[Blood pressure control in hypertensive patients with stable coronary heart disease]

OBJECTIVE

To evaluate systolic blood pressure (SBP) control in hypertensive patients with a stable coronary heart disease (CHD) in general practice in France.

METHODS

A survey was conducted in a sample of 206 general practitionners (GP) representative of the French medical population, in 2003 [LHYCORNE survey]. Each GP had to include 3 hypertensive patients, >18 years old, BP > or = 140/90 mmHg and/or treated for hypertension, and with evidence of CHD documented by myocardial infarction (MI) or angina pectoris (AP) [diagnosis previously established by a cardiologist]. Three office BP measurements were performed, the last two recorded. BP levels were considered as controlled by treatement if they were < 140/90 mmHg.

RESULTS

595 patients were included, 75% men mean age 66 years, 25% women mean age 73 years. All patients had a CHD: MI 46%, AP 54%; 533 (90%) had more than 2 cardiovascular risk factors: hyperlipidemia (411; 69%), smokers (375; 63%), diabetes (158; 27%). Mean BP was 140.7 +/- 14/80.8 +/- 9.7 mmHg; 553 (93%) of these hypertensive patients were treated, and 239 (40%) were considered as having a controlled SBP at the treshold of 140 mmHg: 47% in patients with previous MI and 38% with AP (p < 0.001). Diastolic BP (DBP) was <90 mmHg in 480 (81%) and pulse pressure was >65 mmHg in 202 (34%); 313 (53%) patients received a combination of three drugs or more; 354 (60%) had a beta-blocker, 260 (44%) a calcium channel blocker, 237 (40%) an ACE inhibitor, 287 (48%) other antihypertensive drugs (246 diuretics, 41%); 502 (84%) received antiplatelet therapy, 403 (68%) statins.

CONCLUSION

This survey shows that systolic BP is not at goal in 6/10 hypertensive patients with stable CHD suggesting there is a place for a more effective combination therapy according to evidence-based medicine.

[Investigation of hyperaldosteronism in the hypertensive patient. Why? When? How?]

Primary aldosteronism (PA) has been regarded for a long time as being a rare cause of arterial hypertension, but its prevalence has recently been reassessed as about 10%. This etiology should obviously be sought in the following settings: hypertension associated with hypokaliemia < 3.6 mmol/L (or < 3.9 mmol/L on ACE inhibitors): refractory hypertension: severe hypertension occurring before 40 years of age, especially in women. It must be reminded that more than 20% of PA are normokaliemic. Most of the authors recommend to use the aldosterone/renin ratio (ARR) as a screening test within these selected patients. When ARR turns out to be equal to or higher than 23 (if aldosterone and renin are given in pg/mL or ng/L), a suppression testing should be performed, using salt loading and/or fludrocortisone. Computed tomography scanning yields a specificity of 58% and a positive predictive value of 72%, only. Adenoma and hyperplasia have to be distinguished, using either NP-59 scintigraphy or adrenal venous samplings. Such a strategy appears to be useful, for the following reasons: removal of an adenoma results in a significant blood pressure lowering and in a blood pressure normalization in 95% and in 32% of the patients, respectively; in patients with hyperplasia, spironolactone therapy is followed by a 20% mean reduction in blood pressure.

Hypertension control at hospital discharge after acute coronary event: influence on cardiovascular prognosis--the PREVENIR study

OBJECTIVE

To assess hypertension control in patients admitted to hospital for an acute coronary event and to investigate the influence on prognosis of controlling hypertension before hospital discharge.

DESIGN

Multicentre retrospective cohort study.

METHODS

The medical records were examined of all patients admitted in 77 cardiological centres on January 1998 for myocardial infarction or unstable angina and who survived. Clinical characteristics, blood pressure at hospital discharge, and cardiovascular events during a six month follow up were recorded.

MAIN OUTCOME MEASURES

Cardiovascular deaths and non-fatal myocardial infarction.

RESULTS

Data were available in 1247 patients. At discharge, 411 (32.9%) had uncontrolled hypertension; among these, 276 (22.1%) were uncontrolled on the basis of systolic blood pressure alone. Forty three cardiovascular deaths and 20 non-fatal myocardial infarcts occurred during follow up. In a multivariate analysis, age, left ventricular ejection fraction, previous history of cardiovascular disease, and isolated systolic hypertension (odds ratio 1.9, 95% confidence interval 1.07 to 3.37) were associated with the outcome.

