve the management of hypertension in Asia with the ultimate goal of achieving "zero" cardiovascular events. Asia is a diverse continent, and the prevalence of hypertension has increased over the last 30 years. There are a number of Asia-specific features of hypertension and hypertension-related cardiovascular complications, which means that a region-specific approach is needed. White-coat hypertension will become more of an issue over time as Asian populations age, and masked hypertension is more prevalent in Asian than in Western countries. Identifying and treating masked hypertension is important to reduce cardiovascular risk. Abnormal patterns of blood pressure (BP) variability common in Asia include exaggerated early morning BP surge and nocturnal hypertension. These are also important cardiovascular risk factors that need to be managed. Home blood pressure monitoring (HBPM) is an important tool for detecting white-coat and masked hypertension, and monitoring BP variability, and practices in Asia are variable. Use of HBPM is important given the Asia-specific features of hypertension, and strategies are needed to improve and standardize HBPM usage. Development of HBPM devices capable of measuring nocturnal BP along with other information and communication technology-based strategies are key developments in the widespread implementation of anticipation medicine strategies to detect and prevent cardiovascular events in patients with hypertension. Region-wide differences in hypertension prevalence, control, and management practices in Asia highlight the importance of information sharing to facilitate best practices.
  2. Seven-action approaches for the management of hypertension in Asia - The HOPE Asia network
    Kario K, Chia YC, Siddique S, Turana Y, Li Y, Chen CH, et al.
    J Clin Hypertens (Greenwich), 2022 Feb 16.
    PMID: 35172037 DOI: 10.1111/jch.14440
    Asia is a large continent and there is significant diversity between countries and regions. Over the last 30 years, absolute blood pressure (BP) levels in Asia have increased to a greater extent than those in other regions. In diverse Asia-Pacific populations, for choosing an Asia-specific approach to hypertension management is important to prevent target organ damage and cardiovascular diseases. In this consensus document of HOPE Asia Network, we introduce seven action approaches for management of hypertension in Asia.
  3. Reduction of salt intake: time for more action
    Jones ESW, Lee HY, Khan N, Charchar FJ, Williams B, Chia YC, et al.
    J Hypertens, 2022 Nov 01;40(11):2130-2132.
    PMID: 36205011 DOI: 10.1097/HJH.0000000000003262
  4. Fulltext Healthcare in Asia: a perspective from primary care at the gateway to a continent
    Jiwa M, Othman S, Hanafi NS, Ng CJ, Khoo EM, Chia YC
    Qual Prim Care, 2012;20(5):317-20.
    PMID: 23113999
    Malaysia has achieved reasonable health outcomes even though the country spends a modest amount of Gross Domestic Product on healthcare. However, the country is now experiencing a rising incidence of both infectious diseases and chronic lifestyle conditions that reflect growing wealth in a vibrant and successful economy. With an eye on an ageing population, reform of the health sector is a government priority. As in other many parts of the world, general practitioners are the first healthcare professional consulted by patients. The Malaysian health system is served by public and private care providers. The integration of the two sectors is a key target for reform. However, the future health of the nation will depend on leadership in the primary care sector. This leadership will need to be informed by research to integrate care providers, empower patients, bridge cultural gaps and ensure equitable access to scarce health resources.
  5. Fulltext Who should be screened for primary aldosteronism? A comprehensive review of current evidence
    Huang WC, Lin YH, Wu VC, Chen CH, Siddique S, Chia YC, et al.
    J Clin Hypertens (Greenwich), 2022 Sep;24(9):1194-1203.
    PMID: 36196469 DOI: 10.1111/jch.14558
    Arterial hypertension is a major risk factor for cardiovascular disease. The prevalence of primary aldosteronism (PA) ranges from 5% to 10% in the general hypertensive population and is regarded as one of the most common causes of secondary hypertension. There are two major causes of PA: bilateral adrenal hyperplasia and aldosterone-producing adenoma. The diagnosis of PA comprises screening, confirmatory testing, and subtype differentiation. The Endocrine Society Practice Guidelines for the diagnosis and treatment of PA recommends screening of patients at an increased risk of PA. These categories include patients with stage 2 and 3 hypertension, drug-resistant hypertension, hypertensive with spontaneous or diuretic-induced hypokalemia, hypertension with adrenal incidentaloma, hypertensive with a family history of early onset hypertension or cerebrovascular accident at a young age, and all hypertensive first-degree relatives of patients with PA. Recently, several studies have linked PA with obstructive sleep apnea and atrial fibrillation unexplained by structural heart defects and/or other conditions known to cause the arrhythmia, which may be partly responsible for the higher rates of cardiovascular and cerebrovascular accidents in patients with PA. The aim of this review is to discuss which patients should be screened for PA, focusing not only on well-established guidelines but also on additional groups of patients with a potentially higher prevalence of PA, as has been reported in recent research.
