[Usefulness of different techniques of blood pressure measurements in 2016]

The management of hypertensive patients is greatly influenced by blood pressure levels and accurate measurement of blood pressure is crucial in this context. Mercury sphygmomanometer has been progressively replaced by more precise oscillometric devices that can be widely used in the clinic and ambulatory setting. The purpose of this review was to detail the different methods for evaluating blood pressure, and to refine their indications and clinical benefit. Office blood pressure measurement has a great variability and should follow a strict protocol to give consistent results. National and international guidelines focus on blood pressure measurement in the ambulatory setting. When used by trained patients, home blood pressure monitoring is reproducible and can provide substantial prognostic information, even if ambulatory blood pressure monitoring remains the gold standard. The role of central blood pressure and pulse wave velocity monitoring in the therapeutic strategy of hypertension needs further assessment.

Influence of Blood Pressure and Other Clinical Variables on Long-Term Mortality in a Cohort of Elderly Subjects with Type 2 Diabetes

BACKGROUND

Diabetes mellitus and high blood pressure (HBP) are commonly associated conditions in the elderly population. An effect of treatments, biologic and anthropometric variables on long-term mortality is unknown in this population.

OBJECTIVES

To determine the prevalence of HBP control in a sample of elderly patients with type 2 diabetes with office blood pressure (BP) readings and ambulatory blood pressure monitoring (ABPM) and evaluate the influence of BP, anthropometric and laboratory variables on long term mortality.

METHODS

Cohort study in patients living at home in the area of Sherbrooke, ≥65 years old, receiving reimbursement for antidiabetic medication. The study included medical history, 2 sets of BP measurements, 2 24-hour urinary collections for microalbuminuria, 1 24-hour ABPM, blood level of creatinine and glycosylated hemoglobin. Charts were reanalyzed 8 years later for analysis of cardiovascular and total mortality cases.

RESULTS

198 patients were initially recruited. By history, 83% of the subjects had diagnoses and treatments for high blood pressure. In multivariate analysis, factors associated with an 8-year increased risk for cardiovascular mortality were creatinine ≥84 µmol/L, office seated systolic blood pressure ≤130 and diastolic BP ≤67.6 over 24 hours. Factors associated with total mortality were lower waist circumference, serum creatinine ≥84 and diastolic BP ≤67.6 over 24 hours.

CONCLUSIONS

Lower systolic and diastolic BP (office and ABPM), lower waist circumference and higher creatinine values are associated with an increased mortality risk. This suggests that a lower BP, declining kidney function and frailty are factors associated with this observation.

Prevalence and factors associated with hyperuricaemia in newly diagnosed and untreated hypertensives in a sub-Saharan African setting

BACKGROUND

Few studies have evaluated the link between hyperuricaemia and cardiovascular disease in sub-Saharan Africa.

AIMS

To assess the prevalence of and factors associated with hyperuricaemia among newly diagnosed treatment-naïve hypertensive patients in sub-Saharan Africa.

METHODS

We performed a community-based cross-sectional study from January to December 2012 in Douala, Cameroon (Central Africa). We enrolled newly diagnosed treatment-naïve hypertensive patients, and excluded those with gout or a history of gout. Serum uric acid concentrations were measured by enzymatic colourimetric methods, and hyperuricaemia was defined as a serum uric acid concentration>70IU/mL. Fasting blood sugar concentrations, serum creatinine concentrations and lipid profiles were also measured. Logistic regression was used to study factors associated with hyperuricaemia.

RESULTS

We included 839 newly diagnosed treatment-naïve hypertensive patients (427 women and 412 men; mean age 51±11 years; mean serum uric acid concentration 60.5±16.5IU/L). The prevalence of hyperuricaemia was 31.8% (95% confidence interval [CI] 28.7-34.9) and did not differ by sex (132 women vs. 135 men; P=0.56). Multivariable logistic regression identified age>55 years (adjusted odds ratio [AOR] 1.65, 95% CI 1.12-2.29), family history of hypertension (AOR 1.65, 95% CI 1.01-2.67), waist circumference>102cm in men or>88cm in women (AOR 1.60, 95% CI 1.12-2.29), low-density lipoprotein cholesterol>1g/L (AOR 1.33, 95% CI 0.97-1.82) and triglycerides>1.5g/L (AOR 1.63, 95% CI 1.01-2.65) as independently associated with hyperuricaemia.

CONCLUSION

Hyperuricaemia is common among newly diagnosed treatment-naïve hypertensive patients in sub-Saharan Africa and is associated with some components of the metabolic syndrome.

[Effect of N-3 polyunsaturated fatty acids on the modulation of T lymphocytes in vitro and redox status in obese women with hypertension]

OBJECTIVES

Deepen our knowledge of the immune system alterations associated with obesity-related hypertension and demonstrate that polyunsaturated fatty acids can enhance the proliferation and their profile oxidant/antioxidant and subsequently involved in the strategy prevention and treatment in obese hypertensives.

METHODS

T cells are isolated from the blood of the control and obese women with hypertension the University Hospital of Tlemcen (Algeria), these cells are incubated in the presence of a synthetic mixture of PUFA to 30μM (DHA/EPA/LA) and stimulated by mitogens for 48hours. The cells are counted and used to assess intracellular oxidative status. The biochemical parameters are determined by the use of plasma.

RESULTS

In obese women with hypertension, a significant increase in plasma levels of (glucose, uric acid, creatinine, urea, total cholesterol and triglycerides) compared to controls. In addition, decreased cell proliferation, basal or stimulated by Con A was observed in obese women with hypertension compared with controls. The mixture of PUFA to 30μM reduced lymphoproliferation as well in obese women with hypertension than in controls. The rates in malondialdéhyde (MDA) and protein carbonyl lymphocytes are elevated in hypertensive obese women. PUFA supplementation to 30μM seems correct this redox status in hypertensive obese since rates in protein carbonyl, are similar to those of controls.

CONCLUSION

The mixture of PUFA (n-3 and n-6) can modulate the activity of T lymphocyte proliferation and correct the intracellular redox status in hypertensive obese women.

Retinal arteriolar remodeling evaluated with adaptive optics camera: Relationship with blood pressure levels

AIM

To research a retinal arterioles wall-to-lumen ratio or lumen diameter cut-off that would discriminate hypertensive from normal subjects using adaptive optics camera.

PATIENTS AND METHODS

One thousand and five hundred subjects were consecutively recruited and Adaptive Optics Camera rtx1™ (Imagine-Eyes, Orsay, France) was used to measure wall thickness, internal diameter, to calculate wall-to-lumen ratio (WLR) and wall cross-sectional area of retinal arterioles. Sitting office blood pressure was measured once, just before retinal measurements and office blood pressure was defined as systolic blood pressure>=140mmHg and diastolic blood pressure>=90mmHg. ROC curves were constructed to determine cut-off values for retinal parameters to diagnose office hypertension. In another population of 276 subjects office BP, retinal arterioles evaluation and home blood pressure monitoring were obtained. The applicability of retinal WLR or diameter cut-off values were compared in patients with controlled, masked, white-coat and sustained hypertension.

RESULTS

In 1500 patients, a WLR>0.31 discriminated office hypertensive subjects with a 0.57 sensitivity and 0.71 specificity. Lumen diameter<78.2μm discriminated office hypertension with a 0.73 sensitivity and a 0.52 specificity. In the other 276 patients, WLR was higher in sustained hypertension vs normotensive patients (0.330±0.06 vs 0.292±0.05; P<0.001) and diameter was narrower in masked hypertensive vs normotensive subjects (73.0±11.2 vs 78.5±11.6μm; P<0.005).

CONCLUSION

A WLR higher than 0.31 is in favour of office arterial hypertension; a diameter under<78μm may indicate a masked hypertension. Retinal arterioles analysis through adaptive optics camera may help the diagnosis of arterial hypertension, in particular in case of masked hypertension.

[Impact of the ExSel(®) test administration on the excessive salt consumption in hypertensive patients followed in general practice]

OBJECTIVE

To evaluate the impact of the Exsel(®) test administration on salt intake in hypertensive subjects followed in general practice.

METHOD

In a group practice of general practitioners in the Île-de-France, the ExSel(®) test http://www.comitehta.org/testez-vous/consommez-vous-du-sel-en-exces-test-exsel/ was administered to 329 outpatients. The questionnaire was filled in the waiting room and then commented by the doctor. In patients treated for hypertension, 24hours urinary Na was prescribed after the consultation. Excessive salt consumption (ESC) was defined as a urinary Na≥200mmol/day.