CONCLUSIONS

22.1% of patients admitted to hospital for an acute coronary syndrome have uncontrolled isolated systolic hypertension on discharge. This appears to be an independent predictor of cardiovascular outcome.

[Long-term development of blood pressure profile in hypertensive hemodialysis patients]

OBJECTIVE

The prognostic value of nocturnal blood pressure (BP) in hemodialysis patients has been well established. The aim of this study was to evaluate the long-term outcome of ambulatory BP in hypertensive hemodialysis patients.

DESIGN AND METHODS

Medical records of all hemodialysis patients seen for uncontrolled hypertension between 1993 and 1999 and who underwent an ambulatory blood pressure measurements (ABPM) were retrospectively studied. Uncontrolled hypertension was defined as office BP = 140/90 mmHg and 24 h ABP = 125/80 mmHg. Patients who underwent a second ABPM after an interval of at least 1 year were included in the study. Demographic characteristics, medical history, cardiovascular risk factors and treatments were recorded for each patient. A t-test (bilateral) was used to compare BP.

RESULTS

26 patients were included (545 +/- 18.9 years; 14 men). 7 had previous history of cardiovascular disease and 2 were diabetic. At the end of the follow-up (29 +/- 12.8 months), 9 patients (36%) had 24 h BP < 125/80 mmHg. A significant decrease in diurnal and nocturnal BP was observed (p < 0.05). No significant change was observed for office systolic BP and predialytic BP.

CONCLUSION

Our data show that a long-term decrease in nocturnal BP can be obtained in hypertensive patients on hemodialysis. With respect to the prognostic value of this criteria, randomised trials could be carried out to determine whether nocturnal BP is superior to office BP as a target for antihypertensive therapy in this population.

Prevention of stress-induced hypertension in hypertensive patients

The aim of the study was to assess the course of the alerting reaction during an effective antihypertensive treatment, and to discuss its interference with the conduct of therapy. In 28 patients suffering from mild to moderate hypertension, the basal blood pressure was measured in an outpatient clinic according to a standardized procedure, first by a nurse, then by a 12-min recorded monitoring, and then by a physician using a mercury sphygmomanometer with the patient in the upright and then the supine position. In comparison with the monitoring (mean values recorded at 6, 9, and 12 min), there was a significant increase in diastolic and systolic blood pressure taken by the nurse and by the physician, which diminished at the end of the visit with the physician. Patients then received 10 mg of bisoprolol each morning and presented again on day 30 and day 60, following the same procedure and under identical conditions. Despite the desired antihypertensive effect, the alerting reaction persisted at each visit up to the end of the study, being unchanged in the case of the systolic blood pressure and accentuated in the case of the diastolic blood pressure. Our results confirm those of previous investigations showing that even an effective antihypertensive therapy is unequivocally associated with a persisting alerting reaction irrespective of the antihypertensive drug applied. Thus, patients may be exposed to the potential risk involved with false failures and unnecessary overtreatment. The physician must compare his or her own measurements with readings made outside the consulting office and must program ambulatory blood pressure monitoring in the case of discrepancy. This is a suitable means of confirming and validating blood pressure measurements, as this method does not record the alerting reaction.

[Influence of cardiovascular risk factors on prescribing of antihypertensives]

OBJECTIVE

The World Health Organization Guidelines on the management of Hypertension recommends to take care of cardiovascular risk factors for selecting drug treatment. The aim of the study was to analyze relationship between cardiovascular risk factors and use of antihypertensive drugs in general practice in France.

METHODS

This was a national cross sectional epidemiological survey performed by 3,152 general practitioners between September 1999 and May 2000. Each investigator had to include 5 consecutive hypertensives (HT) (BP > or = 140/90 or presence of antihypertensive treatment). Cardiovascular risk factors, antihypertensive treatments and office BP were recorded. A stepwise logistic regression analysis was performed for each class of antihypertensive treatment in order to determine risk factors associated with prescription. Significant threshold was fixed at 0.05. Results are expressed in the form of odds ratios (OR).