  6. Fulltext Characteristics and control of the 24-hour ambulatory blood pressure in patients with metabolic syndrome
    Huang JF, Li Y, Shin J, Chia YC, Sukonthasarn A, Turana Y, et al.
    J Clin Hypertens (Greenwich), 2021 03;23(3):450-456.
    PMID: 33629806 DOI: 10.1111/jch.14229
    Asian countries are facing an increasing prevalence of metabolic syndrome (MetS), which may aggravate the burden of cardiovascular diseases in this region. MetS is closely associated with ambulatory blood pressure (BP). Patients with MetS, compared to those without, had a twofold higher risk of new-onset office, home, or ambulatory hypertension. Furthermore, the risk of new-onset MetS in patients with white-coat, masked and sustained hypertension was also doubled compared to normotensives. High-risk masked hypertension and blunted nighttime BP dipping are common in patients with MetS, suggesting perfect 24-hour BP control with long-acting antihypertensive drugs and early initiation of combination therapy might be especially important for patients with MetS.
  7. Fulltext The role of renal nerve stimulation in percutaneous renal denervation for hypertension: A mini-review
    Huang HC, Cheng HM, Chia YC, Li Y, Van Minh H, Siddique S, et al.
    J Clin Hypertens (Greenwich), 2022 Sep;24(9):1187-1193.
    PMID: 36196464 DOI: 10.1111/jch.14554
    Recent trials have demonstrated the efficacy and safety of percutaneous renal sympathetic denervation (RDN) for blood pressure (BP)-lowering in patients with uncontrolled hypertension. Nevertheless, major challenges exist, such as the wide variation of BP-lowering responses following RDN (from strong response to no response) and lack of feasible and reproducible peri-procedural predictors for patient response. Both animal and human studies have demonstrated different patterns of BP responses following renal nerve stimulation (RNS), possibly related to varied regional proportions of sympathetic and parasympathetic nerve tissues along the renal arteries. Animal studies of RNS have shown that rapid electrical stimulation of the renal arteries caused renal artery vasoconstriction and increased norepinephrine secretion with a concomitant increase in BP, and the responses were attenuated after RDN. Moreover, selective RDN at sites with strong RNS-induced BP increases led to a more efficient BP-lowering effect. In human, when RNS was performed before and after RDN, blunted changes in RNS-induced BP responses were noted after RDN. The systolic BP response induced by RNS before RDN and blunted systolic BP response to RNS after RDN, at the site with maximal RNS-induced systolic BP response before RDN, both correlated with the 24-h ambulatory BP reductions 3-12 months following RDN. In summary, RNS-induced BP changes, before and after RDN, could be used to assess the immediate effect of RDN and predict BP reductions months following RDN. More comprehensive, large-scale and long term trials are needed to verify these findings.
  8. Agreement regarding overcoming hypertension in the Asian Hypertension Society Network 2022
    Hoshide S, Yamamoto K, Katsurada K, Yano Y, Nishiyama A, Wang JG, et al.
    Hypertens Res, 2023 Jan;46(1):3-8.
    PMID: 36229522 DOI: 10.1038/s41440-022-00994-1
  9. Fulltext Characteristics of hypertension in obstructive sleep apnea: An Asian experience
    Hoshide S, Kario K, Chia YC, Siddique S, Buranakitjaroen P, Tsoi K, et al.
    J Clin Hypertens (Greenwich), 2021 03;23(3):489-495.
