Blood Pressure Increase in Hypertensive Individuals During Resistance Training Protocols With Equated Work to Rest Ratio

Introduction: Despite growing evidence regarding the benefits of resistance training in hypertension, the large and abrupt rise of systolic blood pressure (SBP) observed during resistance exercise execution has resulted in concern about its safety. However, the manipulation of the resistance training protocol (RTP) organization, maintaining the work to rest ratio equated between protocols (W:R-equated), may reduce the SBP increase.

Purpose: To compare cardiovascular responses during two W:R-equated RTPs (3 × 15:88 s vs. 9 × 5:22 s – sets × reps: rest between sets) performed in exercises for the lower and upper limbs.

Methods: Twelve medicated hypertensives (48 ± 8 years) randomly performed two RTPs in the bilateral leg extension (BLE) and unilateral elbow flexion (UEF) exercises at 50% 1RM. Increases (Δ) of SBP, heart rate (HR) and rate pressure product (RPP) during the exercises were measured by photoplethysmography.

Results: In both BLE and UEF exercises, Δ SBP was significantly greater during 3 × 15:88 s than 9 × 5:22 s (peak values: BLE = + 84 ± 39 vs. + 67 ± 20 mm Hg, and UEF = + 46 ± 25 vs. + 37 ± 18 mm Hg, respectively, both p < 0.05). ΔHR and ΔRPP were significantly higher in the 3 × 15:88 s than 9 × 5:22 s in BLE (peak values + 45 ± 17 vs. + 30 ± 8 bpm, and + 15,559 ± 5570 vs. + 10,483 ± 2614 mm Hg. bpm).

Conclusion: In medicated hypertensives, a RTP combining more sets with less repetitions per set and shorter rest intervals between sets (i.e., 9 × 5:22 s) produced a smaller increase in cardiovascular load (ΔSBP, ΔHR and ΔRPP) during its execution than a protocol with fewer longer sets (i.e., 3 × 15:88 s).

Effects of ACEi and ARB on post-exercise hypotension induced by exercises conducted at different times of day in hypertensive men

BACKGROUND

Post-exercise hypotension (PEH) is greater after evening than morning exercise, but antihypertensive drugs may affect the evening potentiation of PEH. Objective: To compare morning and evening PEH in hypertensives receiving angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB).

METHODS

Hypertensive men receiving ACEi (n = 14) or ARB (n = 15) underwent, in a random order, two maximal exercise tests (cycle ergometer, 15 watts/min until exhaustion) with one conducted in the morning (7 and 9 a.m.) and the other in the evening (8 and 10 p.m.). Auscultatory blood pressure (BP) was assessed in triplicate before and 30 min after the exercises. Changes in BP (post-exercise - pre-exercise) were compared between the groups and the sessions using a two-way mixed ANOVA and considering P < .05 as significant.

RESULTS

In the ARB group, systolic BP decrease was greater after the evening than the morning exercise, while in the ACEi group, it was not different after the exercises conducted at the different times of the day. Additionally, after the evening exercise, systolic BP decrease was lower in the ACEi than the ARB group (ARB = -11 ± 8 vs -6 ± 6 and ACEi = -6 ± 7 vs. -8 ± 5 mmHg, evening vs. morning, respectively, P for interaction = 0.014).

CONCLUSIONS

ACEi, but not ARB use, blunts the greater PEH that occurs after exercise conducted in the evening than in the morning.

Spironolactone Versus Clonidine as a Fourth-Drug Therapy for Resistant Hypertension: The ReHOT Randomized Study (Resistant Hypertension Optimal Treatment)

The aim of this study is to compare spironolactone versus clonidine as the fourth drug in patients with resistant hypertension in a multicenter, randomized trial. Medical therapy adherence was checked by pill counting. Patients with resistant hypertension (no office and ambulatory blood pressure [BP] monitoring control, despite treatment with 3 drugs, including a diuretic, for 12 weeks) were randomized to an additional 12-week treatment with spironolactone (12.5-50 mg QD) or clonidine (0.1-0.3 mg BID). The primary end point was BP control during office (<140/90 mm Hg) and 24-h ambulatory (<130/80 mm Hg) BP monitoring. Secondary end points included BP control from each method and absolute BP reduction. From 1597 patients recruited, 11.7% (187 patients) fulfilled the resistant hypertension criteria. Compared with the spironolactone group (n=95), the clonidine group (n=92) presented similar rates of achieving the primary end point (20.5% versus 20.8%, respectively; relative risk, 1.01 [0.55-1.88]; P=1.00). Secondary end point analysis showed similar office BP (33.3% versus 29.3%) and ambulatory BP monitoring (44% versus 46.2%) control for spironolactone and clonidine, respectively. However, spironolactone promoted greater decrease in 24-h systolic and diastolic BP and diastolic daytime ambulatory BP than clonidine. Per-protocol analysis (limited to patients with ≥80% adherence to spironolactone/clonidine treatment) showed similar results regarding the primary end point. In conclusion, clonidine was not superior to spironolactone in true resistant hypertensive patients, but the overall BP control was low (≈21%). Considering easier posology and greater decrease in secondary end points, spironolactone is preferable for the fourth-drug therapy.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01643434.