RESULTS

The population included subjects aged on average 57 years with 43 % of hypertensive patients. According Exsel(®), an ESC was suspected in 36 % of patients and was more common in treated hypertensive patients (44 %; [36-52]) in hypertensive men (57 %; [46-68]) than among non-hypertensive (31 %; [24-38]) and non hypertensive women (18 % [11-25]). Urinary Na has been finally performed by 63 % of subjects and 24hours excretion was 157±56mmol in men and 123±39mmol in women. After this 24hours urinary sodium evaluation, subsequent to ExSel(®) test, ESC frequency was lower among men (19 %) and very low among women (5 %).

CONCLUSION

To estimate the ESC, the ExSel(®) test is easily performed in general practice while 24hours urinary sodium is more difficult to obtain. Achieving an ExSel(®) test was accompanied by a decrease in the frequency of excessive salt consumers with a greater effect in women.

[Arterial hypertension at the time of diagnosis of type 2 diabetes in adults]

AIM OF STUDY

Our aim was to determine the prevalence of arterial hypertension and evaluate its association with vascular chronic complications in newly diagnosed type 2 diabetes patients, in an observational, prospective study.

MATERIAL AND METHODS

We have recruited 327 newly diagnosed type 2 diabetics aged from 40 to 70 years, in general practice units. Arterial blood pressure has been measured according to WHO guidelines. All data on clinical examination, diabetes's chronic complications were collected during 6 months and statistically analyzed with Epi-Info 6.04 database program.

RESULTS

Among the patients, 66.7% had arterial hypertension at diagnosis of diabetes, 28% were known as hypertensive. They were 54.3±8.4years old and have metabolic syndrome in 88.4%. Men have more frequently a higher cardiovascular risk, higher glycaemia and albuminuria; women were more likely to have a metabolic syndrome and a higher BMI. Blood pressure increases with cardiovascular risk and metabolic syndrome components. Microangiopathy is present in 65.7%, atherosclerosis in 59.4 and 71.2% of hypertensive patients who have atherosclerosis have also microvascular complications.

CONCLUSION

The prevalence of arterial hypertension in newly diagnosed type 2 diabetes is high. This association is linked with an alarming level of vascular morbidity. Early detection and treatment of these two diseases need a better implication and motivation of patients and health care providers. Clinicaltrials.gov ID: NCT02002091.

[Determinants of controlled hypertension in patients treated with antihypertensive drugs in France: The French League Against Hypertension Survey (FLAHS 2015)]

OBJECTIVE

The FLASH 2015 survey sought the determinants of hypertension control in subjects treated with antihypertensive drugs in France.

METHOD

Sending self-administered questionnaire by mail to a representative sample of the population living in metropolitan France (MetaScope basis, TNS Sofres, France). Patients who declare taking antihypertensive drugs are considered treated hypertensives. A home blood pressure monitoring during 3 days was asked in subjects owing a blood pressure monitor and the average of 18 measurements was calculated.

RESULTS

A total of 6379 subjects aged 55 and older were included with 2814 (44.1%) treated with antihypertensive drugs. Home blood pressure was obtained from 1455 subjects including 882 (60.6%) treated. SBP/DBP are 129.3±13.5/75.5±9.0mmHg and are higher in treated subjects in each age category. BP<135/85 was observed in 55.4% and BP<140/90 in 71.7%. Determinants of BP control (<135/85) are the number of measurement for averaging (18 measures over 3 days vs 3 measurements on a morning; 55.4%/44.3%), age (55-64 years vs 80 years old; 57.6%/49.1%), gender (women vs men; 60.3%/50.1%), BMI (<25 vs >30; 63.1%/46.1%). In the 80 and older, a SBP<145 was observed in 74.7% of subjects. The control was 61% when considering an SBP/DBP<135/85 in 55-79 years and SBP<145 among 80 and older.

CONCLUSION

The control of hypertension evaluated by home blood pressure on a representative population living in metropolitan France is estimated at between 44.3% and 74.7% and several determinants influence the control of blood pressure like age, gender and BMI.

[Cohort of renal infarction during 2years at Grenoble teaching hospital]

BACKGROUND

Renal infarctions are rare events, clinical symptoms are various and diagnosis may be difficult, leading to diagnosis delay with kidney dysfunction risk.

METHODS

During 24 months (March 2013-February 2015), all patients admitted in nephrology, cardiology, or internal medicine for renal infarction were recorded. Cardiovascular risk, clinic-biologic and radiologic data were recorded. A prospective follow-up at 6 months was offered for each patient.

RESULTS

Eleven patients were admitted from emergency unit and 1 from general practitioner. Clinic symptoms are various: abdominal pain, headache, hypertension, and stroke. Diagnosis was not initially evocated, and was given by CT scan with 3 days median delay. Etiologies were composed of 5 dissections, 4 embolisms (atrial fibrillation), 1 cannabinoid arteritis, 1 thrombosis on atheroma, 1 thrombosis on postradiotherapy stenosis. Initial treatment was anticoagulation alone for 7 patients, with antiplatelet agent for 1 patient, anticoagulation followed by antiplatelet agent for 2 patients, and antiplatelet agent alone for 2 patients. We observed LDH elevation (4 cases on 5 available data) at admission; inflammatory syndrome, hypokalemia, and hypertension at 48-72h of symptoms. At 6months follow-up, one patient had altered glomerular filtration rate, and one patient had recidivism.

CONCLUSION

Delay of diagnosis is a real problem for renal infarction, and need to be evocated every flank pain. LDH elevation may help clinician to suggest renal infarction and lead to CT scan. Association of delayed inflammatory syndrome, hypertension and hypokalemia after flank pain strongly suggest renal infarction.

[Medication reconciliation at hospital discharge focusing on patient with hypertension: Analysis of the output prescription]

PURPOSE

To describe pharmacists' interventions made at patients hospital discharge from Department of Hypertension.

METHODS

This is a single-center and prospective study over an 8-week period. At hospital discharge, the pharmacist compared pre-admission and inpatient medications with discharge orders and written instructions. Pharmacists' interventions were then classified in 4 categories. All variances and discrepancies were discussed with the prescribing physician when possible.

RESULTS

Over the 8-week period, 154 cases were analyzed. Pharmacists' interventions at discharge underwent 48 times on 21% of the patients (n=33) but none was clinically relevant. Among these 48 cases, 40% (n=19) were rated as "inappropriate administration", 27% (n=13) were classified as "incomplete prescription", 19% (n=9) were "variances" and 4% (n=2) were due to "omission prescription". In 10% of the cases (n=5), discrepancies appeared without any possible further analysis as no discussion with the prescriber occurred.

CONCLUSION

One fifth of all patients analyzed was the subject of a pharmacists' intervention. The complementary action of the pharmacist improves the consistency of the prescriptions and strengthens patient safety.

[The use of echocardiography left ventricular filling pressures in hypertensive patients with heart failure and preserved systolic function in a North Africa unit day]

OBJECTIVE

To assess the left ventricular (LV) filling pressures by Doppler Tissulaire Imaging (DTI) in the management of hypertensive patients with heart failure and preserved systolic function (HF-PEF) in our outpatient clinic. To involve the patient on the basis of their clinical, biological and echocardiography data, in identifying the risk factors that need change.

PATIENTS AND METHODS

From 2004 to 2014, heart failure with preserved systolic function (HF-PEF) has been diagnosed in 200 consecutive hypertensive patients (pts) at our Algerian outpatient unit. Data were collected on blood pressure at the time of the examination, body mass index (BMI), waist, comorbid conditions including dyslipidemia, diabetes and atrial fibrillation (AF). LV ejection fraction>50 % is taken as the including criteria with acquisition as described in the Chamber Quantification update. Left ventricular global systolic function by biplane disk summation Simpson method and diastolic function is assessed by the mitral inflow measurements regarding recommendations for the evaluation of left ventricular diastolic function by echocardiography from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE).

