[Ambulatory blood pressure, intima media thickness, global cardiovascular risk and therapeutic decisions]

OBJECTIVE

To determine the influence of ambulatory blood pressure monitoring (ABPM), carotid intima media thickness (IMT) and global cardiovascular risk on the therapeutic strategies issued from our hypertension unit.

METHODS

All essential uncomplicated and never treated hypertensive patients referred to our hypertension unit between 1996 and 1997 for etiologic or target organ damage evaluation were considered eligible. We excluded diabetics and patients with renal disease who need a specific therapeutical approach. 54 patients (44.7 +/- 10.1 years) were included (40 men). All patients underwent an ABPM measurement. The right common carotid IMT measurement had been performed (0.06 +/- 09 mm). The global cardiovascular risks were assessed with the Framingham prediction chart taking into account age, sex, total cholesterol, smoking status and systolic office blood pressure. According to the therapeutic decision three groups were made up: group 1 lifestyle counselling (n = 13), group 2 single drug therapy (n = 31), and group 3 combination therapy (n = 10).

RESULTS

No significant difference was found in age, sex ratio, prevalence of severe hypertension, office systolic blood pressure, body mass index, global cardiovascular risk between the three groups. In contrast ABP (24 h ABP mmHg: group 1: 128.23 +/- 6.91/79.7 +/- 6.4; group 2: 140.48 +/- 9.7/97.48 +/- 8.17; group 3: 152.4 +/- 15.35/99.4 +/- 12.14 p < .0001) and IMT (group 1: 10.55 +/- .09, group 2: .59 +/- .07, group 3: .66 +/- .11 p = .02), were significantly higher in group 3 than in group 2 and in group 1. The percentage of white coat hypertensives was higher in group 1 than in group 3 (group 1: 61.5%, group 2: 3.2%, group 3: 0%). In the whole population, the higher was the global cardiovascular risk, the higher was the common carotid intima media thickness. In this study the global cardiovascular risks are not related to therapeutic decisions. Therapeutic strategies are influenced by ABP level and by the vascular remodeling which depends partly on the global cardiovascular risk.

An attempt to improve blood pressure control in the French population: information and outcome awareness at the general practitioner level

To improve blood pressure (BP) control in general practice, 3122 general practitioners agreed to participate in a result awareness program. A survey carried out 6 months after participating physicians had been informed of the outcome of treatments they had given showed that blood pressure control (cut-off point: BP < 140/90 mm Hg) had not improved. However, using less stringent criteria, a slight improvement in blood pressure control could be observed. Although this improvement was marginal, results are sufficiently encouraging to warrant another study after a new awareness campaign among the medical population.

Prevalence, treatment, and control of hypertension in the French population: data from a survey on high blood pressure in general practice, 1994

A survey was conducted in a cohort of 235 general practitioners (GP) selected by Sofres Medical who were representative of the French medical population, to measure the percentage of patients with hypertension, treated hypertensives and patients with controlled hypertension. Data were collected over 1 week of office consultation. Practitioners were initially instructed to use the same type of mercury sphygmomanometer, equipped with pneumatic cuffs of different sizes. Three consecutive blood pressure (BP) measurements were made and the last two were recorded. Practitioners had to carry out their own survey over a period of 1 week on all patients > 18 years of age who visited their offices. Patients were considered as hypertensive (HP) if the mean of the two recorded BP measurements was > or = 140/90 mm Hg or if they were taking antihypertensive drug treatment. Three cutoff points were used to define controlled hypertension: < 140/90 mm Hg (overall population of HP), < 160/95 mm Hg (HP < 65 years of age), and < 160/90 mm Hg (HP > or = 65 years of age). Among 12,351 patients (mean age, 48.6 years; women, 58%), 5020 were HP, (41%) of whom 2035 were without treatment (41%) and 2985 were receiving antihypertensive drug treatment (59%). Two hundred-thirty patients (4.6%) remained at high risk with moderate or severe hypertension (BP > or = 180 [systolic] or 105 [diastolic] mm Hg), ie, 1 patient/week/GP. The study confirms the high prevalence of hypertension in general practice and shows that 7 of 10 patients have an acceptable control of their BP (< 160/95 or < 160/90 mm Hg according to age) but only 24% of treated HP achieved the target of a BP level < 140/90 mm Hg, representing 28% of the 18 to 64 year old group and 21% of the elderly group. French GP did not choose an optimal control, and the medical community is waiting for answers to crucial questions, ie, does optimal BP control significantly improve the absolute cardiovascular risk? How far should blood pressure be lowered?