Effects of long term device-guided slow breathing on sympathetic nervous activity in hypertensive patients: a randomized open-label clinical trial

PURPOSE

Device-guided slow breathing (DGB) is indicated as nonpharmacological treatment for hypertension. The sympathetic nerve activity (SNA) reduction may be one of the mechanisms involved in blood pressure (BP) decrease. The aim of this study is to evaluate the long-term use of DGB in BP and SNA.

SUBJECTS AND METHODS

Hypertensive patients were randomized to listen music (Control Group-CG) or DGB (aim to reduce respiratory rate to less than 10 breaths/minute during 15 minutes/day for 8 weeks). Before and after intervention ambulatory blood pressure monitoring (ABPM), catecholamines and muscle sympathetic nerve activity (MSNA) by microneurography were performed.

RESULTS

17 volunteers in the DGB and 15 in the CG completed the study. There was no change in office BP before and after intervention in both groups. There was a reduction in systolic and diastolic BP in the awake period by ABPM only in the CG (131 ± 10/92 ± 9 vs 128 ± 10/88 ± 8mmHg, p < 0.05). In relation to SNA, no difference in catecholamines was observed. In the volunteers who had a microneurography record, there was no change the MSNA (bursts/minute): DGB (17(15-28) vs 19(13-22), p = 0.08) and CG (22(17-23) vs 22(18-24), p = 0.52).

CONCLUSION

Long-term DGB did not reduce BP, catecholamines levels or MSNA in hypertensive patients. ClinicalTrials.gov identifier: NCT01390727.

Antihypertensive Efficacy of Amlodipine and Losartan after Two ‘Missed’ Doses in Patients with Mild to Moderate Essential Hypertension

We compared the effects of amlodipine (5 − 10 mg, n = 94) and losartan (50 − 100 mg, n = 94) on the lowering of blood pressure (BP) at steady state and after two missed doses, as well as on tolerability. This was a randomized, double-blind study of 12 weeks of active treatment followed by 2 days of placebo treatment. Twenty-four-hour ambulatory blood pressure monitoring and office BP measurements were performed at baseline, week 12 and after the 2-day drug holiday. After 12 weeks, amlodipine was significantly more effective than losartan in reducing both 24-h systolic blood pressure (SBP) (−18.0 versus −10.8 mmHg) and diastolic blood pressure (DBP) (−10.6 versus −8.0 mmHg). While mean SBP and DBP for both treatments increased comparably during the drug holiday, BP values remained significantly lower than baseline for both treatments. The superior BP-lowering effect of amlodipine compared with losartan was maintained during the drug holiday.

Amlodipine reduces blood pressure during dynamic resistance exercise in hypertensive patients

This study investigated the effect of the dihydropyridine calcium channel antagonist, amlodipine, on blood pressure (BP) during resistance exercise performed at different intensities in hypertensives. Eleven hypertensives underwent 4 weeks of placebo and amlodipine (random double-blinded crossover design). In each phase, they performed knee extension exercise until exhaustion following three protocols: one set at 100% of 1 RM (repetition maximum), three sets at 80% of 1 RM, and three sets at 40% of 1 RM. Intraarterial BP was measured before and during exercise. Amlodipine reduced maximal systolic/diastolic BP values achieved at all intensities (100% = 225 ± 6/141 ± 3 vs. 207 ± 6/130 ± 6 mmHg; 80% = 289 ± 8/178 ± 5 vs. 273 ± 10/169 ± 6 mmHg; 40% = 289 ± 10/176 ± 8 vs. 271 ± 11/154 ± 6 mmHg). Amlodipine blunted the increase in diastolic BP that occurred during the second and third sets of exercise at 40% of 1RM (+75 ± 6 vs. +61 ± 5 mmHg and +78 ± 7 vs. +64 ± 5 mmHg, respectively). Amlodipine was effective in reducing the absolute values of systolic and diastolic BP during resistance exercise and in preventing the progressive increase in diastolic BP that occurs over sets of low-intensity exercise. These results suggest that systemic vascular resistance is involved in BP increase during resistance exercise, and imply that hypertensives receiving amlodipine are at lower risk of increased BP during resistance exercise than non-medicated patients.

Presence of Campylobacter and Arcobacter species in in-line milk filters of farms authorized to produce and sell raw milk and of a water buffalo dairy farm in Italy

The objectives of this study were to investigate the presence of Campylobacter spp. and Arcobacter spp. in dairy herds authorized for the production and sale of raw milk and in a water buffalo dairy farm, and to test the antimicrobial susceptibility of the isolates. A total of 196 in-line milk filters were collected from 14 dairy farms (13 bovine and 1 water buffalo) for detection of Campylobacter spp. and Arcobacter spp. by microbiological culture. For each farm investigated, 1 isolate for each Campylobacter and Arcobacter species isolated was tested using the Etest method (AB Biodisk, Solna, Sweden) to evaluate the susceptibility to ciprofloxacin, tetracycline, chloramphenicol, ampicillin, erythromycin, and gentamicin. A total of 52 isolates were detected in 49 milk filters in 12 farms (85.7%) out of 14 and the isolates were identified as Campylobacter jejuni (6), Campylobacter hyointestinalis ssp. hyointestinalis (8), Campylobacter concisus (1), Campylobacter fetus ssp. fetus (1), Arcobacter butzleri (22), and Arcobacter cryaerophilus (14). The small number of isolates tested for antimicrobial susceptibility precludes any epidemiological consideration but highlights that all Campylobacter isolates were susceptible to macrolides, which are the first-choice drugs for the treatment of campylobacteriosis, and that resistance to fluoroquinolones and tetracycline was detected; for Arcobacter isolates, resistance to ampicillin and chloramphenicol was detected. The sale of raw milk for human consumption by self-service automatic vending machines has been allowed in Italy since 2004 and the presence of C. jejuni in in-line milk filters confirms that raw milk consumption is a significant risk factor for human infection. The high occurrence of emerging Campylobacter spp. and Arcobacter spp. discovered in dairy farms authorized for production and sale of raw milk represents an emerging hazard for human health.