    PMID: 33705599 DOI: 10.1111/jch.14184
    Obstructive sleep apnea (OSA) is a risk of hypertension and is associated with cardiovascular disease (CVD) incidence. In Asian countries, the prevalence of OSA is high, as in Western countries. When blood pressure (BP) is evaluated in OSA individuals using ambulatory BP monitoring (ABPM), the BP phenotype often indicates abnormal BP variability, such as increased nighttime BP or abnormal diurnal BP variation, that is, non-dipper pattern, riser pattern, and morning BP surge, and all these conditions have been associated with increased CVD events. Asians have a higher prevalence of increased nighttime BP or morning BP surge than Westerners. Therefore, this review paper focused on OSA and hypertension from an Asian perspective to investigate the importance of the association between OSA and hypertension in the Asian population. Such abnormal BP variability has been shown to be associated with progression of arterial stiffness, and this association could provoke a vicious cycle between abnormal BP phenotypes and arterial stiffness, a phenomenon recognized as systemic hemodynamic atherothrombotic syndrome (SHATS). OSA may be one of the background factors that augment SHATS. An oxygen-triggered nocturnal oscillometric BP measurement device combined with a pulse oximeter for continuous SpO2 monitoring could detect BP variability caused by OSA. In addition to treating the OSA, accurate and reliable detection and treatment of any residual BP elevation and BP variability caused by OSA would be necessary to prevent CVD events. However, more detailed detection of BP variability, such as beat-by-beat BP monitoring, would further help to reduce CV events.
  10. Fulltext Highlights of the 2019 Japanese Society of Hypertension Guidelines and perspectives on the management of Asian hypertensive patients
    Hoshide S, Kario K, Tomitani N, Kabutoya T, Chia YC, Park S, et al.
    J Clin Hypertens (Greenwich), 2020 03;22(3):369-377.
    PMID: 31891452 DOI: 10.1111/jch.13763
    Unlike other international guidelines but in accord with the earlier Japanese Society of Hypertension (JSH) guidelines, the 2019 JSH guidelines ("JSH 2019") continue to emphasize the importance of out-of-office blood pressure (BP) measurements obtained with a home BP device. Another unique characteristic of JSH 2019 is that it sets clinical questions about the management of hypertension that are based on systematic reviews of updated evidence. JSH 2019 states that individuals with office BP 
  11. Fulltext Development and validation of the Evidence Based Medicine Questionnaire (EBMQ) to assess doctors' knowledge, practice and barriers regarding the implementation of evidence-based medicine in primary care
    Hisham R, Ng CJ, Liew SM, Lai PSM, Chia YC, Khoo EM, et al.
    BMC Fam Pract, 2018 06 23;19(1):98.
    PMID: 29935527 DOI: 10.1186/s12875-018-0779-5
    BACKGROUND: Evidence-Based Medicine (EBM) integrates best available evidence from literature and patients' values, which then informs clinical decision making. However, there is a lack of validated instruments to assess the knowledge, practice and barriers of primary care physicians in the implementation of EBM. This study aimed to develop and validate an Evidence-Based Medicine Questionnaire (EBMQ) in Malaysia.

    METHODS: The EBMQ was developed based on a qualitative study, literature review and an expert panel. Face and content validity was verified by the expert panel and piloted among 10 participants. Primary care physicians with or without EBM training who could understand English were recruited from December 2015 to January 2016. The EBMQ was administered at baseline and two weeks later. A higher score indicates better knowledge, better practice of EBM and less barriers towards the implementation of EBM. We hypothesized that the EBMQ would have three domains: knowledge, practice and barriers.

    RESULTS: The final version of the EBMQ consists of 80 items: 62 items were measured on a nominal scale, 22 items were measured on a 5 point Likert-scale. Flesch reading ease was 61.2. A total of 343 participants were approached; of whom 320 agreed to participate (response rate = 93.2%). Factor analysis revealed that the EBMQ had eight domains after 13 items were removed: "EBM websites", "evidence-based journals", "types of studies", "terms related to EBM", "practice", "access", "patient preferences" and "support". Cronbach alpha for the overall EBMQ was 0.909, whilst the Cronbach alpha for the individual domain ranged from 0.657-0.940. The EBMQ was able to discriminate between doctors with and without EBM training for 24 out of 42 items. At test-retest, kappa values ranged from 0.155 to 0.620.