[Intima media thickness of the carotid artery in white coat and ambulatory hypertension]

Recent epidemiological studies have reported an association between carotid intima media thickness (IMT), ambulatory blood pressure (ABP) and absolute cardiovascular risk. To study the relation between white coat effect and vascular changes in hypertensives (HT), 57 essential HT (office blood pressure (OBP) 152.2 +/- 19.5/93.7 +/- 12.4 mmHg) were recruited (46.4 +/- 11.8 years old, 49 men). After antihypertensive drugs withdrawal, an ABP was performed (Spacelabs 90207). The right common carotid artery IMT 3 cm proximal to the bifurcation was examined by ultrasonography. IMT (0.59 +/- 0.09 mm; Software lotec system) were measured by a reader blinded to the ABP data. White coat hypertension (WCH) was defined by a mean day-time ambulatory BP (d-ABP) lower than the 90th percentile of the distribution of daytime ABP of a normotensive population reported by Verdecchia et al. (131/86 mmHg in women and 136/87 mmHg in men). [table: see text] White coat hypertension was found in 8 from 57 (14%) subjects. IMT was significantly increased in ambulatory HT when compared with white coat HT while age, sex ratio, OBP, smoking status were not different. In stepwise regression age and systolic d-ABP were the only determinants of IMT (p < 0.05). In our hypertensive population. ABP appears more closely related to IMT than OBP and IMT in sustained is greater than in white coat hypertensive.

Influence of nycthemeral blood pressure pattern in treated hypertensive patients on hemodialysis

Arterial hypertension in end-stage renal disease (ESRD) patients is characterized by an altered nycthemeral blood pressure (BP) rhythm and an increased pulse pressure, and it could be suggested that this association of risk factors plays a major role in the cardiovascular prognosis of this population. The aim of this study was to determine the influence of nycthemeral BP pattern on arterial distensibility and pulsatile components of BP in treated hypertensive patients on regular hemodialysis. Forty-two hypertensive patients were included, and all underwent ambulatory BP and pulse wave velocity (PWV) measurements between the femoral and carotid arteries. The patients were divided into two groups according to the magnitude of the nocturnal fall in BP: dippers and non-dippers. The groups were similar in gender, age, duration of hemodialysis, body mass index, body size, history of cardiovascular complications, class and number of antihypertensive drugs used per patient. PWV was significantly higher in non-dippers. For the whole population, a stepwise regression analysis showed that PWV and erythropoietin therapy were independently related to the impaired nycthemeral BP pattern. In addition to its pressor effect, erythropoietin could have a deleterious influence on the ambulatory BP profile of treated hypertensive patients in ESRD. Arterial distensibility and nycthemeral BP impairment are linked, and these cardiovascular risk factors should be taken into account together for the management of hypertensive hemodialysis patients.