RESULTS

14,551 treated hypertensives (mean age 60 +/- 10 years, male 56%) were analyzed. Sixteen per cent of patients were diabetics, 17% current smokers and the mean value of cholesterol was 2.29 +/- 0.37 g/L. ACE inhibitors, diuretics, beta-blockers (BB), dihydropyridines, angiotensin II antagonists (AAII), non DHP calcium antagonists (CA) were prescribed in respectively 47%, 35%, 28%, 18%, 14% and 12% of patients. The main risk factors associated with each kind of prescription was diabetes for ACE (OR = 1.36), coronary artery disease for BB, DHP and non-DHP CA (OR = 2.53; 1.51; 1.4 respectively) and BMI for AAII (OR = 1.03). OR > 1 indicates that risk factors was positively linked to prescription. Age had minor influence on selecting drug treatment. Conversely to BB and AAII, the use of ACE and non-DHP CA increases with presence of diabetes and cholesterol increase.

CONCLUSION

In general practice, presence of cardiovascular risk factors influences mildly management of hypertension. Conversely to BB, ACE are more prescribed in HT with metabolic disorders.

[Arterial hypertension management in general practice in France according to global risk factors]

OBJECTIVE

The absolute benefit of antihypertensive medications increases with the level of cardiovascular risk. Moreover in high risk groups, it has been demonstrated that tight blood pressure (BP) control conferred a substantial reduction in the risk of cardiovascular events compared to less tight BP control. Taking into accounts these data, the WHO guidelines recommend to achieve normal BP in high risk subjects. The aim of the study was to assess BP control in a large population of hypertensives (HT) after stratification by cardiovascular risk.

METHODS

15,514 HT defined as office BP > or = 140/90 or the presence of antihypertensive treatment were recruited in France by 3,152 general practitioners. Cardiovascular risk factors and office BP were recorded. Controlled hypertension was defined as a BP < 140/90 mmHg. In patients free of cardiovascular disease, 10-year cardiovascular risks were calculated on the basis of the equations derived from the Framingham Study.

RESULTS

10-year risks were available in 13,560 HT. Those in the highest quartile had greater body mass index (BMI) and the highest concentration of diabetics and current smokers (upper quartile versus lower quartile: BMI: 28.15 vs 26.51 kg/m2; diabetics: 45% vs 3%; current smoking 32% vs 12%; p < .001). [table: see text] Increasing quartiles of risk were associated with the prevalence of uncontrolled hypertension and at a lesser extent with the use of combination therapy. Subjects in the upper quartile had more frequent calcium-blockers, ACE inhibitors and diuretics use and a less frequent betablocker use.

CONCLUSION

In general practice, 85% of hypertensives at highest risk are uncontrolled whereas half of them are under monotherapy. An antihypertensive strategy based on global risk may improve BP control in high risk patients.

[Aterial hypertension and cardiovascular risk factors associated with diabetes. Report of the PHARE survey in general practice]

OBJECTIVE

To evaluate the characteristics of diabetic hypertensive patients (Pts), in term of associated cardiovascular risk factors and blood pressure control in a representative population issued from a survey "PHARE" conducted in general practice in France in 1999.

DESIGN AND METHODS

PHARE survey was conducted in a sample of 225 GPs representative of the French medical population included in a gallup poll. GPs had to include all patients > 18 years old over a period of one week. Pts were considered as hypertensives (HP) if the mean of two recorded BP measurements was = 140/90 mmHg and/or < 140/90 mmHg if they were under antihypertensive treatment. Patients were considered as diabetics if they were previously known and/or if they received a medication for diabetes. Hypertensives were considered as controlled if their BP levels were overall < 140/90 mmHg or at the recommended threshold < 130/85 mmHg under treatment.

RESULTS

877 diabetic Pts (7%) among 12.342 Pts and 5.190 HP were included in the study. When compared to normotensives, diabetic HP had more frequently associated risk factors with hypertension and diabetes: overweight 71% vs 45%, dyslipidemia 61% vs 34%, sendentarily 73% vs 63%, tobacco consumption 27% vs 20%. The BP control at 140/90 mmHg threshold among treated diabetic HP was 21%, and only 8% at 130/85 mmHg. Regarding WHO classification, 79% of these diabetics had a high or very high cardiovascular risk. The were no difference in antihypertensive drugs used in HP diabetics and non diabetics and 50% of them received ACEI.

CONCLUSIONS

8 from 10 diabetics taken in charge in general practice are hypertensives and 8 from 10 have a very high cardiovascular risk due to a poor BP control and associated cardiovascular risk factors.