RESULTS

Mean age was 65±11 yrs; 66 % were female; waist circumference in men>102cm and in women>88cm was found in 82 % of the pts and 50 % were diabetics. Body weight (BMI)>30kg/m(2) is depicted in 88 (44 %). Dyslipidemia is depicted in 78 pts (39 %). Ischemic heart disease was diagnosed in 64 pts (32 %); history of thromboembolic event in 78 pts (39 %); valvular disease in 40 pts (20 %). ECG showed AF in 60 pts (30 %), complete left bundle branch block (LBBB) in 20 pts (10 %). The echographic findings were as follow: left ventricular hypertrophy (LVH) in 126 pts (63 %) and left atrial (LA) enlargement in 111 pts (55 %). Mean left ventricular ejection fraction (LVEF) is about 55±10 %. Delayed relaxation (Em/Am<1) and deceleration time>150ms (DT) in 80 pts (40 %), of them, 56 had increased filling pressures (Em/Ea>8 and Ap>Am); pseudo-normal patterns (1<Em/Am<2 and DT<150ms) in 80 pts (40 %); restrictive filling pattern (Em/Am≥2) and short DT<100ms in 40 pts (20 %).

CONCLUSIONS

The hypertensive pts referred for an echo examination are often diabetics and frequently demonstrate preserved left ventricular function with increased filling pressures. This is useful for managing their treatments in the context of a cardiac rehabilitation programme.

[Prevalence and characteristics of metabolic syndrome among hypertensive patients in Abidjan]

AIM

Assess prevalence of metabolic syndrome (MetS) in black Africans hypertensive patients.

POPULATION

Prospective survey from 3rd November 2014 to 12th June 2015, at Abidjan Heart Institute. Study was carried out among patients aged 18 years old, admitted to external consultation. Oral consent was obtained. MetS was established based on the definitions of the NCEP-ATP III 2005 and the International Diabetes Federation (IDF).

RESULTS

Over 1246 hypertensive patients, 404 were included in our study. The prevalence of MetS was 48.8% according to the criteria of the NCEP-ATP III 2005 and 51% according to the IDF. We noticed a female predominance (69% against 31%, P<0.001). Central obesity (49.5%) and low HDL-cholesterol (42.1%) were the factors defining the SM most predominant in our series. Low blood pressure control was higher in the presence of MetS (43.6%). The average number of antihypertensive prescribed drugs were significantly higher (2.2±0.8 against 2±0.8, P<0.001). MetS was significantly associated with obesity (BMI≥30kg/m(2) : 40.6% against 14%, P<0.001). Cardiovascular complications were observed in 54.8% of hypertensive patients in the presence of MetS.

CONCLUSION

MetS is a reality in sub-Saharan Africa. Adequate preventive measures are needed to limit its progression.

The impact of different left ventricular geometric patterns on right ventricular deformation and function in hypertensive patients

BACKGROUND

Right ventricular (RV) hypertrophy and RV systolic dysfunction are predictors of poor outcome. No study has investigated RV deformation and function in hypertensive patients with different left ventricular (LV) geometry patterns.

AIM

To investigate RV deformation and function in hypertensive patients with different LV geometric patterns, by using two-dimensional (2D) strain analysis and three-dimensional (3D) echocardiography.

METHODS

This cross-sectional study included 184 hypertensive subjects, all of whom underwent complete 2D and 3D examinations. The participants were separated into two groups (with and without LV hypertrophy [LVH]), and were then divided into four further groups according to different LV geometry patterns: normal LV geometry, concentric remodelling, eccentric LVH and concentric LVH.

RESULTS

Patients with LVH had significantly higher RV end-diastolic and end-systolic volume indexes and stroke volumes than those without LVH. Conversely, 3D RV ejection fraction was lower among subjects with LVH. 3D RV volume indexes gradually increased from subjects with normal LV geometry to those with concentric LVH, whereas 3D RV ejection fraction progressively decreased in the same direction. Global RV longitudinal strain was significantly lower in LVH subjects than in patients without LVH. 2D RV mechanics progressively deteriorated from patients with normal LV geometry to those with concentric LVH. Eccentric and concentric LVH were associated with reduced longitudinal lateral wall RV strain and early diastolic strain rate.

CONCLUSIONS

2D RV myocardial deformation and 3D RV function are affected significantly by LV geometry in hypertensive patients. Concentric and eccentric LVH patterns have the greatest unfavourable effect on RV deformation.

[New insights into sodium in kidney and cardiovascular diseases]

Recent guidelines recommend a restriction of sodium intake below 2,4 g/day (6 g/day of NaCl) in general population to prevent arterial hypertension and cardiovascular disease. Three papers published in 2014 by The New England Journal of Medecine confirm the association between high sodium intake and arterial hypertension. However, marked sodium restriction is also associated with increased mortality. On the other hand, a diet rich in potassium, over 1.5 g/day, is associated with less cardiovascular mortality, and less chronic kidney disease progression.

[Malignant hypertension and cardiac decompensation after overuse of nasal decongestant: A case report and literature review]

INTRODUCTION

Vasoconstrictors, widely prescribed in the congestive states during acute rhinitis, are responsible for many cases of drug-related iatrogenic disease.

CASE REPORT

We report the case of a 40-year-old man, who presented with an episode of malignant hypertensive crisis associated with life-threatening congestive heart decompensation. The patient interview revealed consumption to supra-therapeutic dosage of an association of naphazoline and prednisolone nasal sprays. The diagnostic work-up allowed to rule out disease-related causes of secondary hypertension. The drug-related disease was thus retained.

CONCLUSION

The results of the literature review showed many cases of vasoconstrictor poisoning responsible for central nervous system and cardiovascular involvement, especially in young children. This first case of heart failure related to nasal decongestant administration increases the scope of potentially serious risks of these drugs and demonstrates the outreach needs for health professionals and patients about their proper use.

[Place of clinical pharmacist in the management of drugs in patients with hypertension]

PURPOSE

To synthesize pharmacists' interventions made in the department of internal medicine and hypertension of university hospital of Toulouse and assess the impact on medication orders.

METHODS

This is a single-center, prospective study using pharmacists' interventions recorded between September 2013 and March 2014 on the Act-IP(©) website of the French Society of Clinical Pharmacy. The clinical pharmacist is present everyday in the unit to establish the medication reconciliation of new patients (the process of comparing a patient's medication orders to all of the medications that the patient has been taking), and analysis of medication orders. When a risk of iatrogenic drug is identified, a therapeutic change is proposed to the prescriber.

RESULTS

A total of 2491 medication orders were analyzed for 7 months, leading to 39 pharmacists' interventions (1.6 pharmacists' interventions per 100 medication orders). The most commonly identified drug-related problems were improper administration (33%, n=13), not prescribed drug (21%, n=8), non-conformity to guidelines (18%, n=7), supratherapeutic dose (15%, n=6), and 13% (n=5) targeted prescribed treatment not administered, underdosing, incorrect administration or drug interaction. The most relevant molecules were atorvastatin (10%), bromazepam (8%) and levothyroxine (8%) and only 2 interventions targeted antihypertensive drugs. The rate of physicians' acceptance was 92%.

CONCLUSION

Pharmacists' interventions mainly concern the co-prescriptions of antihypertensive drugs and very few antihypertensive drugs. The clinical pharmacist contributes to preventing iatrogenic in patients with hypertension with a very good acceptance by the clinician.

[Assessment at distance of a self-measurement of blood pressure education program: The PEA]

Current recommendations advocate self-measurement of blood pressure (SMBP) for the diagnosis and monitoring of high blood pressure (HBP). The "PEA" is an education program of the HTA GWAD network. Its mission is to train hypertensive patients with SMBP. The objective of this study is to evaluate between 6 months to 1 year after the efficiency of this program on the theoretical and practical knowledge of patients, as well as their behavior towards hypertension. Hundred and twenty patients were included in the study. In an interview, their knowledge was assessed using a questionnaire. The acquisition of the technique, reading and figures transcription, purchase of a SMBP device were also evaluated. The average questionnaire score was 5.7/13 (σ=2.7) before the educational session, 9.5/13 (σ=1.9) 1 week after the educational session. This improvement persisted over time with 8.9/13 (σ=2.9) correct answers 6 months to 1 year later. Exactly 73.3% (n=88/120) had a self-measurement device. Among them, 44.3% (n=39/88) practiced SMBP before medical consultations and 10% systematically did it before each medical consultation. A number of 84.2% (n=101/120) mastered the technique and 76.7% (n=92/120) of patients knew how to transcribe figures. Reading and understanding figures were acquired by 61.7% (n=74/120) of patients. A high level of education was correlated with a high level of practice. PEA is a sustainable solid and stable education program. However, the practice of SMBP is not yet systematic and remains to be encouraged in some patients. Given this situation, the network offers improvements in its program: highlighting of objectives, calendar reminder, "coaching" nurse.