[Prevalence, treatment and control of hypertension in family practice patients in France during 1994]

The aim of this study was to measure the percentage of patients with hypertension, treated hypertension and controlled hypertension, using data collected over one week by 235 general practitioners well representative of the French medical population and selected by SOFRES Médical. Practitioners had to carry out their own survey over a period of one week on all patients above 18 years of age who visited their office. They were initially instructed to use the same type of mercury sphygmomanometer, equiped with the same pneumatic cuffs of different sizes. Three consecutive blood pressure measurements were effected, the last two were recorded. Patients were considered as hypertensive if the mean of the two recorded BP measurements was > or = 140-90 mmHg, or < 140-90 mmHg under pharmacological treatment. Hypertensive patients were considered as controlled when their blood pressure levels were overall < 140-90 mmHg under treatment. According to age, two other control levels were analysed: blood pressure < 160-95 mmHg before 65 years and blood pressure < 160-90 mmHg at 65 years or more. Among 12,351 patients, 5,020 are hypertensive (4%), 2,985 under pharmacological treatment (59%) and 2,035 without treatment (4%). Among untreated patients, 9% had an hypertension above the borderline values. Before 65 years, 28% had an under treatment blood pressure < 140-90 mmHg and 71% < 160-95 mmHg. Among 65 years or more hypertensive patients, 21% had an under treatment blood pressure < 140-90 mmHg and 60% < 160-90 mmHg. Before 65 years, 25% among patients with a monotherapy remained with a blood pressure > 160-95 mmHg and 34% with a blood pressure > 160-90 mmHg among those of 65 years or more; 230 patients (5%) remained in high risk with a blood pressure > 180-105 mmHg. 176 untreated and 54 despite their treatment. This study carried out in French medical practice yield two main conclusions regarding the management of hypertension: as the prevalence of hypertensive patients is 41%: one patient out of two, high blood pressure has to be a main aim for the medical teaching. Even if a reasonable control of the blood pressure is achieved in most cases, blood pressure got a normal level for 24% only of treated hypertensive patients and too many patients were keeping high risk because they have been not or not enough treated. This study, as a real audit, gives some useful informations to general practitioners in order to improve their scores.

[Aldosterone precursors and hypertension with hypokalemia and adrenal module non caused by primary hyperaldosteronism]

The purpose of the study was to evaluate the interest of aldosterone precursors assays in arterial hypertension with hypokaliemia and adrenal nodules non due to aldosterone. Seven hypertensive patients, 3 men and 4 women, aged 59.5 +/- 10.1 years were included in the study. After drug withdrawal, kaliemia was 3.1 +/- 0.3 mmol/l (2.7-3.6), active renin 2.9 +/- 1.4 ng/l, plasma aldosterone (aldo) 108 +/- 49.4 pg/ml, cortisol 13 +/- 3.1 micrograms/100 ml, and [S] 0.47 +/- 0.5 micrograms/100 ml. Adrenal CT scan showed an adenoma in 3 patients (30.5 +/- 5 mm) and an unilateral nodular hyperplasia in 4 patients. In all patients, the plasma levels (RIA, chomatographic step) of the following steroids in the mineralocorticoid (MC) pathway were determined: DOC, 18 OH-DOC, B, 18 OH-B and aldosterone. Two from 7 (28%) exerted aldosterone precursors excess, 1 with DOC-producing adenoma (DOC-PA) (table), and 1 with a partial 11 beta hydroxylase deficiency (DOC: 211 pg/ml; S: 1 mu/100 ml). Aldosterone/DOC + 18 OH-DOC ratio proposed as a malignancy index was decreased in the patient with DOC-PA (8.1). No dysfunction in the MC pathway was identified in the 5 other patients. [table: see text] The study suggests the relevance of aldosterone precursors assays in low renin hypertension non due to aldosterone and in incidentally discovered adrenal masses.

Relationships between blood pressure components, lipids and lipoproteins in normotensive men