Felypressin increases blood pressure during dental procedures in hypertensive patients

BACKGROUND

Felypressin has been added to local anesthetic to increase the length of the anesthetic effect and reduce toxicity during dental procedures. However, the effect on blood pressure remains uncertain, and this may be highly relevant in the dental treatment of hypertensive patients.

OBJECTIVE

To investigate the effect of felypressin on blood pressure in hypertensive patients with controlled BP.

METHODS

71 subjects with these characteristics and in need of periodontal treatment were studied. After 10 minutes of rest, local anesthesia (prilocaine) was infiltrated with and without addition of felypressin. Then, a deep subgingival scaling was performed. Blood pressure was measured by an automated oscillometric device (DIXTAL DX2010). Ten minutes after the administration of the anesthetic, peak anesthetic action was recorded. The State-Trait Anxiety Inventory (STAI) was used to assess the patients' trait anxiety.

RESULTS

Systolic blood pressure increased after anesthesia, regardless of association with felypressin, throughout the dental procedure (p<0.05) and this response can be explained, at least in part, by the trait anxiety levels of the subjects. However, a further increase in diastolic blood pressure was observed when prilocaine was associated with felypressin (p<0.05), but this response did not change with trait anxiety levels.

CONCLUSION

Felypressin increased the diastolic blood pressure of hypertensive patients with controlled blood pressure. Patients with high trait anxiety presented increases in systolic blood pressure upon some procedures, suggesting that an increase in blood pressure might also be related to fear or anxiety.

Prevention of hypertension in patients with pre-hypertension: protocol for the PREVER-prevention trial

Background

Blood pressure (BP) within pre-hypertensive levels confers higher cardiovascular risk and is an intermediate stage for full hypertension, which develops in an annual rate of 7 out of 100 individuals with 40 to 50 years of age. Non-drug interventions to prevent hypertension have had low effectiveness. In individuals with previous cardiovascular disease or diabetes, the use of BP-lowering agents reduces the incidence of major cardiovascular events. In the absence of higher baseline risk, the use of BP agents reduces the incidence of hypertension. The PREVER-prevention trial aims to investigate the efficacy, safety and feasibility of a population-based intervention to prevent the incidence of hypertension and the development of target-organ damage.

Methods

This is a randomized, double-blind, placebo-controlled clinical trial, with participants aged 30 to 70 years, with pre-hypertension. The trial arms will be chlorthalidone 12.5 mg plus amiloride 2.5 mg or identical placebo. The primary outcomes will be the incidence of hypertension, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new sub-clinical atherosclerosis, and sudden death. The study will last 18 months. The sample size was calculated on the basis of an incidence of hypertension of 14% in the control group, a size effect of 40%, power of 85% and P alpha of 5%, resulting in 625 participants per group. The project was approved by the Ethics committee of each participating institution.

Discussion

The early use of blood pressure-lowering drugs, particularly diuretics, which act on the main mechanism of blood pressure rising with age, may prevent cardiovascular events and the incidence of hypertension in individuals with hypertension. If this intervention shows to be effective and safe in a population-based perspective, it could be the basis for an innovative public health program to prevent hypertension in Brazil.

Trial Registration

Clinical Trials NCT00970931.

A comparison between diuretics and angiotensin-receptor blocker agents in patients with stage I hypertension (PREVER-treatment trial): study protocol for a randomized double-blind controlled trial

BACKGROUND

Cardiovascular disease is the leading cause of death in Brazil, and hypertension is its major risk factor. The benefit of its drug treatment to prevent major cardiovascular events was consistently demonstrated. Angiotensin-receptor blockers (ARB) have been the preferential drugs in the management of hypertension worldwide, despite the absence of any consistent evidence of advantage over older agents, and the concern that they may be associated with lower renal protection and risk for cancer. Diuretics are as efficacious as other agents, are well tolerated, have longer duration of action and low cost, but have been scarcely compared with ARBs. A study comparing diuretic and ARB is therefore warranted.

METHODS/DESIGN

This is a randomized, double-blind, clinical trial, comparing the association of chlorthalidone and amiloride with losartan as first drug option in patients aged 30 to 70 years, with stage I hypertension. The primary outcomes will be variation of blood pressure by time, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new subclinical atherosclerosis and sudden death. The study will last 18 months. The sample size will be of 1200 participants for group in order to confer enough power to test for all primary outcomes. The project was approved by the Ethics committee of each participating institution.