[Relationship between blood pressure, heart rate and cardiac autonomic dysfunction in non-diabetic obese patients]

RATIONALE

Some studies suggest that a high heart rate (HR) would be predictive of the incidence of an elevated blood pressure (BP). Cardiac autonomic dysfunction (CAD) affects a high proportion of obese patients. CAD could be involved in BP increase. Our aim was to examine the relationship between CAD, HR and BP in obese patients without known diabetes.

PATIENTS AND METHODS

We included 428 overweight or obese patients. CAD was assessed by analyzing HR variations during three standard tests (Valsalva, deep breathing, lying-to-standing), which are mostly dependent on vagal control. An oral load in glucose was performed and the Matsuda index was calculated.

RESULTS

The population was separated in 4 groups according to the grade of CAD (no or only one abnormal test, 2 or 3 abnormal tests) and HR (< or ≥ 75 bpm). Age was similar in the four groups. Systolic (P=0.05), diastolic (P<0.005) and mean BP (P<0.001) differed significantly between the 4 groups, and was the highest in the group of patients who had 2 or 3 abnormal tests and HR ≥ 75 bpm. Matsuda index differed across the groups (P=0.018) and was the lowest in this group.

CONCLUSION

These data indicate that among overweight or obese patients with a defect in cardiac vagal activity BP is elevated only in those with a high heart rate, which is indicative of a more marked insulin resistance and probably an excess in sympathetic activity.

[Self-medication among black African hypertensive patients: Factors and consequences]

INTRODUCTION

Self-medication practice is under-evaluated among black African hypertensive patients.

AIM

To assess the level of self-medication among black African hypertensive patients and to determine the factors favoring this practice and their consequences.

METHODS

Prospective study during a 3-month period including 612 hypertensive patients followed in Abidjan cardiology institute.

RESULTS

Mean age was 55.1. The patients had a self-medication use in 60.1% of cases. Medicinal plants and derived products were commonly involved. Self-medication use reasons were: influence of relatives (89.8%) and the fear of antihypertensive drugs adverses effects (54.9%). Multivariate analysis shows that factors of self-medication were age (56.6 years vs. 50.3 years, P<0.001), income less than 762 euros/month (88% vs. 75.4%; OR=2.73; 95% CI: 1.62-4.6; P<0,0001), obesity (70.4% vs. 35.6%; OR=1.24; 95% CI: 0.75-1.15; P=0.037), dyslipidemia (40.8% vs. 27.9%; OR=6.72; 95% CI: 0.57-2.13; P=0.043), antihypertensive association therapy (61.7% vs. 51.4%; OR=2.27; 95% CI: 0.25-0.97; P=0.037). Poor control of high blood pressure (HBP) was a consequence of self-medication (6.5% vs. 47.1%; OR=10.27; 95% CI: 4.65-56.4; P=0.034), repercussions of HBP on major organ (75% vs. 17.2%; OR=12.9; 95% CI: 8.5-19.6; P=0.0001).

CONCLUSION

Self-medication is a common practice in African hypertensive patients. It has many consequences.

[Hypertension and cardiovascular risk associated with obstructive sleep apnea in adult in Guadeloupe (French West Indies)]

BACKGROUND AND PURPOSE

In Guadeloupe, data on the relationships between arterial hypertension and obstructive sleep apnea are unavailable. The aim of this study was: to assess the frequency of hypertension and non-dipper pattern evaluated by 48-hour ambulatory blood pressure monitoring in an adult population identified obstructive sleep apnea/non-obstructive sleep apnea during overnight polygraphy ; to determine the cardio-metabolic factors associated with obstructive sleep apnea.

DESIGN AND METHOD

A cross-sectional study was realized at Pointe-à-Pitre Hospital. Patients were referred for suspected sleep apnea to sleep specialist and performed a nocturnal polygraphy. Diagnosis was confirmed if the apnea-hypopnea index was ≥ 5. We obtained two groups: sleep apnea/non-sleep apnea. All patients underwent 48-hour ambulatory blood pressure monitoring. The cardio-metabolic factors were identified and assessed (fasten level of hs-CRP and Homa-IR index).

RESULTS

A total of 204 patients were included. Mean age at diagnosis was 54 ± 10 years, 63% were women. OSA was present in 69.6% with a higher frequency in men than in women. Difference was not significant between the two groups for hypertension frequency (84.5% vs 77%; P=0.22), non-dipper pattern (77.5% vs 76%; P=0.79) and hs-CRP. Differences for age, snoring, body max index, mean waist circumference, Homa-IR index, obesity, dyslipidemia, and type 2 diabetes were significant.

CONCLUSIONS

Our data highlight raised frequency of cardiovascular metabolic factors in patients with obstructive sleep apnea and confirm their high cardiovascular risk.

[Development and evaluation of ExSel Test to screen for excess salt intake in hypertensive subjects]

OBJECTIVE

Development of a test to screen excess salt intake (ESI) in hypertensive patients.

METHODS

Hypertensive subjects living in Paris area have been included. A 24-hour urinary sodium collection has been performed the day before the visit for a day hospital. A food diary was completed on the day of the urine collection and validated after an interview with a dietetician. An ESI was defined by a urinary sodium ≥ 200mmol/d. Clinical or food characteristics associated to an ESI were retained for the ExSel Test variables. A ROC curve was performed to determine the optimal score for the ExSel Test in detection of ESI in hypertensive patients.

RESULTS

One hundred and forty-eight hypertensive patients have been included living in the Île-de-France area. ESI was observed in 19% with a higher frequency in men. Seven major determinants of ESI have been identified and are the questions that constitute the ExSel Test. A positive response assigns points: man (1); BMI > 30 (2); bread 4 or 5 pieces per day (1) or more than 6 pieces; cheese at least 1 time per day (2); charcuterie at least 2 times per week (2); use of processed broth or pilaf (1); food rich in hidden salt (pizza, cheeseburger, quiche, shrimp, potato chips, smoked fish, olive) at least 2 times per week (1). The ROC curve analysis shows that a score of 5 or more has the best Youden index with a sensitivity of 0.63, specificity of 0.95, PPV of 0.75, NPV of 0.92.

CONCLUSIONS

In hypertensive subjects, an excessive salt intake can be detected by the realization of the ExSel Test based only on a simple food-questionnaire and some clinical parameters. For a clinical use of the ExSel Test, an electronic version is available on http://www.comitehta.org.

["Heart, arteries and women" an innovative care pathway for women at high risk: First evaluation at one year]

INTRODUCTION

Cardiovascular diseases remain the first cause of death in women. To improve women's health cardiologists and gynaecologists should work together on women's specific cardiovascular risk factor.

METHOD

Our study evaluated a care pathway named "heart, arteries and women". One hundred and ninety-one women were included for vascular (n=55) or hypertensive (n=136) explorations from January the first to December the 31st of 2013. We studied their clinical presentation and medical management.

RESULTS

All women were at high cardiovascular risk (38% of them at very high risk). The average age was 52 years old. A woman on three had experienced high blood pressure or diabetes during pregnancy. One on two was postmenopausal woman. We stopped twelve estrogen-progesterone contraceptions; 60% didn't have gynaecological follow-up; 146 had high blood pressures (73% at night, 50% had no dipping blood pressure profile and 15 were newly diagnosed for hypertension). Sleep apnoea syndrome was suspected in half women. Medical therapies were optimized especially for women with atheroma in which 30 to 46% were properly treated (P=0.0005). Only 18% of the gynecologists received conclusive reports.

CONCLUSION

At one year, our care pathway "heart, arteries and women" allowed to optimize medical therapy and clinical management. Everyone should be aware of this program.

[Physical activity level and home blood pressure measurement: Pilot study "Acti-HTA"]

While physical activity (PA) is recommended for high blood pressure management, the level of PA practice of hypertensive patients remains unclear. We aimed to assess the association between the level of both PA and blood pressure of individuals consulting in 9 hypertension specialist centres. Eighty-five hypertensive patients were included (59 ± 14 years, 61% men, 12% smokers, 29% with diabetes). Following their consultation, they performed home blood pressure measurement (HBPM) over 7 days (2 in the morning+2 in the evening), they wrote in a dedicated form their daily activities to estimate the additional caloric expenditure using Acti-MET device (built from International physical Activity Questionnaire [IPAQ]). Thus, patients completed a self-administered questionnaire "score of Dijon" (distinguishing active subjects with a score>20/30, from sedentary<10/30). Subjects with normal HBPM value (<135/85 mm Hg) (55% of them) compared to those with high HBPM were older, had a non-significant trend towards higher weekly caloric expenditure (4959 ± 5045 kcal/week vs. 4048 ± 4199 kcal/week, P=0.3755) and score of Dijon (19.44 ± 5.81 vs. 18.00 ± 4.32, P=0.2094) with a higher proportion of "active" subjects (48.9% vs. 34.2%, P=0.1773). In conclusion, our results demonstrate a "tendency" to a higher level of reported PA for subjects whose hypertension was controlled. This encourages us to continue with a study that would include more subjects, which would assess PA level using an objective method such as wearing an accelerometer sensor.