The aim of this study is to assess the relationships between pulse pressure (PP) mean arterial pressure (MAP), clinical and lipid parameters in normotensive men. One hundred and twenty-seven normotensive men aged 35-64 years from the French department of Haute-Garonne were analysed. Blood pressure (BP) was measured using a random zero device. Correlation analysis was performed using Pearson's coefficient. Variables significantly related to PP and MAP were then introduced in a stepwise multiple regression analysis. On univariate analysis, PP was significantly and positively related to total cholesterol, triglycerides, VLDL and LDL-cholesterol and apo B. MAP was positively related to age, body mass index (BMI), triglycerides and VLDL-cholesterol. Stepwise multiple regression analysis showed only apo B to be independently related to PP after adjustment for MAP. Also, after adjustment for PP, only BMI and VLDL-cholesterol were related to MAP. Hence, MAP is related to BMI and VLDL-cholesterol, which are a common feature of hyperinsulinism. PP is linked to apo B, an important proatherogenic factor. These biological parameters appear specific of steady and pulsatile components of BP. The relationship between PP and apo B suggests a possible link between lipids and arterial stiffness, and may partly explain the prognostic value of PP in myocardial infarction.

[Course of ischemic risk in treated atheromatous hypertensive patients. The PRIHAM study (Prognosis of Ischemic Risk in Atheromatous Patients under Mediatensyl)]

Hypertension is one of the major cardiovascular risk factors. However it seldom occurs alone in a patient and the antihypertensive treatment should be taken into account when assessing global cardiovascular status. The PRIHAM study was an open study which enrolled 3,216 hypertensive atheromatous patients who already has had a clinical ischaemic accident. Patients were followed-up for 3 years. The lowering effect on cardiovascular risk, starting from the fifteenth month was confirmed to the end of 36-month study. The effect on blood pressure was observed from the third month. Stabilized blood pressure observed within the first year persisted throughout the three years without tachyphylaxis. It was effective on SBP (-14.4%) and on DBP (-15%) while maintaining a stable heart rate both in the supine position or immediately upon standing or after 3 minutes in the standing position. Tolerance was globally judged as good or very good by the investigating practitioners and the patients expressed an improvement in their feeling of well-being. In conclusion, from the level of effectiveness obtained and the low incidence of adverse effects, urapidil appears well adapted and easy to manage in a population with a particularly high cardiovascular risk.

Non-invasive ambulatory blood pressure variability and cardiac baroreflex sensitivity

AIM

The objective of this study was to evaluate the relationship between non-invasive ambulatory blood pressure variability and cardiac baroreflex sensitivity in hypertensive patients.

SUBJECTS AND METHODS

Ambulatory blood pressure measurements (15-min intervals for 24 h) and continuous blood pressure measurements (Finapres, 20 min at rest after a 10-min resting period) were performed in 123 untreated hypertensives (resting diastolic blood pressure > or = 90 mmHg; 80 males, 43 females; mean +/- SD age 49 +/- 12 years, range 19-73). Fourier series were used to model 24-h blood pressure profiles (four harmonics). Ambulatory blood pressure variability was assessed by determination of the residuals in each 24-h blood pressure profile (measured minus predicted pressures). Resting blood pressure variability was defined as the SD of the mean Finapres value. Baroreflex sensitivity was evaluated by automatic detection of blood pressure and pulse interval sequences of > or = 3 beats when systolic blood pressure and pulse interval sequences changed in the same direction (increase or decrease: 1 mmHg for systolic blood pressure and 4 ms for RR interval), and was assessed as the slope of the regression line for each sequence.

RESULTS

Ambulatory systolic blood pressure variability increased with age (r = 0.28*) and systolic pressure (r = 0.44**). Baroreflex sensitivity (increasing systolic pressure/pulse interval) decreased significantly with age (r = -0.48**) and systolic pressure (r = -0.23**), and was significantly related to increased ambulatory blood pressure variability (r = -0.33**). In a multivariate stepwise analysis the relationship between ambulatory blood pressure variability and baroreflex sensitivity (increasing systolic pressure/pulse interval) was statistically independent of age and systolic pressure (R = 0.55, P<0.001); this relationship was not observed with the corresponding decreasing sequence.

CONCLUSIONS

This study shows that in uncomplicated hypertension, ambulatory blood pressure variability is related to baroreflex sensitivity independently of the blood pressure level. This finding has prognostic implications for this non-invasive measurement, which needs to be confirmed by large longitudinal studies.

