Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P <0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg; P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Essential competencies in prescribing: A first european cross-sectional study among 895 final-year medical students

European medical students should have acquired adequate prescribing competencies before graduation, but it is not known whether this is the case. In this international multicenter study, we evaluated the essential knowledge, skills, and attitudes in clinical pharmacology and therapeutics (CPT) of final‐year medical students across Europe. In a cross‐sectional design, 26 medical schools from 17 European countries were asked to administer a standardized assessment and questionnaire to 50 final‐year students. Although there were differences between schools, our results show an overall lack of essential prescribing competencies among final‐year students in Europe. Students had a poor knowledge of drug interactions and contraindications, and chose inappropriate therapies for common diseases or made prescribing errors. Our results suggest that undergraduate teaching in CPT is inadequate in many European schools, leading to incompetent prescribers and potentially unsafe patient care. A European core curriculum with clear learning outcomes and assessments should be urgently developed.

Causes of secondary hypertension in the young population: A monocentric study

OBJECTIVE

To study the prevalence of different causes of hypertension in young adults referred to a hypertension center in the south west of France.

METHODS

We conducted a retrospective overview of patients younger than 40years old hospitalized consecutively in the Hypertension department of Toulouse University Hospital between 2012 and 2014. Clinical data about gender, age, anthropomorphic parameters and blood pressure measurement by 24h Ambulatory Blood Pressure Monitoring (ABPM) were recorded. Biological data concerned dosages of kalemia, renin and aldosterone in the supine or after 15min of seating. Recorded radiological examinations were renal artery ultrasound and abdominal CT scan.

RESULTS

One hundred and forty-eight detailed medical records were analyzed, 69 women and 79 men. Among the 69 women, the causes of secondary hypertension were primary aldosteronism (n=7), fibromuscular dysplasia (n=5) and renal disease (n=4). Oral contraceptives were involved in 13 women. In addition, essential hypertension concerned 40 women (58%). Among the 79 men, the causes of secondary hypertension were primary aldosteronism (n=10), fibromuscular dysplasia (n=3), left main renal artery entrapment by a diaphragmatic crura (n=2), renal disease (n=1), pheochromocytoma (n=3) and coarctation of the aorta (n=2). In addition, essential hypertension concerned 58 men (73%).

CONCLUSIONS

In our population, the prevalence of secondary hypertension is close to 33% (42% of females and 27% of males), with the following main causes: primary aldosteronism for 11.5%; fibromuscular dysplasia for 5.4%. Oral contraceptives were involved in the hypertension of 19% of the females.

[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.

[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.

Effect of postural changes on aldosterone to plasma renin ratio in patients with suspected secondary hypertension

AIMS

To study the influence of postural changes on aldosterone to renin ratio (ARR) in patients with suspected secondary hypertension and to evaluate the sensitivity and specificity of the recommended seated ARR compared to supine and upright ARR for primary aldosteronism screening.

METHODS

Fifty-three hypertensive patients were prospectively hospitalized for secondary hypertension exploration (age: 51 ± 12, 66% males). After withdrawal of drugs interfering with renin angiotensin system, plasma aldosterone and direct renin concentration were measured in the morning, at bed after an overnight supine position, then out of bed after 1 hour of upright position and finally 2 hours later after 15 minutes of seating. Minimal renin value was set at 5 μUI/mL.

RESULTS

Referring to ARR cut-off of 23 pg/μUI, the sensitivity of seated ARR was 57.1% and specificity was 92.3%. The negative and positive predictive values were 95.1% and 45.2% respectively. Compared to these results, a cut-off of 19 improved sensitivity to 85.7% with a specificity of 89.7%. Negative and positive predictive values were 98.3% and 41.1% respectively. Seated ARR mean value was lower than supine and upright ARR mean values, due to an overall increase in renin at seating compared to the supine position by factor 1.9 while aldosterone just slightly increased by factor 1.2. Seated ARR correlated to supine and upright ARR: correlation coefficients (r) 0.90 and 0.93 respectively (P<0.001).