DISCUSSION

The putative pleiotropic effects of ARB agents, particularly renal protection, have been disputed, and they have been scarcely compared with diuretics in large clinical trials, despite that they have been at least as efficacious as newer agents in managing hypertension. Even if the null hypothesis is not rejected, the information will be useful for health care policy to treat hypertension in Brazil.

CLINICAL TRIALS REGISTRATION NUMBER

ClinicalTrials.gov: NCT00971165.

Biopsychosocial variables and attitudes towards treatment influence complicated hypertension

BACKGROUND

Complicated hypertension can be influenced by the characteristics of hypertensive patients.

OBJECTIVE

To associate the condition of complicated hypertension with biosocial variables such as attitudes and beliefs about the disease and treatment and subjective well-being.

METHODS

We studied 251 uncomplicated hypertensive patients (SBP > 140 mmHg and/or 90 < DBP < 110 mmHg for patients under no treatment and DBP <110mmHg for patients under treatment without target organ damage and other diseases) and 260 complicated hypertensive patients (DBP > 110 mmHg with or without treatment, with target organ damage or other diseases).

RESULTS

Complicated hypertensive patients were significantly different from uncomplicated ones (p <0.05) in relation to: 1 - Prevalence of men, not white (53.0%), higher body mass index (29.5 ± 4.6 vs 28.5 ± 4.0 kg/m²), over 10 years of disease (54.0%), completion of previous treatment (53.0%) and reports of sadness about life as a whole (74.0%) 2 - Complicated hypertensive patients never bring the drugs when they travel (59.0%), nor do they buy them before running out the drugs (71.0%) and rarely follow eating guidelines (69.0%) 3 - Uncomplicated hypertensive patients showed no more migraines, joint pain and, among women, menopausal status and hormone replacement therapy, and 4 - Of those who had pressure control (< 140/90 mmHg), 61.9% were uncomplicated hypertensive patients; and 5 - Complicated hypertensive patients were not aware that treatment can prevent kidney problems and they thought that young people do not have high blood pressure.

CONCLUSION

Complicated hypertensive patients showed more negative structural and psychosocial characteristics, more negative attitudes towards treatment and are unaware of the disease.

Hypertension in the city of São Paulo: self-reported prevalence assessed by telephone surveys

BACKGROUND

Little is known about the prevalence of hypertension in São Paulo, Brazil.

OBJECTIVE

To identify the prevalence of self-reported hypertension in the city of São Paulo.

METHODS

There were 613 telephone interviews using directories of household land-lines. The sample was calculated with an estimated prevalence of hypertension in 20.0%.

RESULTS

The prevalence of self-reported hypertension was 23.0% and 9.0% of respondents reported that the value of their last pressure measurement was greater than 140/90 mmHg, but they were unaware that they were hypertensive, with a total prevalence 32.0%. Hypertensive patients reported that: 89.0% were under treatment and 35.2% were controlled; 27.0% miss medical appointments; 16.2% stop taking drugs; 14.8% have a history of stroke; 27.8% had heart disease and 38.7% had hypercholesterolemia; 71.2% received advice to reduce salt, 64.6% to perform physical activity, 60.0% to lose weight loss and 26.2% to control stress; and 78.9% measured pressure regularly. There was a statistically significant relation (p < 0.05) for: 1) missing medical appointments with longer treatment and irregular health monitoring; 2) stop taking the drugs with smoking, alcohol and failure to monitor health; 3) carry out treatment for hypertension with dyslipidemia, higher age and longer use of contraceptives for women; and 4) body mass index changed with diabetes, hypercholesterolemia, uncontrolled systolic blood pressure and use of more than one anti-hypertension drug.

CONCLUSION

The prevalence of self-reported hypertension in the city of São Paulo resembles the prevalence found in other studies.

Acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure

Hypertension is a ubiquitous and serious disease. Regular exercise has been recommended as a strategy for the prevention and treatment of hypertension because of its effects in reducing clinical blood pressure; however, ambulatory blood pressure is a better predictor of target-organ damage than clinical blood pressure, and therefore studying the effects of exercise on ambulatory blood pressure is important as well. Moreover, different kinds of exercise might produce distinct effects that might differ between normotensive and hypertensive subjects.The aim of this study was to review the current literature on the acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure in normotensive and hypertensive subjects. It has been conclusively shown that a single episode of aerobic exercise reduces ambulatory blood pressure in hypertensive patients. Similarly, regular aerobic training also decreases ambulatory blood pressure in hypertensive individuals. In contrast, data on the effects of resistance exercise is both scarce and controversial. Nevertheless, studies suggest that resistance exercise might acutely decrease ambulatory blood pressure after exercise, and that this effect seems to be greater after low-intensity exercise and in patients receiving anti-hypertensive drugs. On the other hand, only two studies investigating resistance training in hypertensive patients have been conducted, and neither has demonstrated any hypotensive effect. Thus, based on current knowledge, aerobic training should be recommended to decrease ambulatory blood pressure in hypertensive individuals, while resistance exercise could be prescribed as a complementary strategy.

Intra-arterial blood pressure response in hypertensive subjects during low- and high-intensity resistance exercise

OBJECTIVE

The aim of this study was to describe blood pressure responses during resistance exercise in hypertensive subjects and to determine whether an exercise protocol alters these responses.