[Microalbuminuria, pulse wave velocity and common carotid artery intima-media thickness in type 2 diabetes]

The aim of the study was to evaluate pulse wave velocity (PWV) and carotid intima-media thickness (IMT) in type 2 diabetics with microalbuminuria (mualb). The study concerned 37 patients type 2 diabetics, age: 53.4 +/- 6.6, years free of cardiovascular complications. HbA1C was 7.73 +/- 1.39%, waist circumference 104.2 +/- 11.7 cm. 19 patients with BP > 130/85 mmHg were identified as mild hypertensives (17/19 under treatment). All patients underwent ABPM, PWV and IMT measurements. The study population was separated into 2 subgroups according to median of mualb (mg/24 h): 18.9. [table: see text] In patients with mualb > 18.9 mg/24, IMT and PWV were significantly increased (p = 0.06; p < 0.01). After adjustment to BP and age, there was no significant difference in IMT and PWV in the subgroups. In this selected population of type 2 diabetics, microalbuminuria appears associated to a pressure-dependant vascular remodeling.

[Regional management of arterial hypertension in France. Report of a survey of general practitioners]

A survey was conducted in 14 regional samples of general practitioners (GPs) included in Gallup-up poll. 2,423 GPs contributed to the study and had to include all patients > 18 years old over a period of one week. Patients were considered hypertensives if the mean of two recorded BP measurements was > or = 140/90 mmHg and/or < 140/90 mmHg if they were under antihypertensive treatment. Hypertensives were considered as controlled if there BP levels were overall < 140/90 mmHg under treatment. The risk factors associated with hypertension were collected in order to evaluate the cardiovascular risk, according to 1999 ISH-OMS recommendations. 156,470 patients recruited by 2423 GPs were included in the study representing 14 different French regions: Ile-de-France I (1), Ile-de-France II (2), Ile-de-France-Pays-de-la-Loire (3), Bretagne (4), Normandie-Picardie (5), Nord-Pas-de-Calais (6), Alsace-Lorraine (7), Bourgogne-Franche Comté (8), Rhônes-Alpes (9), Provence-Côte d'Azur (10), Languedoc-Provence (11), Limousin-Auvergne (12), Midi-Pyrénées (13), Aquitaine (14). Among 70,073 hypertensives, 23,054 had never received antihypertensive treatment, and 32,059 (47%) had a high or a very high cardiovascular risk. 67% of hypertensives (47,019) were treated, and 32.8% of treated hypertensives (15,422) had a BP < 140/90 mmHg. The study illustrated few differences in prevalence and control of hypertension in the different French regions: BP control at the 140/90 mmHg threshold vary from 28.5 to 36.6% among treated hypertensives and % of patients at high cardiovascular risk from 42.1% (South-France) to 49.7% (East-France).

[Blood pressure control after acute coronary events. Results of the PREVENIR study]

OBJECTIVE

The difficulty in controlling hypertension in coronary patients has been underlined. The aim of the study was to assess blood pressure profile (BP) at hospital discharge in a large population of survivors of an acute coronary syndrome.

DESIGN AND METHODS

An observational study was conducted in France in 77 cardiological centers. The medical records of all patients admitted in these hospitals on January 1998 for a myocardial infarction or unstable angina and who survived were studied. Clinical characteristics and BP at hospital discharge were recorded. Patients with blood pressure > or = 140/90 mmHg were considered as uncontrolled hypertensives (HT).

RESULTS

Data were available in 1327 of the 1394 patients recruited: at hospital discharge, 344 patients (25.9%) were controlled and 431 (32.4%) were uncontrolled hypertensives. Among these patients, 406 (94.1%) had systolic blood pressure > or = 140 mmHg, 139 (32.2%) had diastolic blood pressure > or = 90 mmHg and 292 patients (67.7%) had systolic blood pressure > or = 140 mmHg and diastolic blood pressure < 90 mmHg. Pulse pressure in controlled hypertensives (51.02 +/- 10.93 mmHg) was quite similar to that in normotensives (47.81 +/- 9.84 mmHg) whereas pulse pressure was significantly higher in uncontrolled hypertensives (65.86 +/- 13.29 mmHg).

CONCLUSION

At hospital discharge after a coronary event, arterial hypertension is uncontrolled in 32.4% of patients mainly because of poor systolic blood pressure control. Achieving normal blood pressure throughout the hospitalisation should improve long term blood pressure control, reduce pulse pressure and improve the prognosis in this high risk population.