[Hypertension in the elderly in France: Characteristics of treatments and frequency of cognitive complaint according to the 2014 French League against Hypertension Survey]

OBJECTIVE

Describe hypertensive patients treated in 2014 in France by age and estimate the degree of cognitive complaint among subjects aged 55 and over.

METHOD

French League against Hypertension Survey (FLAHS) was conducted by mail in a representative sample of subjects aged 35 and over living in metropolitan France. Antihypertensive treatment data were obtained by self-administered questionnaire. Among the owners of a self-measurement device, blood pressure was considered to be controlled if the average of three measurements in the morning was below 135/85 mmHg. Cognitive complaint was detected by the cognitive complaint questionnaire (QPC) and analyzed by age and medical history of each subject.

RESULTS

In 2014, 30% of the population aged 35 and over (11.6 million) was treated with antihypertensive drugs. The number of treated hypertensive was: 3.45 million in the 75 and older, 2.96 million in 65-74 years, 3.24 million in 55-64 years, 1.58 million in the 45-54 years and 0.441 million in 35-44. The mono/bi/tri/quad-therapy is used in 46%/35%/14%/5% of patients. This distribution varies with age with monotherapy used in 63% of subjects under 55 years but in 40% of subjects 75 years and over. A positive QPC was noted in 11% of 55-64 years, in 21% of 75 years and older (P<0.001), in 20% of uncontrolled hypertensive patients, and in 34% of subjects with a personal history of stroke.

CONCLUSION

In France, hypertension is a disease that affects mainly the elderly. The modalities of treatment are different depending on age. Cognitive complaints are more common in uncontrolled hypertensive patients and in patients with a history of stroke.

[Presumption of sleep apnea in a black African hypertensive population: Importance of the Epworth sleepiness scale in the diagnostic approach]

INTRODUCTION

Sleep apnea syndrome (SAS) is very little described in the hypertensive black African.

PURPOSE

To screen sleep apnea syndrome using the rating scale of Epworth daytime sleepiness, and to investigate the determinant factors and to infer therapeutic consequences.

METHOD

This is a retrospective and prospective study with descriptive and analytical purpose that focused on 200 hypertensive outpatients of the Cardiology Institute of Abidjan. The primary endpoint studied was the SAS. The diagnostic approach of SAS was performed using the rating scale of Epworth daytime sleepiness.

RESULTS

The prevalence of sleep apnea was 45%. The average age of sleep apnea carriers was 56.1 years, with a male predominance (60%). The determinant factors of sleep apnea syndrome were male gender (60% versus 40%, P=0.021), obesity (77.8% versus 62.7%, P<0.0001), diabetes (26.7% versus 15.5%, P=0.5) and dyslipidemia (54.4% versus 27.3%, P=0.0009). Life in urban areas, occupation and smoking were not correlated with SAS in our series. The control of hypertension was better in non-apneic patients compared to apneic patients (63.6% versus 38.9%, P=0.04). The visceral impact of hypertension in apneic patients was highly significant (77.8% versus 41.7%, P=0.014). Therapeutically, it was noted the preferential prescription of combination therapy in apneic patients compared to non-apneic patients (82.3% versus 74.4%).

[Arterial hypertension and control in Brazzaville (Congo): role of ambulatory blood pressure monitoring (ABPM)]

OBJECTIVES

To evaluate the rate control in the hypertensive patients and to identify the predictive factors of non-control.

METHODS

It was about a cross-sectional study with prospective collection of data over a period of 36 months. It has been held in Brazzaville, and included a consecutive series of 620 hypertensive patients known and treated for at least 6 weeks, having profited from an ambulatory blood pressure monitoring (ABPM) with therapeutic aiming. We used the TONOPORT V and the software Cardiosoft 6.51 of GE Health Care, respectively for the recording and the data analysis. The threshold fixed on the average of 24-hour was BP<130/80 mmHg, and the patients divided into two groups according to whether they were or not controlled.

RESULTS

They were 352 men (56.8%) and 268 women (43.2%), old on average of 53.8 ± 9.7 years (ranges: 29 and 89 years). The standard of living of the patients was average in 330 cases (53.2%), weak in 132 cases (21.3%), and high in 71 cases (11.5%). The other associated risk factors were sedentariness in 275 cases (44.4%), overweight/obesity in 134 cases (21.6%), dyslipidemia in 121 cases (19.5%), diabetes mellitus in 90 cases (14.5%), and tobacco addiction in 25 cases (4%). The hypertension, old of 5.8 ± 5.7 years on average, was controlled among 215 patients (34.7%). The 24- hour BP average was 139 ± 14 mmHg for the SBP and 88.2 ± 10.2 mmHg for the DBP. The awake and asleep BP averages were respectively 141 ± 14 mmHg and 133 ± 16.2 mmHg for the SBP, 90.5 ± 10.5 and 81.2 ± 11.1 mmHg for the DBP. The antihypertensive protocol used was a monotherapy in 130 cases (21%), bitherapy in 287 cases (46.3%), tritherapy in 154 cases (24.8%), quadritherapy or more in 27 cases (4.3%). Prevalence of non-dipping was 43%. Age and male gender were the significant predictors of poor control.

CONCLUSION

The rate control of hypertension in our study population remains low. Its improvement passes by the education of the hypertensive patients and the improvement of their living conditions.

[Middle aortic coarctation: a rare vascular disorder]

OBJECTIVE

Coarctation of the descending thoracic aorta is uncommon, with controversial etiology. Usually, severe hypertension is the main symptom; lower extremity claudication is less often found. Surgical management remains the standard for long coarctation and provides good results.

METHODS

We report three cases of coarctation of the descending aorta operated at our department of cardiovascular surgery of Hospital La Rabta between January 2012 and December 2013.

RESULTS

The median age was 19 years and the median follow-up was 16 months. Hypertension was the most common clinical manifestation. The diagnosis was made by computed tomography angiography. Two cases were treated by an aorto-aortic bypass and one by subclavian-descending aorta bypass. Recovery was excellent, with a decrease in antihypertensive medications (four to two) and restoration of all distal pulses.

CONCLUSIONS

Middle aortic coarctation is a rare entity. Etiologies include congenital, acquired, inflammatory and infectious causes. The condition is considered a life-threatening emergency as a result of the complications associated with severe hypertension. Depending on technical considerations, open surgical bypass remains the standard repair for mid-aortic syndrome.

[Peripheral arterial disease of the lower limbs in African diabetic patients: ultrasonography and determining factors]

INTRODUCTION

Diabetic peripheral arterial disease (PAD) of the lower limbs is underdiagnosed.

METHODOLOGY

This was a prospective study conducted over a six-month period from November 2012 to April 2013. A total of 308 diabetic patients were included from three diabetes centers in Abidjan (Ivory Coast).

AIM

To screen for PAD of the lower limbs in a diabetic population and to identify the determining factors.

RESULTS

Among the 308 patients, the ankle-brachial index (ABI) was<0.9 in 68 (22.07%) patients considered to have PAD; the ABI was>1.3 in 56 (18.2%) patients who had suspected mediacalcosis. The average age of the PAD patients was 60.2 years. Female gender predominated (55.9%). The mean duration of diabetes was 9.6 years: 97.1% type 2 diabetes. The other cardiovascular risk factors in this population were hypertension (58.8%) and dyslipidemia (40.9%). Smoking was present in 29.4% of patients and obesity in 23.9%. PAD of the lower limbs was mild in 46 patients (67.6%), moderate in 16 (23.5%) and severe in 6 (8.8%). Duplex Doppler commonly showed lesions of the tibial arteries. Determining factors of diabetic PAD of the lower limbs were hypertension (58.8% vs 36.6%; OR=2.46; 95% CI: 1.13-5.36; P=0.034) and dyslipidemia (40.9% vs 8.3%; OR=7.6; 95% CI: 2.31-25.08; P=0.0009). For mediacalcosis, male gender (71.5% vs 39.7; OR=0.26 95% CI/0.10-0.64. P=0.004) was the only factor identified.