INTRODUCTION

Resistance exercise has been recommended as a complement for aerobic exercise for hypertensive patients. However, blood pressure changes during this kind of exercise have been poorly investigated in hypertensives, despite multiple studies of normotensives demonstrating significant increases in blood pressure.

METHODS

Ten hypertensive and ten normotensive subjects performed, in random order, two different exercise protocols, composed by three sets of the knee extension exercise conducted to exhaustion: 40% of the 1-repetition maximum (1RM) with a 45-s rest between sets, and 80% of 1RM with a 90-s rest between sets. Radial intra-arterial blood pressure was measured before and throughout each protocol.

RESULTS

Compared with normotensives, hypertensives displayed greater increases in systolic BP during exercise at 80% (+80 +/-3 vs. +62 +/-2 mmHg, P<0.05) and at 40% of 1RM (+75 +/-3 vs. +67 +/-3 mmHg, P<0.05). In both exercise protocols, systolic blood pressure returned to baseline during the rest periods between sets in the normotensives; however, in the hypertensives, BP remained slightly elevated at 40% of 1RM. During rest periods, diastolic blood pressure returned to baseline in hypertensives and dropped below baseline in normotensives.

CONCLUSION

Resistance exercise increased systolic blood pressure considerably more in hypertensives than in normotensives, and this increase was greater when lower-intensity exercise was performed to the point of exhaustion.

How to avoid discontinuation of antihypertensive treatment: The experience in São Paulo, Brazil

OBJECTIVES

To evaluate the importance of providing guidelines to patients via active telephone calls for blood pressure control and for preventing the discontinuation of treatment among hypertensive patients.

INTRODUCTION

Many reasons exist for non-adherence to medical regimens, and one of the strategies employed to improve treatment compliance is the use of active telephone calls.

METHODS

Hypertensive patients (n=354) who could receive telephone calls to remind them of their medical appointments and receive instruction about hypertension were distributed into two groups: a) "uncomplicated" - hypertensive patients with no other concurrent diseases and b) "complicated" - severe hypertensive patients (mean diastolic ≥ 110 mmHg with or without medication) or patients with comorbidities. All patients, except those excluded (n=44), were open-block randomized to follow two treatment regimens ("traditional" or "current") and to receive or not receive telephone calls ("phone calls" and "no phone calls" groups, respectively).

RESULTS

Significantly fewer patients in the "phone calls" group discontinued treatment compared to those in the "no phone calls" group (4 vs. 30; p<0.0094). There was no difference in the percentage of patients with controlled blood pressure in the "phone calls" group and "no phone calls" group or in the "traditional" and "current" groups. The percentage of patients with controlled blood pressure (<140/90 mmHg) was increased at the end of the treatment (74%), reaching 80% in the "uncomplicated" group and 67% in the "complicated" group (p<0.000001).

CONCLUSION

Guidance to patients via active telephone calls is an efficient strategy for preventing the discontinuation of antihypertensive treatment.

[Prevalence of arterial hypertension in branch retinal vein occlusion patients]

PURPOSE

To identify in patients with branch retinal vein occlusion using ambulatory blood pressure monitoring and clinical blood pressure measures: hypertension prevalence, and nocturnal profile of blood pressure.

METHODS

Prospectively, 93 eyes of 83 patients with branch retinal vein occlusion were submitted to ophthalmological examination. Afterwards the patients were submitted to clinical evaluation and blood pressure monitoring. Non-dipper was defined as a fall in systolic blood pressure <or= 10%, and dipper when this value was higher.

RESULTS

Disease affected one eye in 73 (88%) patients. The temporal superior branch was the site of occlusion in 61 (65.6%) eyes, while in the others the infero-temporal branch was affected. Seventy six (92%) patients were diagnosed as hypertensive after clinical evaluation. Ambulatory blood pressure monitoring identified 76 hipertensives, 5 normotensives, 1 white-coat hypertensive and one masked hypertensive subjects. The two latter were excluded from the analysis. Of the 81 analyzed patients, forty (49%) were dippers and 41 (51%) were non-dippers. Among the HT (n=76), 36 (47%) were dippers and 40 (53%) were non-dippers.

CONCLUSION

Prevalence of hypertension in our series was extremely high (92%) which suggests that physiopathology of the disease has a close relationship with changes promoted by hypertension. A little more than half of the hypertensives were non-dippers (n=40; 52,6%). These evidences suggest that a 24-hour sustained level of blood pressure may be an additional risk factor for branch retinal vein occlusion.

Reasons for resubmission of research projects to the research ethics committee of a university hospital in São Paulo, Brazil

INTRODUCTION

It is important to know the reasons for resubmitting research projects to the Research Ethics Committee in order to help researchers to prepare their research projects, informed consent forms and needed research documentation.

OBJECTIVES

To verify the reasons for resubmitting projects that were previously rejected by the Ethics Committee.

METHOD

This is a cross-sectional study that evaluated research projects involving human beings. Research projects were submitted in 2007 to the Research Ethics Committee of the Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo.