CONCLUSIONS

Current recommended measurement of ARR in the seating position is fairly correlated to supine and upright ARR. A suggested cut-off value of 19 instead of 23 pg/μUI increased the discriminating power of this test.

Orthostatic hypotension is associated with more severe hypertension in elderly autonomous diabetic patients from the French Gerodiab study at inclusion

Orthostatic hypotension (OH) has deleterious effects on patients' cardiovascular prognoses. The combination of increased age and diabetes adds to the risk of OH. The aim of the study was to describe the elderly diabetic population relative to the degree of hypertension, the occurrence of complications, medications and cognitive function.

METHODS

In the Gerodiab study (a 5-year French multicentre, prospective, observational study), a total of 987 type 2 diabetic autonomous patients, aged 77±5 years, were recruited between June 2009 and July 2010. Clinical blood pressure measurements were taken supine and then after 1, 3 and 5minutes in a standing position. OH was defined as a decrease in systolic blood pressure (SBP) of at least 20mmHg and/or a decrease in diastolic blood pressure (DBP) of at least 10mmHg at any of the measurements while standing.

RESULTS

At inclusion 301 (30.5%) patients had OH; SBP and DBP at rest were higher in patients with OH than in those without (146±21/78±11mmHg vs. 138±17/72±10mmHg; P<0.001). Individuals with OH exhibited higher pulse pressure (PP) than individuals without (68±18 vs. 65±15mmHg; P<0.05). A significant increase in waist-to-hip ratio was recorded in those with OH versus patients without (P<0.01). Despite more severe hypertension (SBP>160mmHg at inclusion; P<0.01), no significant difference was recorded in the mean number of antihypertensive drugs (1.7±1.1), or in the class of antihypertensive drugs, including beta-blockers (P=0.19) and diuretics (P=0.84). Patients with OH were more likely to have a history of peripheral arterial disease and amputations (31% vs. 24%, P<0.05, and 3.3% vs. 1.5%, P=0.056). There was no significant association between OH and history of peripheral neuropathy (P=0.37), stroke, heart failure or ischemic heart disease. In multivariate analysis, OH remained associated with severe hypertension (P<0.01), increased waist-to-hip ratio (P<0.05) and amputations (P<0.05).

CONCLUSION

About one-third of elderly, autonomous diabetic patients had OH. They had more severe hypertension, with higher SBP, DBP and PP at rest. However, the number of anti-hypertensive drugs did not differ compared to patients without OH. This could reflect the medical teams' fears about intensifying treatment.

Is it useful to repeat an adrenal venous sampling in patients with primary hyperaldosteronism?

Adrenal venous sampling (AVS) is a challenging technical procedure and few patients had AVS procedure twice.

AIM

To evaluate the reproducibility of the AVS, why AVS were repeated and the conclusions drawn from them.

PATIENTS AND METHODS

From 1997-2012, 12 patients underwent two AVS. A cortisol level in the adrenal vein greater than or equal to 1.1 to inferior vena cava defined a successful catheterization and a lateralization of secretion corresponded to an aldosterone-to-cortisol vein ratio greater than or equal to 2 between the one side to another.

RESULTS

The same side of lateralization of secretion was found in 75% of them. The second AVS were due to technical failure (n=4), unproven lateralization (n=2), a lateralization opposite to the main nodule and ipsilateral to hyperplasia (n=4) on first AVS. For two patients, as the CT was normal, AVS was required again. The second AVS was successful in all patients, including those with an initial technical failure but only patient with technical failure underwent surgery, as BP and kaliemia were controlled. Lateralization on the side of hyperplasia or opposite to the biggest nodule was confirmed in two of four cases.

CONCLUSION

When AVS is unsuccessful for technical reasons, it is worth doing it again but after being sure that surgery is still possibly indicated.