[Prevention in cardiovascular pathology]

National and international recommendations on the management of arterial hypertension and hypercholesterolemia suggest a treatment decision based on the evaluation of absolute cardiovascular risk. In order to evaluate the cardiovascular risk level, Anderson's equation (Framingham) has been proposed but does not apply to the French population. In medical practice, cardiovascular risk has to be appreciated according to the estimated cardiovascular risk of the country or area. The limits of a decision based on cardiovascular risk have been emphasized, particularly the balance age/life expectancy in respect of early prevention of atherosclerosis. However, the benefit of treatment of hypertension with beta-blockers, diuretics and recently ACE inhibitors and calcium antagonists or hypercholesterolemia with statins has been clearly stated--the higher the cardiovascular risk the higher the benefit. Secondary prevention in patients with major cardiovascular events is effective and necessary. The discussion concerns only primary prevention and from an economic point of view may concern patients at high cardiovascular risk. The general population have to be informed on cardiovascular risk factors, and patient education must be encouraged and developed via the healthcare network.

Arterial stiffness and cardiovascular risk factors in a population-based study

OBJECTIVE

To determine the relationships between pulse wave velocity (PWV), an estimate of arterial distensibility and cardiovascular risk factors.

DESIGN

This cross-sectional population-based study was carried out from 1995 to 1997 to investigate these relationships.

POPULATION AND METHODS

Some 993 subjects, aged 35-64 years (52.7% men), living in the south-west of France, were randomly selected from electoral rolls and participated in a cross-sectional study. Medical examinations were performed by specially trained medical staff. Carotid-femoral PWV was measured using a semiautomatic device (Complior, Garges les Gonesse, France). The relationships between PWV and risk factors were assessed, first in subjects not treated with hypolipidaemic, antidiabetic and antihypertensive drugs and then in treated subjects. In subjects not treated for cardiovascular risk factors, age, gender, systolic blood pressure (SBP) and heart rate (P< 0.001) were the variables significantly associated with PWV. In treated patients, age (P < 0.01), SBP (P < 0.001), heart rate (P < 0.001), apolipoprotein B (P< 0.05) and the number of treated cardiovascular risk factors (P< 0.05) were positively correlated with PWV.

CONCLUSION

This study shows that, in a sample of subjects at high risk, the cumulative influence of risk factors, even treated, is an independent determinant of arterial stiffness. These results suggest that PWV may be used as a relevant tool to assess the influence of cardiovascular risk factors on aortic stiffness in high-risk patients.

[Acute blood pressure elevations]

Blood pressure (BP) elevations may correspond to different clinical situations. Hypertensives emergencies are situations that require immediate reduction in BP because of acute or rapidly progressing target organ damage: accelerated malignant hypertension, hypertensive encephalopathy, acute myocardial infarction, acute aortic dissection, acute left ventricular failure, and eclampsia. Hypertensive urgencies are those with marked elevated BP in which it is desirable to reduce BP progressively within few hours, such as severe hypertension, progressive target organ damage, perioperative hypertension. Cerebrovascular accidents have to be individualized. In most patients in the immediate post-stroke period, BP should not be lowered. Caution is advised in lowering BP in these patients because excessive falls may precipitate cerebral ischemia. In situations without symptoms or progressive target organ it is necessary to exclude proximate causes of elevated BP such as pain and elevated BP alone rarely requires antihypertensive treatment. Among parenteral antihypertensive (AH) drugs labetalol, nicardipine, urapidil, and nitroprussiate are generally used, and the choice of AH drug depends on the clinical situation. It is not required to normalize BP immediately but to reduce mean BP no more than 25%, then toward 160/100 mmHg as recommended by JNC VI, in order to avoid an impairment of renal, cerebral or coronary ischemia. Oral long-acting dihydropyridines are often subsequently administrated, except in myocardial ischemia. Therapeutic attitudes vary considerably according to the clinical situation: abstention, immediate decrease or progressive decrease in BP have to be decided.

Nocturnal blood pressure and 24-hour pulse pressure are potent indicators of mortality in hemodialysis patients

BACKGROUND

Cardiovascular (CV) complications are the leading cause of mortality in hemodialysis patients. The role of arterial hypertension on the prognosis of CV in hemodialysis patients is not as clear as in the general population. The purpose of this study was to investigate the prognostic role of ambulatory blood pressure (BP) on CV mortality in treated hypertensive hemodialysis patients.