RESULTS

One thousand two hundred and fifty six research projects were submitted to the ethics committee and the average time for evaluating the research projects and related documents until a final decision was reached was 49.95 days. From the total, 399 projects were reviewed in 2 or more meetings until a final decision was reached. Of these, 392 research projects were included in the study; 35 projects were subsequently excluded for involving animals. Among the research projects included, 42.5% concerned research with new drugs, vaccines and diagnostic tests, 48.5% consisted of undergraduate students' research projects, 68.9% of the research had no sponsorship, and 97.5% were eventually approved. The main reasons for returning the projects to the researchers were the use of inadequate language and/or difficulty of understanding the informed consent form (32.2%), lack of information about the protocol at the informed consent form (25.8%), as well as doubts regarding methodological and statistical issues of the protocol (77.1%). Other reasons for returning the research projects involved lack of, inaccuracy on or incomplete documentation, need of clarification or approval for participation of external entities on the research, lack of information on financial support.

CONCLUSION

Among the research projects that were returned to the researchers for additional clarification, the main reasons were inadequacies or doubts about the terms used in the informed consent form as well as lack of information regarding the research at the informed consent form and methodological and statistical issues regarding the protocol.

Dietary salt restriction increases plasma lipoprotein and inflammatory marker concentrations in hypertensive patients

BACKGROUND

Dietary salt restriction has been reported to adversely modify the plasma lipoprotein profile in hypertensive and in normotensive subjects. We investigated the effects of the low sodium intake (LSI) on the plasma lipoprotein profile and on inflammation and thrombosis biomarkers during the fasting and postprandial periods.

METHODS

Non-obese, non-treated hypertensive adults (n=41) were fed strictly controlled diets. An initial week on a control diet (CD, Na=160 mmol/day) was followed by 3 weeks on LSI (Na=60 mmol/day). At admission and on the last day of each period, the 24-h ambulatory blood pressure was monitored and blood was drawn after an overnight fasting period and after a fat-rich test meal.

RESULTS

The dietary adherence was confirmed by 24-h urinary sodium excretion. Fasting triglyceride (TG), chylomicron-cholesterol, hsC-reactive protein (CRP), tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) concentrations, renin activity, aldosterone, insulin, and homeostasis model assessment insulin resistance (HOMA-IR) values were higher, but non-esterified fatty acids (NEFA) were lower on LSI than on CD. For LSI, areas under the curve (AUC) of TG, chylomicron-cholesterol, apoB and the cholesterol/apoB ratio were increased, whereas AUC-NEFA was lowered. LSI did not modify body weight, hematocrit, fasting plasma cholesterol, glucose, adiponectin, leptin, fibrinogen and factor VII (FVII), and AUC of lipoprotein lipase and of lipoprotein remnants.

CONCLUSION

LSI induced alterations in the plasma lipoproteins and in inflammatory markers that are common features of the metabolic syndrome.

Blood pressure measurements taken by patients are similar to home and ambulatory blood pressure measurements

OBJECTIVE

To compare blood pressure measurements taken at home by physicians, nurses, and patients with office blood pressure measurement , ambulatory blood pressure monitoring and home blood pressure measurement.

METHODS

A total of 44 patients seen by a home care program were studied. Protocol 1 a) blood pressure was measured by the patient, a physician and a nurse during a regular home visit (Home1); b) home blood pressure measurement was measured for 4 days (HBPM1); c) office blood pressure measurement was measured by a physician, a nurse, and the patient; and by 24-hour ambulatory blood pressure monitoring. Protocol 2 blood pressure was measured by the patient, a physician, and a nurse during a special home visit in the presence of a physician and a nurse only (Home2); and b) home blood pressure measurement was taken for the second time (HBPM2). Echocardiography, guided by a two-dimensional echocardiograph, was performed.

RESULTS

Protocol 1: a) office blood pressure measurement and Home1 were significantly higher than ambulatory blood pressure monitoring, except for systolic and diastolic office blood pressure measurement taken by the patient or a family member, systolic blood pressure taken by a nurse, and diastolic blood pressure taken by a physician. b) ambulatory blood pressure monitoring and HBPM1 were similar. Protocol 2: a) HBPM2 and Home2 were similar. b) Home2 was significantly lower than Home1, except for diastolic blood pressure taken by a nurse or the patient. There were significant relationships between: a) diastolic blood pressure measured by the patient and the thickness of the interventricular septum, posterior wall, and left ventricular mass; and b) ambulatory and HBPM2 diastolic and systolic blood pressure taken by a physician (home2) and left ventricular mass. Therefore, the data indicate that home blood pressure measurement and ambulatory blood pressure monitoring had good prognostic values relative to "office measurement."

CONCLUSION

This study showed that the measurement most similar to home blood pressure measurement and ambulatory blood pressure monitoring was blood pressure measured by the patient, and that home blood pressure measurement and ambulatory blood pressure monitoring had good prognostic value relative to "office measurements".