[Arterial hypertension and insulin resistance]

Insulin resistance manifested by hyperinsulinism is an important risk factor for the development of cardiovascular diseases. When associated with characteristic disorders of the lipid metabolism and arterial hypertension it is regarded today as a metabolic syndrome X. To detect hyperinsulinism in patients with arterial hypertension in everyday practice, it is advisable to determine the rations "circumference of the waist, circumference of the hips", while its abnormal values necessitate a carbohydrate challenge. Hyperinsulinism in AH patients should be born in mind when devising therapeutic measures, the mainstay of which is dietary therapy, with Calcium antagonists and inhibitors of the converting enzyme being used as hypotensive agents.

Plasma levels of aldosterone versus aldosterone precursors: a way to estimate the malignancy of asymptomatic and nonsecretory adrenal tumors: a French Retrospective Multicentric Study

The aim of this study was to find out whether the dysfunction of aldosterone pathway, previously proposed as a marker of secretory adrenal carcinoma, is also found in nonsecretory adrenal carcinomas, which pose even more difficult diagnostic problems even for patients with hypertension accompanied or not by hypokalemia. The exploration consisted of using the same method (RIA preceded by a chromatographic step) to determine the plasma levels of the following steroids in the mineral corticosteroid pathway: deoxycorticosterone (DOC), 18-hydroxydeoxycorticosterone (18-OHDOC), corticosterone (B), 18 hydroxycorticosterone (18 OH B), and aldosterone. The subjects included 16 adults, each presenting with an endocrinologically asymptomatic adrenal mass associated for some patients with hypokalemia and hypertension (8 with adrenal carcinoma, 2 with adrenal metastasis from other forms of cancer, and 6 adenomas). These results show that even in nonsecretory adrenal carcinoma, there is a dysfunction of the aldosterone pathway, which can be evaluated from the ratio between aldosterone and the substrate of 11 beta hydroxylase (DOC) and its derivative (18-OH DOC). This study suggests that exploration of mineralocorticosteroid pathway can be used as a hormonal marker of adrenal carcinoma for both secretory and non-secretory malignant masses.

[Combination therapy in the therapeutic strategy of arterial hypertension]

The standard treatment of mild-to-moderate hypertension is monotherapy chosen from one of the five main classes of antihypertensives following the World Health Organisation and Joint National Committee guidelines. If first-line monotherapy fails, the physician must decide whether to increase the dose, choose a drug from a different class or add a second antihypertensive. However, greater efficacy must not be obtained at the cost of an unacceptable increase in side-effects. Sequential monotherapy is partly based on the impossibility of predicting the blood pressure response to a given antihypertensive. The validity of this strategy is supported by the findings of the Materson study, which suggest combination therapy only after the failure of at least two monotherapies. The aim of combination therapy is to optimize treatment by using two different classes of antihypertensives with synergistic effects. The anticipated advantages are ease of use, the enhancement or addition of the antihypertensive effects, and the possibility of administration to a wide population. This has led to the development of fixed combinations which are low-dosed to reduce the incidence of side-effects. Validated combinations (dosed differently according to the medicinal product) include: beta-blocker + diuretic, beta-blocker + dihydropyridine (DHP) calcium antagonist, angiotensin converting enzyme (ACE)-inhibitor + diuretic and in the future, ACE-inhibitor + calcium antagonist. The pharmacokinetic interaction of beta-blocker + DHP at the hepatic level must be considered to assess the efficacy of this combination.(ABSTRACT TRUNCATED AT 250 WORDS)

[Drug interactions with antihypertensive drugs]