CONCLUSION

Hypertension and dyslipidemia were predictive factors for diabetic PAD of the lower limbs in our African population.

[Renal injury in Takayasu's arteritis]

Renal involvement in Takayasu's arteritis is frequent and worsens the progression of the disease. This is primarily a renal artery stenosis causing renovascular hypertension. The glomerular disease is exceptional. This study was undertaken to determine the clinical, radiological, biological features and therapeutic response in patients with kidney disease associated with Takayasu arteritis. A retrospective chart review was conducted on 11 patients (five men and six females), with a mean age of 31.1 years (19-40 years). The discovery of kidney disease preceded the diagnosis of Takayasu's arteritis in eight cases. Ten patients developed hypertension. Laboratory finding showed proteinuria in five cases of which one case was due to nephrotic syndrome. Renal failure was found in six cases including four cases in stage of terminal chronic renal failure. Impairment of the renal artery was present in nine patients, proximal in seven cases and distal in two cases, bilateral in five cases and unilateral in four cases. Narrowing renal artery was found in seven cases. The renal biopsy revealed membranoproliferative glomerulonephritis in one case and nephrosclerosis in another case. Eleven patients were followed for an average period of 155 months (3-335 months). Remission of nephrotic syndrome was concomitant with the remission of the disease. Seven patients developed outbreaks of Takayasu's arteritis of which six were in care. Relapse of nephrotic syndrome was concomitant with the outbreak of the disease followed by spontaneous remission of both diseases. Improved pressure was obtained in 5 cases and worsening renal function in seven cases. Death was observed in two cases.

[Medical practice in support of hypertension as risk factor kidney in general medical practice, and primary prevention in children in schools, and the pregnant woman in Annaba (Algeria)]

OBJECTIVE

To study medical practice in the management of hypertension as a factor in renal risk in general medical practice and primary prevention in children at school, and pregnant women under prenatal monitoring.

METHOD

The longitudinal study, observational over a year, focused on medical practice in schools, maternal health and medical practice among 100 physicians (general practitioner and specialist practitioner) in Annaba (Algeria).

RESULTS

In children in schools, measurement of blood pressure is never done on the grounds because this gesture is considered unnecessary in 100% of cases. In pregnant women, the measurement of blood pressure is not performed in more than 26% of pregnant women because it is deemed unnecessary by the midwife in 89% of pregnant women and default material in 11% of they. In current medical practice, 69% of doctors routinely take blood pressure. For the rest, represented mainly by specialists, it is the patient who does not justify. Sixty-two percent of physicians, that is hypertension, above 140/90mmHg, and 15% of physicians that is hypertension, above 145/95mmHg. Among the physicians, 58.7% did not use urinary strip, either, because they think that this review should be done in a laboratory (64.8%), or because the urinary strip are not available at even consulting (35.2%).

CONCLUSION

Inadequacies in the coverage (care) of the HTA are real. Their effects on the progress of prevalence of the renal insufficiency chronic terminal treated are possibly important.

[High blood pressure and physical exercise]

High blood pressure is a frequent pathology with many cardiovascular complications. As highlighted in guidelines, the therapeutic management of hypertension relies on non-pharmacological measures, which are diet and regular physical activity, but both patients and physicians are reluctant to physical activity prescription. To acquire the conviction that physical activity is beneficial, necessary and possible, we can take into account some fundamental and clinical studies, as well as the feedback of our clinical practice. Physical inactivity is a major risk factor for cardiovascular morbidity and mortality, and hypertension contributes to increase this risk. Conversely, regular practice of physical activity decreases very significantly the risk by up to 60%. The acute blood pressure changes during exercise and post-exercise hypotension differs according to the dynamic component (endurance or aerobic and/or strength exercises), but the repetition of the sessions leads to the chronic hypotensive benefit of physical activity. Moreover, physical activity prescription must take into account the assessment of global cardiovascular risk, the control of the hypertension, and the opportunities and desires of the patient in order to promote good adherence and beneficial lifestyle change.

[Hypertension and pregnancy in Lome (sub-Saharan Africa): epidemiology, diagnosis and risk factors]

AIM

Describe the epidemiology, diagnosis and risk factors of hypertension in pregnant women in Lome.

METHODS

It was a prospective, descriptive and comparative study during 12 months (October 1st, 2011 to September 31st, 2012) on 200 cases of hypertension among 1620 pregnant women, in the department of gynecology and obstetrics at the Tokoin teaching hospital of Lome.

RESULTS

We had 200 cases of hypertension on 1620 pregnant women. The prevalence of hypertension in pregnant women in Lome was 12.3%. The average age of pregnant women was 30±7 years, with extremes of 15 and 44 years. Hypertension was more common (50%) in ages of 30-39 years. The society the most represented were housewives (33.33%), civil servants (16.67%) and traders (16.66%). Hypertension was found incidentally or during a complication especially during the third trimester of pregnancy. Preeclampsia (44%) and pregnancy-induced hypertension (33%) were the most represented. The main risk factors where primiparity (especially older primipars >30ans), nulliparity, familial history of hypertension, low economic level, history of pregnancy-induced hypertension, age >30 years, twinning, obesity and stress.

CONCLUSION

Hypertension in pregnancy is frequent in Lome. A regular follow-up before and after delivery is important according to fetal and maternal complications, and the risk of heart and kidney disease at mild and long outcome.

[Correlation between urinary catecholamines dosage and apnea-hypopnea index in a hypertension population: pilot study]

AIMS

Sleep disorders like obstructive sleep apnea in adults are associated with increased sympathetic activity, which induced high blood pressure and could be associated with resistant hypertension. Some studies have demonstrated that high urinary catecholamine levels in obstructive sleep apnea patients may be decreased with continuous positive airway pressure therapy. However, very few studies have demonstrated a correlation between apnea-hypopnea index and urinary catecholamine levels in hypertension patients.

METHODS

In this pilot study, 20 hypertensive patients referred for hypertension work-up including night-time polygraphy and 24h urinary catecholamine dosage were included.

RESULTS

Mean age was 51±11 years (30-76), 68% were males. Diagnosis of obstructive sleep apnea was confirmed in 13 patients at the end of the work-up. Mean apnea-hypopnea index was 14±9 (2-32). The only urinary catecholamine parameter significantly increased in patients with obstructive sleep apnea was 24h urinary normetanephrine (1931±1285 vs 869±293nmol/24h; P<0.05). However, this difference was not significant when this parameter was adjusted to 24h urinary creatinine. We observed a significant positive correlation between AHI and 24h urinary normetanephine (r=0.486; P=0.035).

CONCLUSION

This pilot study confirms an isolated elevation of 24h urinary normetanephrine in hypertensive patients with obstructive sleep apnea and shows a significant correlation between sleep disorders expressed by apnea-hypopnea index and urinary catecholamines excretion.

[Variability of plasma angiotensinogen levels and risk of hypertension in a transgenic rat model]

AIM

Genetic polymorphisms of the human angiotensinogen gene are frequent and may induce up to 30% increase of plasma angiotensinogen concentrations with a blood pressure increase of up to 5mmHg. Their role for the pathogenesis of human arterial hypertension remains unclear. High plasma angiotensinogen levels could increase the sensitivity to other blood pressure stressors.

METHODS

Male transgenic rats with a 9-fold increase of plasma angiotensinogen concentrations and male non-transgenic rats aged 10 weeks were treated or not with NG-Nitro-L-arginine-methyl ester for 3 weeks in their drinking water (n=3/group). Systolic blood pressure and body weight were measured at baseline and at the end of the study when left ventricular weight and ventricular expression of angiotensin I-converting enzyme and procollagen Iα1 were determined (polymerase chain reaction).

RESULTS

At baseline, transgenic rats had +18mmHg higher bood pressure and -8% lower body weight compared to non-transgenic rats (P<0.05) without significant changes for the vehicle groups throughout the study (P>0.05). NG-Nitro-L-arginine-methyl ester increased blood pressure, left ventricular weight and left ventricular weight indexed for body weight by +41%, +17.6% and +18.6% (P<0.05) in transgenic and +25%, +5.3% and +6.7% (P>0.05) in non-transgenic rats compared to untreated animals, respectively. Cardiac gene expression showed no differences between groups (P>0.05).