Neurovascular and hemodynamic responses to hyperinsulinemia in healthy postmenopausal women

Acute hyperinsulinemia produces sympathetic activation, vasodilation, and cardiovascular changes in healthy young men. Postmenopausal period is accompanied by sympathetic, vascular and cardiovascular changes. Nevertheless, the effects of acute insulin infusion were not known in postmenopausal women. To study this aspect, 26 postmenopausal healthy women were submitted to an euglycemic hyperinsulinemic clamp performed during 120 min. Heart rate (HR: ECG), blood pressure (BP: oscillometric method), forearm blood flow (FBF: plethysmography), plasma norepinephrine (NE), plasma epinephrine (EP), and cardiovascular autonomic modulation (spectral analysis of R-R interval and BP variabilities) were measured before and during the clamp. Glycemia was kept similar to baseline during the clamp (84.6+/-1.2mg/dl versus 87.1+/-1.6 mg/dl), while plasma insulin increased significantly to a level of 89.3+/-5.6 microU/ml. Insulin infusion significantly increased plasma NE (+45+/-17 pg/ml), EP (+20+/-9 pg/ml), and low to high frequency ratio of R-R interval variability (LH/HF: 1.2+/-0.4), but did not change low frequency component of BP variability. FBF (+0.7+/-0.2 ml min(-1)100ml(-1)) was also significantly enhanced by hyperinsulinemia. HR and systolic BP increased with insulin infusion (+4+/-1 bat/min and +6+/-2 mmHg, respectively, P<0.05), while diastolic BP did not change. In conclusion, in healthy postmenopausal women, acute hyperinsulinemia produces sympathetic activation, and vasodilation, which results in HR and systolic BP enhancements, with no change in diastolic BP. This pattern of response is similar to the one usually observed in healthy young men.

Do Brazilian physicians follow the Brazilian guidelines on hypertension?

OBJECTIVE

To evaluate whether procedures adopted by Brazilian physicians in the diagnosis and treatment of hypertension are in compliance with those advocated by the IV Brazilian Hypertension Guidelines.

METHOD

Survey carried out by means of telephone interviews with Brazilian physicians. The survey featured application of a questionnaire aimed to assess receipt of and compliance with the guidelines, and to evaluate various aspects regarding the treatment of hypertensive patients.

RESULTS

68.3% of the respondents had received the guidelines and answered the questionnaire in full. The total sample consisted of 483 physicians--47% cardiologists, 31.7% internists, and 21.3% nephrologists. The survey showed high compliance with certain guideline topics such as more than one measurement at different times for the diagnosis of hypertension (94%), and providing guidance regarding lifestyle changes as a therapeutic strategy. As to arterial pressure levels used for diagnosis and therapeutic target, compliance with guideline recommendations lacks uniformity. The survey showed a clear preference for pressure levels lower than those recommended, especially in patients with comorbidities. Attempts to assess cardiovascular risk also proved to be low. Only 64.7% of the respondents reported that they seek to determine the presence of diabetes mellitus, and 56.4% check for dyslipidemia. The majority (59.3%) mentioned diuretics as the preferred drug class for initial drug treatment of hypertension.

CONCLUSION

We concluded that there is only partial compliance with Brazilian Hypertension Guidelines and that certain factors should be taken into consideration when drawing up future guidelines, such as: improved distribution; standardization of values for diagnosis and therapeutic target; more extensive coverage of ways for physicians to approach hypertensive patients to better evaluate their overall cardiovascular risk.

Validity of four indirect methods to measure adherence in primary care hypertensives

High blood pressure (HBP) is one of the most important risk factors for morbidity and mortality in the world. Non-adherence to medication is associated with the lack of control of HBP. The objective of this study was to assess the validity of four indirect methods for measuring adherence to medication to control HBP in primary health care. A random sample of 120 hypertensive patients who were undergoing treatment for at least 2 months in a primary care unit in Florianópolis (Brazil) were included in the study. The independent variables were four indirect methods to measure adherence to medication: knowledge regarding the HBP medication, the blood pressure level, attitude regarding the medication intake (Morisky-Green test) and self-reported adherence. The classification of HBP was based on criteria established by the Brazilian Ministry of Health. The gold standard used for measuring adherence was the pill count. Logistic regression was used to estimate sensitivity (highest value of 88.2% for self-report), specificity (highest value of 70.7% for HBP control), positive predictive value (highest value of 46.4% for HBP control) and negative predictive value (highest value of 79.1% for Morisky-Green test) for each of the indirect methods. No indirect method of measuring adherence had a good positive predictive value for adherence, which was best predicted by patients' age and whether they managed to control HBP. The results also revealed low treatment adherence (31.2%) and low control of HBP (37.6%). Non-adherence was mainly associated with side effects of the treatment.

Post-resistance exercise hypotension, hemodynamics, and heart rate variability: influence of exercise intensity

The occurrence of post-exercise hypotension after resistance exercise is controversial, and its mechanisms are unknown. To evaluate the effect of different resistance exercise intensities on post-exercise blood pressure (BP), and hemodynamic and autonomic mechanisms, 17 normotensives underwent three experimental sessions: control (C-40 min of rest), low- (E40%-40% of 1 repetition maximum, RM), and high-intensity (E80%-80% of 1 RM) resistance exercises. Before and after interventions, BP, heart rate (HR), and cardiac output (CO) were measured. Autonomic regulation was evaluated by normalized low- (LF(R-R)nu) and high-frequency (HF(R-R)nu) components of the R-R variability. In comparison with pre-exercise, systolic BP decreased similarly in the E40% and E80% (-6 +/- 1 and -8 +/- 1 mmHg, P < 0.05). Diastolic BP decreased in the E40%, increased in the C, and did not change in the E80%. CO decreased similarly in all the sessions (-0.4 +/- 0.2 l/min, P < 0.05), while systemic vascular resistance (SVR) increased in the C, did not change in the E40%, and increased in the E80%. Stroke volume decreased, while HR increased after both exercises, and these changes were greater in the E80% (-11 +/- 2 vs. -17 +/- 2 ml/beat, and +17 +/- 2 vs. +21 +/- 2 bpm, P < 0.05). LF(R-R)nu increased, while ln HF(R-R)nu decreased in both exercise sessions.