Numerous of pharmacokinetic and pharmacodynamic interactions with antihypertensive drugs have to be considered. In this review, interactions are analysed in the major organ sites of these interactions and in cardiovascular target sites of arterial hypertension, with respect to the major antihypertensive drugs. Many antihypertensive drugs are metabolized in the liver (calcium antagonists, liposoluble beta-blockers, and some ACE-inhibitors) via the cytochrome-oxidase system. Phenytoin, barbiturates, and rifampin can accelerate the breakdown of these drugs; conversely, cimetidine, which inhibits oxidase system, can increase antihypertensive drug levels, resulted in greater therapeutic effect. Hepatic blood flow can be modified by propranolol and nifedipine with opposite effects. When combined with nifedipine the breakdown of propranolol is accelerated because of an increase of hepatic blood flow. In the kidney, some anti-hypertensive agents interact with other cardiovascular drugs by competing for renal clearance; calcium antagonists alter the renal clearance of digoxin, but the mechanism remains unclear. In vascular muscle cells, excess vasodilatation or vasoconstriction can be observed. The combination of an alpha 1-blocking agent with a dihydropyridine can induce hypotension, which is sometimes severe. Non-steroidal antiinflammatory drugs (NSAIDs) are able to lessen the antihypertensive effects of beta-blockers, diuretics and ACE-inhibitors, via vascular prostaglandin inhibition. The cardiac pharmacodynamic interactions of beta-blockers and calcium antagonists, verapamil and diltiazem, at the sino-atrial node, atrio-ventricular node, conduction system and myocardium are well established and must be avoided. The main interactions with beta-blockers concern calcium antagonists, class I antiarrhythmic drugs and NSAIDs.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of glucose metabolism on nycthemeral blood pressure variability in hypertensives with an elevated waist-hip ratio. A link with arterial distensibility

We studied the influence of glucose metabolism on the nycthemeral blood pressure (BP) pattern and arterial distensibility in 33 nontreated hypertensive patients, 45.6 +/- 8.5 years old, with elevated waist/hip ratio. All patients underwent an ambulatory BP monitoring, a pulse wave velocity (PWV) measurement, and an oral glucose tolerance test. The ratio of mean nocturnal:diurnal systolic BP (N/D ratio) was used to assess nycthemeral BP variability. N/D ratio correlated positively with PWV (r = 0.62; P < .01). When considered according to their glycemic status, N/D ratio and PWV were significantly higher (P < .05; P < .01) in diabetics and in glucose intolerants compared to patients with normal glucose levels. Our data indicate that the nycthemeral BP pattern was different according to the metabolic status. The loss of nocturnal decline in BP is associated with carbohydrate disturbances and reduced arterial stiffness.

[Peripheral vasodilators: from the hemodynamic effect to clinical benefit]

Patients with chronic occlusive arterial disease of lower limbs have an excess mortality due to associated cardiovascular diseases or cancer. They also have an important morbidity with a high prevalence of coronary artery diseases and strokes. In this context, the only benefit of peripheral vasodilators devoid of any effect on morbidity and mortality, could be only on quality of life. Haemodynamic effects of these drugs have been evaluated by several reproducible techniques in order to measure the peripheral blood flow (plethysmography, 133Xe clearance, transcutaneous oxygen-pressure, electromagnetic debimetry). An increase in blood flow has been demonstrated in patients receiving pentoxifylline, naftidrofuryl, or blufomedil in phase II clinical trials using these different methods. No general haemodynamic effect has been observed with these drugs which were better denominated vaso-active drugs. However the most relevant criteria remained to confirm a clinical benefit, particularly on intermittent claudication. Number of positive clinical trials in patients with intermittent claudication have been published, but from a methodological point of view few of them were suitable and demonstrated a statistically significant benefit. Criticisms were mainly related to the type of trial (cross-over is not recommended because of the drug-period effect), the lack of 'intention to treat' analysis, the inhomogeneity of the compared groups (for example different percentages of diabetics and excess of drop-outs). In spite of an established haemodynamic effect and of a demonstrated benefit in claudicants, peripheral vasodilators appear to have a slight interest in the global care of patients with occlusive arterial disease of lower limbs mainly on functional symptoms.