Evaluation of oral health related to body mass index

OBJECTIVE

Poor oral health has previously been related to high body mass index (BMI). We aimed at exploring the link between BMI and several oral health markers, after adjustment for dietary patterns and plasma insulin, both of which could act as mediators.

SUBJECTS AND METHODS

 Dental examination was performed in a sample of 186 French subjects aged 35-64 years and selected from the general population to assess number of missing teeth, periodontitis, clinical attachment loss (CAL), probing pocket depth (PD), gingival index (GI) and plaque index (PI). Data collection also included a food-frequency questionnaire. BMI (considered as outcome variable) was categorized into quartiles, and as BMI<25; 25 ≤BMI<30; and BMI ≥ 30 kg m(-2) .

RESULTS

After adjustment for age, gender, education level, smoking, physical activity, energy intake and C-reactive protein, BMI was statistically associated with missing teeth, PD and PI, but not with CAL, GI or periodontitis. After additional adjustment for 'high-carbohydrate' diet and plasma insulin or HOMA (homeostasis model assessment) index for insulin resistance, the statistical relationship between BMI and oral variables remained significant only for PD and PI.

CONCLUSIONS

Plaque index, reflecting dental plaque, and PD, closely linked with periodontal inflammation and infection, are statistically associated with high BMI and obesity, independently of dietary patterns and insulin resistance.

Prognostic value of nocturnal blood pressure and reverse-dipping status on the occurrence of cardiovascular events in hypertensive diabetic patients

AIM

To assess whether reverse-dipping status is associated with cardiovascular (CV) events such as CV death, myocardial infarction (MI) or stroke in diabetic patients with hypertension.

METHODS

A total of 97 diabetic patients underwent their first ambulatory blood pressure monitoring (ABPM 1). "Reverse dippers" were defined as patients with a nighttime systolic and/or diastolic blood pressure (BP) greater than daytime systolic and/or diastolic BP. Other patients were called "others". A second ABPM (ABPM 2) was done after a median delay of 2.6 years. Patients were then followed for a further 2.9-year median period (total median follow-up: 5.5 years).

RESULTS

After ABPM 1, CV events occurred in 53% of the reverse dippers (n=15) and in 29% of the others (n=82). Kaplan-Meier curves showed significant differences between the two groups (P=0.003). Mean nighttime systolic BP on ABPM 1 was 148+/-23 mmHg and 142+/-19 mmHg in patients who did and did not experience a CV event, respectively. With Cox analysis adjusted for confounders, a 10 mmHg increase in nighttime systolic BP was associated with a 35% increase in the risk of a CV event (hazard ratio [HR]: 1.35, P=0.003). The HR for a CV event in reverse- versus nonreverse-dipping status was 2.79 (P=0.023). After ABPM 2, the relationship between the reverse-dipping status and occurrence of CV events was no longer evident (P=0.678). Nighttime systolic BP remained predictive of CV events (P=0.001).

CONCLUSION

These findings suggest that nighttime systolic BP per se appeared to be a stronger predictor of an excess risk of CV events compared with reverse-dipping status.

Prevention of progression to dementia in the elderly: rationale and proposal for a health-promoting memory consultation (an IANA Task Force)

Alzheimer's disease (AD) is the most frequent form of dementia and according to the most recent estimation it affects nearly 27 million people in the world. The onset of the disease is generally insidious. It is becoming increasingly evident that the underlying pathophysiological mechanisms are active long before the appearance of the clinical symptoms of the disease. In the current context, it is important to develop strategies to delay the onset of cognitive decline. Delaying the onset by 5 years would reduce the prevalence by half at term, and a delay of 10 years would reduce it by three-quarters. The effectiveness of currently suggested preventive approaches remains to be confirmed, but certain strategies could be applied straight away to at-risk subjects. We propose that a health-promoting memory consultation should be set up for elderly persons who have attended a specialized memory consultation and in whom the diagnosis of dementia and of AD in particular, has not been established by standardized tools. Through this consultation, they would be offered full multidimensional investigation of all aspects of their health status, follow-up could be organized, general practitioners in private practice could be made more conscious of this population and the elderly could be made more aware of the risk factors to which they are exposed. The development of an information policy for the elderly would meet a present need. In our reflection, we must take into account the question of how to give this preventive consultation its due place in the healthcare pathway of the elderly person in order to ensure coordinated follow-up with all the other health professionals involved. The principle of the health-promoting memory consultation is undergoing validation in a large French multicentre preventive trial in 1200 frail elderly persons aged 70 years followed for three years, the Multidomain Alzheimer Preventive Trial (MAPT).