CONCLUSION

Increased plasma angiotensinogen levels may sensitize to additional blood pressure stressors. Our preliminary results point towards an independent role of angiotensinogen in the pathogenesis of human hypertension and associated end-organ damage.

[Factors associated with poor blood pressure control in 253 treated hypertensive patients]

INTRODUCTION

Hypertension is a major public health problem throughout the world. The blood pressure control and the decrease of global cardiovascular risk are two main goals of the treatment of hypertension. The purpose of this study was to determine the proportion and associated factors of uncontrolled hypertension in hypertensive patients followed by private cardiologists in Oran.

MATERIALS AND METHODS

This study included 253 hypertensive patients followed by 7 private cardiologists in Oran. Was regarded as uncontrolled high blood pressure, a systolic blood pressure (SBP) superior or equal to 140 mmHg and/, or a diastolic blood pressure (DBP) superior or equal to 90 mmHg. A logistic regression analysis was performed to determine the associated factors with poor blood pressure control.

RESULTS

The proportion of uncontrolled hypertension was 69.6 % (75.8 % of men and 65.8 % of women). Using multivariate analysis, poor blood pressure control was found to be associated with salt consumption (ORa=2.71; CI 95 %=[1.42-5.18]).

CONCLUSION

Nutritional actions are required for better blood pressure control.

[Cardiovascular morbimortality after a follow-up of six years in black hypertensive in South Algeria]

INTRODUCTION

Arterial hypertension is a major public health problem not only internationally, but also in our country, and it is the major risk factor for cardiovascular diseases. In south Algeria, the black population is nearly half the population of the oases of the Algerian Sahara.

THE OBJECTIVES OF THE STUDY

The objectives of the study are to analyze the long-term fate of the black hypertensive subjects in Algerian oases in southern Algeria, in terms of morbidity and mortality, comparing the morphometric profile and cardiovascular complications with the white population of the same oases.

MATERIALS AND METHODS

One thousand four hundred and twenty-five subjects of both sexes were included (811 blacks and 614 white subjects), aged 40 and older, living in the Algerian Sahara and were reviewed after six years of decline. The control consisted of filling a questionnaire oriented on civil status, target organ damage, the number of hospitalizations and mortality. All calculations and statistical analyzes are processed by the SPSS 17.0 and Epi Info6 software.

RESULTS

Mean age for the black population and the white population was 60.3±11.1 and 58.6±10.6years, respectively. The incidence of hypertension was 50 % among blacks. The main complications observed were: stroke in 3.8 %, heart failure in 3.1 %, myocardial infarction in 1.7 %, hospitalizations related to cardiovascular complications of the black population was around 4.4 %, mortality 5.4 %.

CONCLUSION

These data on hypertension black subjects emphasize the importance of a policy of adequate local health issues raised, both in terms of the management of hypertension, as in investment in local medical research.

[Cardiovascular morbidity associated with obstructive sleep apnea syndrome]

INTRODUCTION

The obstructive sleep apnoea syndrome (OSAS) had become a major public health concern in modern society due to its high prevalence but, above all, to its associated morbidity, especially cardiovascular.

BACKGROUND

Untreated OSAS is associated with an increased incidence of fatal (myocardial infarction and stroke) (odds ratio: 2.87) and non-fatal cardiovascular events (myocardial infarction, stroke, coronary artery bypass surgery and coronary angiography) (odds ratio: 3.17). Moreover, the prevalence of hypertension in patients with OSAS is high, between 35 and 80%. The pathophysiological mechanisms leading to these complications are mainly due to intermittent hypoxia secondary to repeated episodes of apnoea/hypopnoea during sleep. These mechanisms include sympathetic hyperactivation, impairment of vasomotor reactivity, vascular inflammation, oxidative stress and metabolic disorders. In patients with OSAS, the impact of continuous positive pressure is proven in terms of prevention of cardiovascular events although blood pressure reduction is limited. Obviously these effects are proportional to observance.

CONCLUSION

OSAS does increase the cardiovascular risk, independently of other risk factors. Although the impact of treatment is relatively low in decreasing blood pressure, it seems essentially effective in preventing cardiovascular morbidity. Therefore, OSAS screening, and the association of specific treatments in cardio-metabolic patients and OSAS patients respectively, should be included in clinical strategies.

[A specific questionnaire to evaluate therapeutic inertia in hypertensive patients: a pilot study]

BACKGROUND

Therapeutic inertia (TI) is a recent concept still unknown by many physicians. In chronic diseases such as hypertension, it is defined as the tendency of physicians not to increase or change antihypertensive medications when the target blood pressure is not reached. Acting on TI could improve blood pressure control in France.

METHOD

This was a single-center prospective pilot study conducted by hypertension specialist physicians at the University Cardio-Vascular Center in Lille (France). It was conducted between March and June 2011. Data was collected from 161 hypertensive patients (mean age: 61.64±11.18 years; 98 (60.9%) male; 75 secondary prevention patients). Each physician completed a questionnaire on therapeutic inertia. TI was defined as a consultation in which treatment change was indicated (systolic blood pressure [BP]≥140 and/or diastolic BP≥90mmHg in all patients), but did not occur, with absence of an adapted justification of this choice. We considered as an adapted justification: a white coat effect demonstrated by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring; scheduled reassessment of the BP by ABPM; recent change in antihypertensive treatment (less than 4 weeks); hospitalization needed for complete evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage in patients with grade 1 or 2 hypertension. Our study aimed to evaluate rates of TI, to identify factors associated with TI, and to test the TI questionnaire.

RESULTS

Therapeutic inertia as defined in this study occurred in 11 consultations (8.3%) of the 133 hypertensive patients having uncontrolled BP above or equal to 140 and/or 90mmHg. Significant factors associated with TI were older age (Z=2.35, P<0.05) and sleep apnea syndrome (χ(2)=8.33, P<0.05). The absence of ambulatory blood pressure monitoring before the consultation (χ(2)=4.28, 0.1>P>0.05) and the number of consultations (Z=1.92, 0.1>P>0.05) exhibited a significant trend to be associated with TI.

CONCLUSIONS

Although the rate of TI was low in our study conducted in a specialized center, a well-accepted definition of therapeutic inertia would be useful for further study. The feasibility of using the questionnaire tested with this study shows that this measurement tool could help physicians become more aware of TI, both in the hospital and primary care setting. Further multicenter studies are needed for validation.

[Fluid overload and arterial hypertension in hemodialysis patients]

The water sodium overload is a factor of morbi-mortality and its treatment is one of the markers of adequacy of the hemodialysis treatment. Its first clinical assessment was improved by tools such as echocardiography and ultrasonography of the inferior vena cava, the per-dialytic curve of plasma volume, measuring BNP or proBNP and by impedancemetry. The combination of the evaluation of these parameters and of the clinical situation allows one to assess the extracellular overload, the state of the blood volume and the potential of plasma refilling. The latter is a key factor of the per-dialytic hemodynamic tolerance. It is itself a determining factor in weight can be achieved at the end of the session. Getting the "dry" weight can require modifications of the prescriptions of the hemodialysis sessions, a filling by albumin even a drugs support. Finally, the overload treatment is the central part of the treatment of arterial hypertension, which has to benefit however often from antihypertensive treatment the profit of which is demonstrated.

[Transthoracic echocardiography in a heart institute in Abidjan (Ivory Coast): Indications and evaluation of the request appropriateness]

OBJECTIVES

The aim of this study was to clarify the clinical situations motivating indications of transthoracic echocardiography (TTE) in a cardiology institute in Côte d'Ivoire and to assess the appropriateness of indications.

PATIENTS AND METHODS

This is a prospective and observational study conducted over a period of 6 months. The 1733 enrolled were classified according to the indications and their relevance defined by the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Echocardiography and the American Heart Association (ACCF/ASE/AHA).

RESULTS

In five cases (0.3%), indications were not listed in the document ACCF/ASE/AHA. The most common indication was the initial evaluation of hypertension (HTA) and suspicion of hypertensive heart disease (47.3%). All indications, the assessment in the context of hypertension represented 853 examinations (49.2%). Heart failure accounted for 5.3% of indications, but consisted of 302 applications (17.4%) when was associated hypertension with signs suggestive of heart failure. Requests were considered as appropriate in 95.3%, inappropriate in 3.2% and uncertain in 1.6%. In the group of inappropriate indications patients were significantly younger, and were examinations more often normal and less often absolutely abnormal.