    CONCLUSIONS: The EBMQ was found to be a valid and reliable instrument to assess the knowledge, practice and barriers towards the implementation of EBM among primary care physicians in Malaysia.

  12. Fulltext Personal continuity of care in a university-based primary care practice: impact on blood pressure control
    Hanafi NS, Abdullah A, Lee PY, Liew SM, Chia YC, Khoo EM
    PLoS One, 2015;10(7):e0134030.
    PMID: 26214304 DOI: 10.1371/journal.pone.0134030
    Continuity of care is an important quality outcome of patient care. This study aimed to investigate the relationship between personal continuity and blood pressure (BP) control among the patients with hypertension in an academic primary care centre. Between January and May 2012, we conducted a retrospective review of medical records of patients with hypertension who had been followed up for at least 1 year in the Primary Care Clinic, University of Malaya Medical Centre, Malaysia. In this setting, doctors who provided care for hypertension included postgraduate family medicine trainees, non-trainee doctors and academic staff. Systematic random sampling (1:4) was used for patient selection. BP control was defined as less than 130/80 mm Hg for patients with diabetes mellitus, proteinuria and chronic kidney disease and less than 140/90 mm Hg for all other patients. Continuity of care was assessed using the usual provider continuity index (UPCI), which is the ratio of patient visits to the usual provider to the total number of visits to all providers in 1 year. A UPC index of zero denotes no continuity while an index of one reflects perfect continuity with only the usual provider. We reviewed a total of 1060 medical records. The patients' mean age was 62.0 years (SD 10.4). The majority was women (59.2%) and married (85.7%). The mean number of visits in a year was 3.85 (SD 1.36). A total of 72 doctors had provided consultations (55 postgraduate family medicine trainees, 8 non-trainee doctors and 9 academic staff). The mean UPCI was 0.43 (SD 0.34). Target BP was achieved in 42% of the patients. There was no significant relationship between BP control and personal continuity after adjustment for total number of visits. Continuity of care was not associated with BP control in our centre. Further studies are needed to explore the reasons for this.

    Study site: Primary care clinic, University Malaya Medical Centre (UMMC)
  13. Communication skills teaching in primary care medicine
    Hanafi NS, Chia YC
    Med J Malaysia, 2002 Dec;57 Suppl E:74-7.
    PMID: 12733197
    The teaching of clinical communication skills to undergraduate medical students in the Faculty of Medicine, University of Malaya is described. It is a continuous process throughout the five-year medical curriculum which is divided into Phases I, II and III. Students are introduced to communication skills early in Phase I through an interactive session as well as a workshop on general communication skills. In Phase II, small-group two-day workshops cover the basic principles of clinical communication skills using videotapes, group discussion and role-plays. Direct contact between students and patients in actual clinical setting begin in Phase IIIA. Communication skills teaching with feedback training is carried out by videotaping the consultations. In Phase IIIB the two-way mirror is utilized as well as having workshops on certain difficult areas such as 'breaking bad news' and 'taking a sexual history'. Formal assessment is done by evaluating the behavior, language and actual interview content.
  14. Fulltext Clinical significance of nocturnal home blood pressure monitoring and nocturnal hypertension in Asia
    Fujiwara T, Hoshide S, Tomitani N, Cheng HM, Soenarta AA, Turana Y, et al.
    J Clin Hypertens (Greenwich), 2021 03;23(3):457-466.
    PMID: 33591641 DOI: 10.1111/jch.14218
    Nocturnal home blood pressure (BP) monitoring has been used in clinical practice for ~20 years. The authors recently showed that nocturnal systolic BP (SBP) measured by a home BP monitoring (HBPM) device in a Japanese general practice population was a significant predictor of incident cardiovascular disease (CVD) events, independent of office and morning home SBP levels, and that masked nocturnal hypertension obtained by HBPM (defined as nocturnal home BP ≥ 120/70 mmHg and average morning and evening BP 
  15. Fulltext How should Malaysia respond to its ageing society?
    Forsyth DR, Chia YC
    Med J Malaysia, 2009 Mar;64(1):46-50.