METHODS

Fifty-seven treated hypertensive hemodialysis patients (56.87 +/- 16.22 years, 30 men) were prospectively studied. All patients initially underwent an ambulatory BP monitoring between two dialysis sessions. The outcome event studied was CV death; kidney transplantation and deaths not related to CV disease were censored.

RESULTS

The duration of follow-up was 34.4 +/- 20.39 months, during which 10 CV and 8 non-CV fatal events occurred. In the 10 patients who died from CV complications, age, previous CV events, ambulatory systolic BP, ambulatory pulse pressure (PP), and life-long smoking level were significantly higher, and the office diastolic BP was lower at the time of inclusion than in those who did not die from CV complications (N = 47). Based on Cox analysis and after adjustment for age, sex, and previous CV events, a low office diastolic BP [relative risk (RR) 0.49, 95% CI, 0.25 to 0.93, P = 0.03], an elevated 24-hour PP (RR 1.85, 95% CI, 1.28 to 2.65, P = 0.009), and an elevated nocturnal systolic BP (RR 1.41, 95% CI, 1.08 to 1.84, P = 0.01) were predictors of CV mortality (RR associated with a 10 mm Hg increase in BP and in PP).

CONCLUSION

This study demonstrates that nocturnal BP and 24-hour PP are independent predictors of CV mortality in treated hypertensive hemodialysis patients. Randomized trials are needed to investigate whether nocturnal BP and 24-hour PP are superior to office BP as targets for antihypertensive therapy in this high-risk group.

[Treatment of arterial hypertension in the diabetic]

BLOOD PRESSURE CONTROL: More than half of all diabetic patients have high blood pressure. Even more so than in the general population, hypertension compromises the cardiovascular and renal prognosis. Optimal blood pressure control can limit the progression of microangiopathy and macroangiopathy as clearly demonstrated in the HOT and UKPDS studies. For the WHO, the goal is to control pressures < 130/85 mmHg. In this respect, there has been no demonstration of a J-curve relationship between pressure lowering with antihypertension drugs and incidence of cardiovascular events among patients with coronary artery disease included in the HOT study.

MULTIPLE DRUG THERAPY

Regular long-term monitoring and, in most cases, multiple-drug regimens, are prerequisites for maintaining pressure figures below 130/85. When elaborating a blood pressure control protocol, it is important to consider the presence of coronary artery disease, suggesting use of beta blockers, or renal disease, which should lead to the use of angiotensin converting enzyme inhibitors. Diuretics play an important role in combination regimens and are indispensable in three-drug protocols or in case of altered renal function.

SYSTOLIC HYPERTENSION

Subgroup analyses in the SHEP and SYST-EUR studies demonstrated the importance of treating pure systolic hypertension in diabetics. The protection obtained has the same or even more impact than in the general population.

RISK FACTORS

Diabetes control must of course be maintained and coherent management requires taking into consideration all the risk factors, especially smoking and dylipidemia.

User procedure for self-measurement of blood pressure. First International Consensus Conference on Self Blood Pressure Measurement

OBJECTIVE

To review the medical literature regarding the methodology of self-measurement of blood pressure and to provide some practical recommendations regarding protocol and procedure for measurement, documentation and analysis of data, choice and provision of devices and education of patients and physicians.

PROCEDURE AND PROTOCOL FOR MEASUREMENTS

Technical recommendations regarding measurement of blood pressure do not differ from usual guidelines. Frequency of measurement remains a matter of discussion. At the beginning of the self-measurements of blood pressure and during the titration phase, there should be a 7-day measurement period with two measurement of blood pressure each morning and two measurements in the evening at pre-stipulated times. For long-term observation, a minimum measurement period of 1 week per quarter is required. The minimum number of measurements performed during each period should be a total of 12 readings recorded within seven working days. Depending on individual needs (e.g. poor compliance) or for pharmacologic studies, a higher frequency of readings could be used.

DOCUMENTATION AND ANALYSIS OF DATA

Owing to the lack of reliability of patients' diaries, the use of printer-equipped or memory-equipped devices is advocated. All the recorded data, except those obtained on the first day, must be used for analysis.