Association of eNOS Glu298Asp gene polymorphism with circadian blood pressure rhythm

Hypertensive patients with altered circadian blood pressure (BP) profile experience greater repercussion of hypertension on target organs and a higher risk of cardiovascular events, compared with those with physiological variations in BP. It has been demonstrated in animal models, that circadian variations in BP depend on several regulatory systems, in particular the nitric oxide-cGMP pathway. eNOS298 Glu/Asp polymorphism is a functional variant and may alter the amount of NO generated or eNOS activity. The objective of the present study was to find out whether eNOS298 gene polymorphism affects circadian BP regulation in 110 healthy subjects and 155 never-treated hypertensive patients recruited at Hypertension Units in Grenoble, Toulouse and Lille (France).

[French as 2005-recommendations on the management of arterial hypertension]

Self blood pressure measurements (home BP) and/or ambulatory BP measurements are recommended in mild to moderate hypertension (140/90 - 179/109 mmHg) in order to confirm sustained hypertension and identify white coat and masked hypertension. The evaluation of target organ damages (TOD) has to be integrated in cardiovascular risk estimate and taken into account in the management of hypertensive patients. Beside echocardiography, there is a place for the screening of microalbuminuria in non diabetic hypertensive patients, but these investigations should not be performed systematically. Arterial stiffness evaluation and carotid intima-media thickness quantification are not yet recommended. Cardiovascular risk (CV risk) estimate plays a pivotal role in the therapeutic decision and strategy. The cardiovascular risk grade is based on [1] the list of cardiovascular risk factors (same list AFSSAPS recommendations on dyslipidemia), [2] the presence or absence of TOD and [3] cardiovascular complications: "low", "medium", and "high" CV risk. Lifestyle modifications are recommended in all hypertensive patients. Five antihypertensive drugs are recommended for first line therapy: beta-blockers, thiazide diuretics, ACEIs, ARA II and CCBs (and fixed low dose combinations with AFSSAPS agreement for first line). In order to initiate the treatment, Evidence-based therapy (according to clinical trials conducted in different clinical situations), certain comorbid conditions (compelling indications), efficacy and side-effects in a previous experience, and the cost are the determinants of the first choice. Most hypertensive patients require more than one agent to achieve target blood pressure and for second line therapy the recommended combinations are: betablockers-diuretics, ACEIs-diuretics, ARAII-diuretics, betablockers-CCBs (DHP), ACEIs-CCBs, ARA II-CCBs and CCBs-diuretics. The delay to establish a combination therapy depend on CV risk. The BP goals are those recommended by ESH-ESC 2003: BP<140/90 mmHg in all, BP<130/80 mmHg in diabetic patients and in patients with chronic renal failure. Beside lowering BP, the reduction in proteinuria <500 mg/24 h is a new goal in these high risk patients. These guidelines provide a tool for every day practice and applicability should be evaluated.