    PMID: 19852321
    As Malaysia ages its health and social care systems will have to adapt to a changing pattern of disease and dependency. Improved public health measures extend life expectancy at the relative expense of increased prevalence of currently incurable conditions such as dementia and Parkinson's disease. In this article we discuss how these demographic changes will impact and suggest possible means of coping with the altered epidemiology of disease and disability. Malaysia will need to swiftly develop sufficient expertise in acute Geriatric Medicine, rehabilitation of older people; the management of long-term conditions in older people with multiple complex problems within Primary Care; as well as an infrastructure for home and institutional care.
  16. Fulltext Streptococcal pharyngitis in a primary care clinic
    Foong HB, Yassim M, Chia YC, Kang BH
    Singapore Med J, 1992 Dec;33(6):597-9.
    PMID: 1488669
    A study to determine the sensitivity and specificity of the Directogen Group A Streptococcal Test was carried out in a primary care clinic in University Hospital, Kuala Lumpur. The study also looked at the prevalence of streptococcal pharyngitis in the clinic. We found that the rapid test has a sensitivity of 90.9% and a specificity of 90.7%. Viral pharyngitis is the commonest form (63%) of pharyngitis followed by Group A Beta haemolytic streptococcal pharyngitis (14.2%). The presence of exudates, tonsillar enlargement and the presence of tender cervical lymph nodes have a significantly higher association with streptococcal pharyngitis.
    Study site: Primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
  17. Lateral Flow Assay Based on Paper-Hydrogel Hybrid Material for Sensitive Point-of-Care Detection of Dengue Virus
    Choi JR, Yong KW, Tang R, Gong Y, Wen T, Yang H, et al.
    Adv Healthc Mater, 2017 Jan;6(1).
    PMID: 27860384 DOI: 10.1002/adhm.201600920
    Paper-based devices have been broadly used for the point-of-care detection of dengue viral nucleic acids due to their simplicity, cost-effectiveness, and readily observable colorimetric readout. However, their moderate sensitivity and functionality have limited their applications. Despite the above-mentioned advantages, paper substrates are lacking in their ability to control fluid flow, in contrast to the flow control enabled by polymer substrates (e.g., agarose) with readily tunable pore size and porosity. Herein, taking the benefits from both materials, the authors propose a strategy to create a hybrid substrate by incorporating agarose into the test strip to achieve flow control for optimal biomolecule interactions. As compared to the unmodified test strip, this strategy allows sensitive detection of targets with an approximately tenfold signal improvement. Additionally, the authors showcase the potential of functionality improvement by creating multiple test zones for semi-quantification of targets, suggesting that the number of visible test zones is directly proportional to the target concentration. The authors further demonstrate the potential of their proposed strategy for clinical assessment by applying it to their prototype sample-to-result test strip to sensitively and semi-quantitatively detect dengue viral RNA from the clinical blood samples. This proposed strategy holds significant promise for detecting various targets for diverse future applications.
  18. Fulltext Detection of airflow limitation using a handheld spirometer in a primary care setting
    Ching SM, Pang YK, Price D, Cheong AT, Lee PY, Irmi I, et al.
    Respirology, 2014 Jul;19(5):689-93.
    PMID: 24708063 DOI: 10.1111/resp.12291
    BACKGROUND AND OBJECTIVE: Early diagnosis of chronic obstructive pulmonary disease (COPD) in primary care settings is difficult to achieve chiefly due to lack of availability of spirometry. This study estimated the prevalence of airflow limitation among chronic smokers using a handheld spirometer in this setting.
    METHODS: This is a cross-sectional study performed on consecutive patients who were ≥40 years old with ≥10 pack-years smoking history. Face-to-face interviews were carried out to obtain demographic data and relevant information. Handheld spirometry was performed according to a standard protocol using the COPd-6 device (Model 4000, Vitalograph, Ennis, Ireland) in addition to standard spirometry. Airflow limitation was defined as ratio of forced expiratory volume in 1 s (FEV1 )/forced expiratory volume in 6 s <0.75 (COPd-6) or FEV1 /forced vital capacity <0.7. Multiple logistic regression analyses were used to determine predictors of airflow limitation.