CHOICE AND PROVISION OF DEVICES

Self-measurement of blood pressure should be performed with validated fully automated devices using a brachial cuff. The preference should be given to apparatus offering the possibility of storing and transmitting measurements. Wrist apparatus should be used with caution due to the risk of measurement errors if it is used inappropriately. A manual device should be considered for patients suffering from irregular cardiac rhythms and patients with large or small arm circumferences, since automated devices have not been validated for use in these situations. Reimbursement of hypertensive patients using validated devices should be considered, so long as they are adequately trained and supervised.

EDUCATION OF PATIENTS

In a therapeutic perspective, self-measurement of blood pressure should be performed by trained patients under the supervision of their practitioner. Teaching must be performed by skilled staff in hypertension centers and ultimately in general practice. Self-measurement of blood pressure is to be recommended for any hypertensive patient who is sufficiently motivated to participate in the treatment of his own hypertension. Patients with physical problems or mental disabilities that make them unable to perform or to understand the measuring technique represent the limits of the method. Education of patients must encompass information about hypertension and cardiovascular risk, blood-pressure-measurement procedures, advice on items of equipment and their proper use, protocols, and interpretation of data. A patient's proficiency must be checked before he or she should be considered competent at performing the procedure. Annual reevaluation is required.

[Influence of absolute risk and sex on the treatment of arterial hypertension in Haute-Garonne]

OBJECTIVE

WHO management plan for mild hypertension recommends to take into account total cardiovascular risk in the decision treatment making process. However, despite a lower coronary risk in women than in men, hypertension awareness, treatment and control were higher in women than in men. This study was designed to evaluate the relationships between sex, coronary risk, awareness and treatment of hypertension in Haute-Garonne a south western French region.

METHODS

1,160 subjects aged 35-64, 600 men, were recruited between 1994 and 1996 by the Toulouse MONICA center. Subjects were selected by stratified randomization on age and size of home area. For each patient a score of coronary risk based on Framingham equation was calculated.

RESULTS

157 treated hypertensives (HT), 73 men and 84 women (G1) whom 046 adequately treated were identified, 16 men and 30 women. 60 known but untreated HT, 38 men and 22 women (G2), 171 newly diagnosed HT, 115 men and 53 women (G3). In men, the coronary risk score was higher in treated hypertensives compared with G2 and G3 (G1: 19.19 +/- 5.77 vs G2: 16.71 +/- 6.12 vs G3: 17.42 +/- 5.65) while no significant difference was observed in BP between these three groups (G1: 150.73 +/- 18.6/88.57 +/- 10.81 vs G2: 151.97 +/- 10.59/89.73 +/- 8.04 vs G3: 146.68 +/- 12.14/90.05 +/- 9.19) were observed between these three groups. In treated men, patients were older, total cholesterol was lower, intake of hypolipidemic drugs and diabetes were more prevalent than in the other two groups. In women, coronary risk score were not significantly different between the three groups.

CONCLUSION

This study confirms the higher rate of awareness, treatment and control of hypertension in women. In men, treated hypertensives are at higher coronary risk than untreated and/or unawareness hypertensives: an improvement of hypertension control appears the prerequisite to decrease absolute cardiovascular risk in this group. In women, treated patients have a risk close to the level observed in untreated hypertensives.

[Pulmonary embolism in patients using estrogen-progestagen contraceptives]

OBJECTIVES

The risk of thromboembolism in patients taking estrogen-progestagen oral contraceptive drugs has apparently increased since the introduction of third-generation progestagens (desogestrel, gestodene). We examined the clinical features, risk factors and outcome of pulmonary embolism in this context.

PATIENTS AND METHODS

We reviewed 11 cases of thromboembolism in patients on oral contraception and hospitalized in emergency situations in 1995 and 1996 for pulmonary embolism in order to determine the gravity of the thromboembolic event, risk factors and type of drug used.

RESULTS

Early clinical signs had preceded the onset of embolism by 2 to 164 days. PaO2 was below 70 mmHg in 4 patients. Diagnosis was achieved with pulmonary scintigraphy (11 cases), spiral CT (3 cases) and angiopneumography (2 cases). Duplex Doppler visualized the phlebitis in 7 patients. Given heparin (with fibrinolysis in 3 cases) then anti-vitamin K, and after withdrawal of the oral contraceptive, outcome was favorable in all cases. There were no recurrences. The nature of the oral contraceptive varied. Five patients were taking third-generation progestagens. In two cases, embolism had occurred following a change from a second-generation to a third-generation progestagen. Family history of phlebitis and/or abnormal laboratory findings were observed in 6 patients: resistance to activated protein C (2 patients), protein C deficiency (2 patients), anticardiolipin (2 patients) and low-titre antinuclear antibodies (2 patients).