[Conceptual basis and diagnosis of primary hyperaldosteronism]

Primary aldosteronism comprises two different conditions, the tumoral form usually caused by an adenoma and the idiopathic form due to nodular hyperplasia of the two adenals. More rarely, an adenoma of the adrenal cortex, glucocorticosteroid-sensitive hyperplasia, and angiotensin-sensitive adenoma or an autonomous nodule transformed to primary tumoral hyperplasia, may be observed. Primary alderosteronism may be conceived as a spectrum of genetic abnormalities which express themselves either by hyperplasia or by a tumour. A defect in steroid genesis and prolonged stimulation of the cortex would lead to the formation of nodules which may become autonomous and generate a tumour. Hypertension may be isolated. Detection requires three sampling of serum potassium in all hypertensive patients, a study of the aldosterone-renin axis when the value is less than 3.6 mEq, or whenever the hypertension is severe or resistant to treatment. The diagnosis is made by the association of an increased plasma aldosterone level before getting up in the morning and a plasma renin unaffected by orthostatism. The choice of medical or surgical treatment depends on the uni- or bilateral anatomic substrate. Computerised tomography, very sensitive but not specific, like hormonal studies, often provides incomplete answers. Adrenalectomy is indicated in the presence of a mass of centimetric proportions with concordant results of the dynamic test. In other situations, investigations are continued with the search for an aldosterone gradient by selective venous sampling. This is very valuable to determine the lateralisation but fails in 25% of cases, and its results have to be compared with those of imaging techniques: CT scan, venography and, when necessary, scintigraphy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Course of ischemic risk in treated atheromatous hypertensive patients. The PRIHAM study]

Hypertension is one of the major cardiovascular risk factors. However seldom occurs alone in a patient and the antihypertensive treatment should be taken into account when assessing global cardiovascular status. The PRIHAM study was an open study which enrolled 3,216 hypertensive atheromatous patients who already has had a clinical ischaemic accident. Patients were followed-up for 3 years. The lowering effect on cardiovascular risk, starting from the fifteenth month was confirmed to the end of 36-month study. The effect on blood pressure was observed from the third month. Stabilized blood pressure observed within the first year persisted throughout the three years without tachyphylaxis. It was effective on SBP (-14.4%) and on DBP (-15%) while maintaining a stable heart rate both in the supine position or immediately upon standing or after 3 minutes in the standing position. Amongst diabetic and dyslipidemic patients, an absence of deleterious metabolic effects was noticed, parallel with the effectiveness. Tolerance was globally judged as good or very good by the investigating practitioners and the patients expressed an improvement in their feeling of well-being. In conclusion, from the level of effectiveness obtained and the low incidence of adverse effects, urapidil appears well adapted and easy to manage in a population with a particularly high cardiovascular risk.

[Ambulatory measurement of blood pressure and plasma catecholamines in the study of orthostatic hypotension]

The purpose of the study was to investigate the interest of ambulatory blood pressure (BP) monitoring (ABPM) and plasma catecholamines in the management of orthostatic hypotension (OH). Fifteen patients, 4 men, 11 females, 53.3 +/- 21.1 years old, with OH were included in the study: 7 with dysautonomia (G1) = multiple systemic atrophy, pure autonomic failure, OH in elderly people; 8 with OH from other origin (G2) = hypovolemia, neurodystonia, vaso-vagal syncope. ABPM and plasma catecholamines assays (HPLC) in lying then in standing position were carried out in all patients. BP was 131.2 +/- 31.9/78.1 +/- 12.0 mmHg in lying and 112.1 +/- 25.3/75.4 +/- 15.8 in standing position (n = 15). The systolic (S) standing-induced (delta) decrease in BP after 1 min and 10 min (delta SBP) correlated with standard-deviation and variation coefficient of mean SBP (r = 0.78, p < 0.01; r = 0.82, p < 0.01 for delta sBP 1 min and r = 0.80, p < 0.01; r = 0.81, p < 0.01 for delta sBP 10 min), but not with norepinephrine (NorE) or epinephrine levels. There was a significant correlation between diastolic nycthemeral BP variability expressed by mean night-time DBP/mean day-time DBP ratio/diastolic N/D) and standing-induced decrease in DBP after 1 min (r = 0.59, p < 0.05). delta SBP 1 min and 10 min, delta DBP 1 min (p = 0.02, p = 0.05, p = 0.01) and systolic and diastolic N/D (p = 0.02; p < 0.01) were significantly different in G1 and G2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arterial blood pressure changes, circadian rhythm and arterial elasticity in hemodialysed patients]