    RESULTS: A total of 416 patients were recruited with mean age of 53 years old. The prevalence of airflow limitation was 10.6% (n = 44) with COPd-6 versus 6% as gauged using standard spirometry. Risk factors for airflow limitation were age >65 years (odds ratio (OR) 3.732 95% confidence interval (CI): 1.100-1.280), a history of 'bad health' (OR 2.524, 95% CI: 1.037-6.142) and low to normal body mass index (OR 2.914, 95% CI: 1.191-7.190).
    CONCLUSIONS: In a primary care setting, handheld spirometry (COPd-6) found a prevalence of airflow limitation of ∼10% in smokers. Patients were older, not overweight and had an ill-defined history of health problems.
    KEYWORDS: Malaysia; chronic obstructive pulmonary disease; prevalence; primary care; smoke
    Study site: Public primary health‐care clinic (Klinik Kesihatan), Sepang District, Selangor, Malaysia
  19. Fulltext Prevalence and determinants of left ventricular hypertrophy in hypertensive patients at a primary care clinic
    Ching SM, Chia YC, Wan Azman WA
    Malays Fam Physician, 2012;7(2-3):2-9.
    PMID: 25606250 MyJurnal
    Left ventricular hypertrophy (LVH) has prognostic significance on cardiovascular mortality and morbidity. However, echocardiography screening for LVH is not routinely done for hypertensive patients in a primary care setting. Thus, this quantitative study aims to determine the prevalence and factors associated with LVH in hypertensive patients at a primary care setting. This was a cross-sectional study of 359 consecutive patients with uncomplicated essential hypertension attending a hospital-based clinic in Malaysia. All subjects underwent an echocardiography test. LVH occur when the left ventricular posterior wall thickness together with inter-ventricular septal thickness is ≥11 mm. It was found that 24% patients fulfilled the criteria for LVH. The mean age of the study population was 59.2±7.7 years; mean duration of hypertension was 9.7±7.5 years; and mean blood pressure was 136.5/81.5 (±13.7/7.7) mmHg. Using multiple logistic regression analysis, patients who were obese [odds ratio (OR) 8.34, 95% confidence interval (CI) 3.14, 22.22] and male gender (OR 1.96, 95% CI 1.08, 3.16) had significant positive association with LVH. LVH was found in approximately one fourth of the hypertensive patients at a hospital-based primary care setting. There was a significant positive association between LVH and obesity and being male. Guidelines for enhancing use of echocardiography in detecting LVH may be needed.

    Study site: university primary care centre in Kuala Lumpur, Malaysia
  20. Long term visit-to-visit variability of systolic blood pressure and cardiovascular disease events in a primary care setting: a 10-year retrospective cohort study [Abstract OS 04-05]
    Ching SM, Chia YC, Lim HM
    J Hypertens, 2016 Sep;34 Suppl 1 - ISH 2016 Abstract Book:e56.
    PMID: 27753921
    Conference abstract:
    OBJECTIVE: This study aims to determine the relationship of long term visit to visit variability (VVV) of SBP and cardiovascular disease (CVD) in a primary care setting.
    DESIGN AND METHOD: This is a retrospective study of a cohort of 1416 patients over a period of 10 years (1998-2007). Demographic data, three monthly clinic BP readings and CVD events were captured from patient records. We derived the mean BP and VVV of SBPs for each subject and divided them into three groups defined as non hypertension, developed hypertension along the 10-year follow-up and persistent hypertension. We examined differences in cardiovascular events across these groups.
    RESULTS: Mean age of the participants at baseline was 56.5 ± 10.1 years, 34.6% were males. Table 1 describes mean SBP, BPV and CVD events of the study population.Those with both low mean SBP and low BPV have the lowest CVD events, conversely those with both high mean SBP and high BPV have highest CVD events. In those patients with the same mean SBP, whether high or low, those with higher BPV have more events than those with lower BPV. However patients with low mean SBP but high BPV have more CVD events compared with those patients with high mean SBP but low BPV (p = 0.04) suggesting BPV is more important than mean SBP in causing CVD events.We used ROC of VVV SBP to identify the cut off point of 12.9 mmHg as the indicator for increase in CVD events.
    CONCLUSIONS: In our study, we found that patients with hypertension have higher BPV than normotensive subjects. Furthermore those with higher BPV also had more CVD events. As such, we should prioritize lowering not only mean systolic BP but lowering BPV as well. Long term VVV SBP should be another target in the management of patients with hypertension.
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