[The best of hypertension in 2006]

The TROPHY study was designed to show the feasibility of pharmacological prevention of hypertension with respect to the group of patients with "prehypertension" as defined by the JNC VII recommendations. This clinical trial compared candesartan 16 mg/day with placebo and the result at 4 years was a reduction in the relative risk of developing hypertension of 15.6%. The antihypertensive drug delayed the onset of hypertension in a mainly overweight masculine population. Staessen, Zhu and O'Brien's groups suggest measuring an index of arterial rigidity obtained from ambulatory blood pressure monitoring: the ambulatory arterial stiffness index (AASI). This is calculated as [1- slope of systolic/diastolic pressure]. The reference values for AASI vary with age from 0.50 to 0.70. The CAFE study, a spin-off of the ASCOT trial, showed that the central blood pressure decreased more than the peripheral blood pressure with the association amlodipine-perindopril as compared with atenolol and a thiazide diuretic. The capacity of an antihypertensive drug or an association of antihypertensives to decrease the central blood pressure could be a pertinent factor of evaluation to be taken into account in the interpretation of clinical trials. The study of the Italian cohort PAMELA showed a progressive increase in cardiovascular and global mortality with respect to the findings of increased blood pressure by one, two or three methods of measurement (at the office, at home, ambulatory) compared with patients declared normotensive by the same methods. This registry confirmed the implication of masked hypertension on cardiovascular prognosis and also showed that "white coat" hypertension was not completely benign. The "3 cities" study is a French epidemiological study of persons over 65 years of age. The control of the blood pressure of the treated elderly hypertensives was 57% in men and 70% in women when the cut-off was 160/95 mmHg and 31% for all patients in a cut-off level of 140/90 mmHg. Lafontan et al. are studying the mobilisation of fat induced by exercise, resistant to betablockers therapy and attributed to natriuretic peptides. This metabolic pathway could be of relevance in the metabolic syndrome and in cardiac failure. Renin inhibitors, such as aliskiren, are being developed. The outlook is the possible use of these drugs with ACE inhibitors or angiotensin II inhibitors, taking into account the risk/benefit ratio.

[The best of hypertension 2005]

In 2005, new data on the prognostic value of blood pressure measurement in the home and by ambulatory recordings were published from the Italian (PAMELA) and Japanese (OHASAMA) registers. The ambulatory BP has a greater prognostic value than that measured in the physician's office in hypertensive patients whereas the difference in prognostic value is less in normotensive patients. The prevalence of masked hypertension is estimated at 15 to 26% with reference to the diastolic and systolic BP. The cardiovascular risk is significantly higher in patients with permanent or masked hypertension compared with normotensive subjects and "white coat" hypertensive patients. The ASCOT trial showed that in primary prevention of hypotensive patients with more than 3 associated cardiovascular risk factors, a strategy based on amlodipine secondarily associated with a diuretic, provided better control of the blood pressure than that of a betablocker secondarily associated with a diuretic: the therapeutic trial was negative with respect to the primary criterion including fatal coronary events and non-fatal myocardial infarction but the trial was stopped prematurely because of a significant reduction in cardiovascular and global mortality in the amlodipine-perindopril arm compared with the atenolol-thiazide arm. The metaregression of Verdecchia confirmed that the reduction of the BP remains the essential beneficial factor of antihypertensive therapy, but suggested that; in addition to the reduction of the blood pressure, ACE inhibitors provided better protection against coronary disease than calcium antagonists whereas the calcium antagonists were superior to ACE inhibitors for prevention of stroke. The endothelium is confirmed as a potential therapeutic target. Endothelial dysfunction has been demonstrated in resistance and conduction vessels. The study of antihypertensive therapy on endothelial vasodilation is a new pharmacological approach which may help differentiate the benefits of different classes. New data has documented the relations between inflammation, the vessel and hypertension, and different cytokines hs-CRP, ICAM1, IL6, TNF alpha and MCP-1 may be implicated. The new HAS 2005 recommendations for the management of adult hypertensive patients have been published recently; they are an updated reference for the optimisation of treatment in everyday clinical practice in France. The value of auto-measurement and ambulatory BP recording, the necessary estimation of global cardiovascular risk, the use of the 5 classes of antihypertensive drugs having shown a reduction in cardiovascular morbid-mortality, constitute the key points of these recommendations. Finally, data is now available concerning the incidence of hypertension in France in a working population (IPHAF study) and is estimated at 3% in men and 1.34% in women.

[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.