CONCLUSION

Pulmonary embolism in patients on oral contraceptives persists despite changes in the hormone content of the drugs. Diagnosis is often delayed. Family history of thrombosis or biological risk factors are often found.

Ambulatory blood pressure and urinary albumin excretion in diabetic (non-insulin-dependent and insulin-dependent) hypertensive patients: relationships at baseline and after treatment by the angiotensin converting enzyme inhibitor trandolapril

The aim of the present study was to examine the relationships between ambulatory blood pressure (ABPM) and urinary albumin excretion (UAE) in diabetic (non-insulin dependent [NIDDM] and insulin-dependent [IDDM]) hypertensives at baseline and after treatment by an angiotensin converting enzyme (ACE) inhibitor. After a 3-week placebo period, patients were treated for 16 weeks with trandolapril, 2 to 4 mg/day. The UAE and blood pressure (mercury sphygmomanometer and 24-h ABPM) were measured at baseline and repeated on trandolapril. Predictive factors of abnormal UAE (24-h UAE > or = 30 mg) were determined using univariate and multivariate analysis (logistic regression). Predictors of UAE decrease were also searched. One hundred seventy-one patients entered the analysis. Baseline office BP was 164+/-14 / 97+/-6 mm Hg and 24-h BP was 142+/-17 / 83+/-10 mm Hg. Seventy-four patients (43%) had UAE > or = 30 mg. Independent risk factors for abnormal UAE were nighttime diastolic BP (odds ratio [OR] = 4.1, confidence interval [CI] = 2.0 to 8.6, P = .0001), diabetes duration (OR = 2.4, CI = 1.1 to 5.0, P = .025), and presence of retinopathy (OR = 3.2, CI = 1.0 to 10.0, P = .047). Conversely, office BP level was not significantly related to UAE. On treatment, office BP levels decreased to 143+/-13 / 82+/-8 mm Hg (P < .0001) and 24-h BP levels to 134+/-17 / 78+/-9 mm Hg (P < .0001). In the abnormal UAE group, UAE significantly decreased from 76 to 50 mg/day (P = .006). After treatment, independent predictive factors of abnormal UAE were: on-drug fasting plasma glucose (OR = 3.5, CI = 1.7 to 7.4, P = .0009) and on-drug nighttime diastolic BP (OR = 3.5, CI = 1.7 to 7.4, P = .001). The only predictor of UAE decrease was a 24-h systolic BP decrease (OR = 2.3, CI = 1.3 to 4.3, P = .007). We conclude that in diabetic hypertensives with abnormal UAE, trandolapril exhibited a sustained 24-h antihypertensive effect and provided a consistent reduction of microalbuminuria. This study confirmed the superiority of ABPM over clinical BP to predict target organ damage.

[Influence of global cardiovascular risk assessment on the management of hypertension in southwestern France]

1,160 subjects aged 35-64 years were recruited by the Haute-Garonne MONICA center, and selected by stratified randomization on age and size of home area. The hypertensive group included: 176 subjects newly diagnosed as hypertensives (blood pressure > or = 140/90 mmHg), 86 known but untreated hypertensives and 178 hypertensives under treatment. For each subject a score of coronary heart disease risk based on the Framingham point score probability algorithm was calculated. The prevalence of hypertension was 37.9%. Among the 440 subjects considered as hypertensives, 60% were aware of having hypertension. Only 30% of the 178 patients treated achieved blood pressure control. The population as a whole was at low coronary heart disease risk (< 5% at 10 years); the groups at higher risk were newly diagnosed hypertensives and treated hypertensives. Among known hypertensives, the risk level was higher in treated compared with untreated. In this survey 1) the prevalence of hypertension was high; 2) only 30% of treated hypertensives were below 140/90 mmHg; 3) usual care failed to recognize 40% of hypertensives at same risk level as treated ones; 4) treated hypertensives had higher coronary heart disease risk than untreated known hypertensives. The hypertension therapeutic strategy could be based on the reduction of blood pressure below the threshold 140/90 mmHg rather than on the absolute cardiovascular risk.