CONCLUSION

The profile of cardiovascular morbidity in our institution is dominated by the spectrum of hypertension and heart failure. Each indication must be balanced for the profitability of the ETT.

[Bilateral stellate neuroretinitis as presenting sign of pheochromocytoma]

We report the case of a 21-year-old male patient admitted emergently with progressive bilateral severe visual loss for 1 month. Posterior segment examination revealed bilateral stellate neuroretinitis. Infectious serologies were negative, and brain CT was normal. Physical examination was remarkable for malignant hypertension of 220/150 mmHg. Diagnostic work-up revealed a pheochromocytoma documented by histopathological exam upon adrenalectomy. The disc edema and macular exudates resolved once the hypertension was controlled.

[Assessment of educational benefits in 73 hypertensive patients by telephone survey at distance of HTA Vasc educational program]

HTA Vasc offers an approved educational program for hypertensive patients at high cardiovascular risk (CVR).

METHOD

A telephone survey (December 2011-July 2012) evaluated the benefits of different workshops "my treatment", "my blood pressure" and "my nutrition", more than 6 months after the end of the program. The follow-up data (TS) were compared to inclusion data (T0) and to final data (TF) in 73 hypertensive patients.

RESULTS

The follow-up period was 6 to 31 months. The number of hypertensive controlled patients [blood pressure (BP)<140/90 mmHg] increased from 55.4% to 75.4% (P=0.0158) in TF, which remained over time. The practice of physical activity increased from 47.9% (T0) to 79.5% (TS) (P=0.001). The follow-up period of 18 months or more was associated with a tendency to weight gain (P=0.0059) and with a decline in physical activity [89.7% (<18 months) to 67.5% (≥ 18 months) (P=0.0198)]. The practice of self-measurement BP increased from 41.1% (T0) to 71.2% (TS) (P<0.0001); knowledge of the "rule of three" increased from 6.8% (T0) to 74% (TS) (P<0.0001).

CONCLUSION

An educational support contributes to a better long-term BP control. The motivation for lifestyle rules decreases with time. The implementation of a structured motivational follow-up could maintain the lifestyle motivation at these CVR patients.

[Relationship between noise and blood pressure in an airport environment]

OBJECTIVES

The authors have tried to assess the noise annoyance and its relation with the development of hypertension for the staff working at the civilian airport of Algiers. This population is constantly subject to aircraft noises. The noise, through creating stress, acts on the central nervous system and on the autonomic nervous system and is likely to cause hypertension by increasing peripheral resistance, total cholesterol, fatty acids, adrenaline, cortisol and blood glucose. A number of studies revealed that starting from 65 decibels, the noise causes hypertension for patients of more than 40 years following 5 years of exposure.

METHODS

An analytical study was conducted in 2000, which made the comparison between two groups of men working at Air Algérie company. There were 91 officers belonging to air crew, whose number was estimated at that time at 547, and whose average age was 49 years, compared with 111 officers of the ground crew on a total of 1200 persons and whose average age was 56 years. All those officers have received work medical consultation. Patients with suspected hypertension were systematically oriented to cardiologist. Similarly, everyone has had a biological assessment, an ophthalmologic consultation and ENT consultation as well.

RESULTS

Hypertension was found in 9.25% of the ground crew and in 16.63% of the air crew (P<0.001). Hypertension is more common among air crew, subject to a more important noise nuisance, at a younger age and with less risk factors than the ground crew, who develops hypertension with similar prevalence to general population's but at a younger age. The air crew gives more importance to treatment due to the risk of losing their navigation license. The ENT examination was abnormal in 39% of the air crew versus 8% of the ground crew.

CONCLUSION

In the light of these results, the noise seems to really interfere in the development of hypertension in airport environment. It would be more interesting to identify the number of strokes and particularly acute coronary syndromes which are far from being rare in this population subject to this noise annoyance. Preventive measures are of course extremely important.

[Trends in the use of antihypertensive drugs in France from 2002 to 2012: FLAHS surveys]

OBJECTIVE

To evaluate from studies conducted between 2002 and 2012, trends in the use of antihypertensive drugs in France.

METHOD

French League Against Hypertension Survey (FLAHS) were conducted in a representative sample of subjects aged 35 and over living in France. A list including the names for all antihypertensive drugs marketed at the time of each survey made it possible to detail drug therapies employed. Data analysis has taken the patient as a unity. The data obtained in 2002, 2007 and 2012 are subject to this analysis.

RESULTS

In 2012, 30% of the French population aged 35 and older was treated with antihypertensive drugs (11.4 million), while 24% were treated in 2002 (8.2 million). On average, prescription of antihypertensive included 1.4 ± 0.7 pills in 2002, 1.5 ± 0.8 in 2007 and 1.8 ± 0.9 in 2012, which corresponds to a pharmacological monotherapy prescribed in 47% of subjects in 2012, a different percentage than in 2007 (46%) and 2002 (56%). Over the period, the percentage of prescriptions of diuretics (41% to 42%) and ACE inhibitors (24% to 23%) and beta-blockers (35% to 36%) is stable, but they are increasing with ARBs (23% to 47%) and calcium antagonists (24% to 34%). The prescriptions of fixed-dose combinations were also increased (19% to 30%). In 2012, fixed-dose combinations included a diuretic (79%), an ARB (65%), an ACEI (23%) and a calcium antagonist (20%). Blood pressure control estimated with home blood pressure monitoring increases from 38% in 2002 to 50% in 2007 and 2012.

CONCLUSION

Changes in the use of antihypertensive drugs in France between 2002 and 2012 led to the prescription of antihypertensive treatment with associations in the majority. ARBs or ACEI are present on 70% of prescriptions with diuretics combined in 80%. Extensive use of fixed-dose combinations with diuretics and ARA2 characterizes this period in which it was observed an increase in blood pressure control in France.

[Imaging of retinal arteries with adaptative optics, feasibility and reproducibility]

OBJECTIVE

Adaptative optic is a new non-invasive imaging technique that allows to measure arterioles wall thickness and diameter with a resolution near two microns. Our objectives were to evaluate the feasibility and the reproducibility of this technique in untreated hypertensive patients.

DESIGN AND METHODS

In 23 naive hypertensive patients and in 14 normotensives, the internal diameter (ID) and the wall thickness of the superior temporal artery were automatically measured. Those measurements were made on a temporal artery segment and led to determine a whole vessel cross sectional area (WCSA) and a wall to lumen ratio (WLR). Intra-observer reproducibility was evaluated by realizing three consecutive measurements in 14 subjects. Inter-observer reproducibility was assessed by two independent readers in 17 patients. Variation coefficient was calculated as SD/mean values. A comparison of retinal parameters was made between normal and hypertensive subjects.

RESULTS

Inter-observer reproducibility indicated a variation coefficient of 1.3% for ID, 3.7% for the WCSA and 3.2% for the WLR. Intra-observer reproducibility indicated a variation coefficient of 3.2% for the WLR. Arterial remodeling was present in hypertensive patients at baseline with a significantly increased WLR as compared to normal subjects (0.32 ± 0.04 vs. 0.26 ± 0.04; P<0.05), both population having the same ID.

CONCLUSION

Adaptative optics is feasible and reproducible technique. The possibility of a direct and non-invasive assessment of retinal arterioles must assess the attractions in this technique in hypertensive patients' care.

[Prevalence of hypertension in El-Menia oasis, Algeria, and metabolic characteristics in population]

INTRODUCTION

El-Menia is an oasis located in the middle of Algerian Sahara. The drinking water in this oasis has low sodium content. The objectives of this study were to estimate the prevalence of hypertension, to describe the metabolic characteristics of population study and to assess the factors associated with blood pressure levels.

METHODS

A cross sectional study was conducted in 2010. Subjects (n=722) were selected from individuals aged 40 years or older by random cluster sampling. Blood pressure measurements, combined with a clinical questionnaire, and standard blood samples for the detection of dyslipidemia and diabetes mellitus, were collected.

RESULTS

Sixty-seven percent of subjects were females and 18% were black. The mean age was 58.5 ± 13.2 years. The prevalence of hypertension was 50.2%: 49.7% in females and 51.3% in males. The factors associated with presence of hypertension following a logistic multivariate regression were age, skin colour, waist circumference, and plasma glucose. The treatment and control of hypertension were 41% and 20% respectively.

CONCLUSIONS

The prevalence oh hypertension was high in this oasis and the rate of treatment control was low. Our findings suggest that appropriate healthcare should be given to hypertensive subjects, including a better information on hypertension.