An increased blood pressure variability (BVP) and a loss of nocturnal decline in BP could enhance cardiovascular disease. Peripheral resistances and arterial compliance determine systolic BP. BVP could depend on arterial stiffness. We tested this hypothesis in patients with end-stage renal disease (ERSD) who have arterial elasticity impairment. Twenty one ESRD patients (49.9 +/- 16.7 years) 12 mean and 9 women, undergoing maintenance hemodialysis were studied; 19 had treated hypertension. Ambulatory (ABP) monitoring was performed in all patients: BP was measured every 15 minutes in day-time and every 30 minutes at night. Systolic diurnal variation coefficient was calculated as the ratio between standard deviation and the mean of systolic diurnal BP. Nycthemeral BP pattern was evaluated as the ratio between mean diurnal and nocturnal systolic BP (N/D). Pulse wave velocity (PVW), an index of arterial stiffness, was determined between carotid and femoral sites (11.6 +/- 4.22 m/s). These investigations were performed after the midweek dialysis session. We found a positive correlation between PVW and systolic diurnal BPV (stepwise regression F = 12.9, p < 0.01). This correlation was independent of hypertension, antihypertensive treatment, duration of hemodialysis, and erythropoientin. We also found a positive correlation between N/D and PWV (stepwise regression: F = 8.9 p < 0.05). Our study shows that arterial distensibility links BPV and N/D. It is suggested that an arterial distensibility impairment could enhance BPV and modify nycthemeral BP pattern.

Renal artery stent placement: long-term results with the Wallstent endoprosthesis

PURPOSE

To evaluate clinical success and long-term patency of a Wallstent in the renal artery.

MATERIALS AND METHODS

Twenty-five Wallstents were placed in 21 patients to treat delayed restenosis after previous balloon angioplasty (n = 13) or inadequate immediate postangioplasty response (n = 8). Indications for angioplasty were hypertension in all patients and renal preservation in seven. Stenosis was atheromatous in 15 patients, involving ostium in seven.

RESULTS

Stent placement was successful in all patients. At follow-up angiography (range, 12-60 months), four patients (20%) had stent restenosis. Of these, three had undergone treatment for restenosis after angioplasty and three had ostial lesions. Cumulative primary patency rate was 95%, 85%, and 77% at 7, 9, and 15 months, respectively. Hypertension was cured in three patients and improved in 18.

CONCLUSION

Arterial stent placement has good clinical results and high long-term patency rates after conventional renal angiography or delayed restenosis, especially in ostial lesions.

Blood pressure measurements and left ventricular mass in young adults with arterial hypertension screened at high school check-up

The aim of this study was to determine which BP measurement is the best related to target organ damage. There were 49 young adults with a history of childhood hypertension (school check-up) and to increase the prevalence of hypertension in the study group, 25 males 24 females, aged 20.1 +/- 2.2 years old were included in the study. All patients had a diurnal ambulatory BP monitoring and office BP measurements taken with a sphygmomanometer and with an oscillometric device during a 15 minute period monitoring (Dinamap BP). Echocardiography and blood samples (cholesterol and triglycerides) were performed in all patients. In contrast with office BP, a mean ambulatory SBP and mean Dinamap SBP significantly correlated to left ventricular mass index (LVMI) (P < 0.01). There was also a correlation between triglycerides and mean Dinamap SBP (P < 0.01) which could suggest an early insulin resistance. In this selected population, a short period BP monitoring, as well as ambulatory BP, is more closely related to LVMI than office BP.