IN CONCLUSION

Low- and high-intensity resistance exercises cause systolic post-exercise hypotension; however, only low-intensity exercise decreases diastolic BP. BP fall is due to CO decrease that is not compensated by SVR increase. BP fall is accompanied by HR increase due to an increase in sympathetic modulation to the heart.

Postexercise hypotension induced by low-intensity resistance exercise in hypertensive women receiving captopril

OBJECTIVE

The present study investigated the effect of a single bout of low-intensity resistance exercise on recovery blood pressure in hypertensive women receiving captopril.

METHODS

Twelve essential hypertensive women, who were receiving captopril, underwent two experimental sessions: control (C - 40 min of seated rest) and low-intensity resistance exercise (E - six resistance exercises, three sets, 20 repetitions, 40% of one repetition maximum). Clinic blood pressure was measured in the laboratory, before and for 120 min after exercise or rest. Moreover, ambulatory blood pressure was also measured for 21 h after exercise or rest.

RESULTS

Clinic blood pressures decreased significantly after exercise (systolic blood pressure =-12+ or -3 mmHg and diastolic blood pressure =-6+ or -2 mmHg, P<0.05), but not after rest. Mean awake blood pressures (systolic: C=132+ or -5 mmHg vs. E=125+ or -4 mmHg and diastolic: C=83+ or -3 mmHg vs. E=78+ or -2 mmHg, P<0.05) were significantly lower in the E than in the C session, while 21-h (systolic blood pressures: C=128+ or -5 mmHg vs. E=123+ or -4 mmHg; and diastolic blood pressures: C=80+ or -3 mmHg vs. E=76+ or -2 mmHg) and asleep (systolic blood pressures: C=120+ or -7 mmHg vs. E=118+ or -5 mmHg; and diastolic blood pressures: C=73+ or -4 mmHg vs. E=71+ or -3 mmHg) blood pressures did not differ between the experimental sessions. Moreover, there was a positive correlation between blood pressure measured in the C session and blood pressure reduction observed in the E session, showing that blood pressure decrease was greater when blood pressure level was higher.

CONCLUSION

In hypertensive women receiving captopril, a single bout of low-intensity resistance exercise reduces blood pressure. This reduction persists for 10 h, during the awake period, while patients were engaged in their daily living activities. It was greater in patients with higher ambulatory blood pressure.

Aftereffects of exercise and relaxation on blood pressure

OBJECTIVE

To study the acute aftereffects of exercise and relaxation, performed alone and in combination, on blood pressure (BP) measured at baseline and during stressful conditions.

DESIGN

Clinical trial with comparison of groups and repeated measures in each group.

SETTING

Exercise Hemodynamic Laboratory, University of São Paulo, Brazil.

PARTICIPANTS

Fourteen normotensive (NT) and 16 essential hypertensive (HT) subjects.

INTERVENTIONS

Four random experimental sessions: relaxation (RX-20 min); exercise [EX-cycle ergometer, 53 min, 50% peak oxygen uptake (VO2peak)]; exercise plus relaxation (EX+RX); and control (C-73 min rest). Measures were taken before and after interventions at baseline and during Stroop color test.

MAIN OUTCOME MEASURES

Auscultatory and plesthysmographic BPs.

RESULTS

Systolic and diastolic BPs decreased significantly after all the interventions. The decreases in both BPs were significantly greater after the EX+RX session, and were also greater in the HT (EX+RX session, -10+/-1/-7+/-1 and -15+/-2/-8+/-1 mm Hg for the NT and HT, respectively). During mental stress, systolic BP increased significantly and similarly after all the experimental sessions. Diastolic BP also increased significantly during stress; however, the increase was significantly greater after the RX session. At the end of the mental stress, diastolic BP was significantly lower after the EX (74+/-3 mm Hg) and EX+RX (72+/-3 mm Hg) sessions than after the C (79+/-3 mm Hg) and RX (78+/-3 mm Hg) sessions.

CONCLUSIONS

In NT and HT subjects, a single bout of exercise or relaxation has hypotensive effects, further enhanced by their combination, and greater in the HT. Moreover, exercise performed alone or in combination with relaxation decreases systolic and diastolic BPs during mental stress.

Estudo "LOTHAR": avaliação de eficácia e tolerabilidade da combinação fixa de anlodipino e losartana no tratamento da hipertensão arterial primária

OBJECTIVE

The LOTHAR study evaluated medium and long term (one year) efficacy, tolerability and metabolic effects of the fixed combination of amlodipine and losartan compared to amlodipine or losartan alone.

METHODS

Brazilian multicenter, randomized, double-blind and comparative trial performed with 198 patients in stage 1 and 2 essential hypertension.

RESULTS

The fixed combination has a high antihypertensive efficacy that is sustained in the long term with very low percentage of loss of blood pressure control. This percentage is incidentally lower than that of the two monotherapy comparative regimens. In the long term, more than 60% of the patients treated with the fixed combination remained with DBP < or = 85 mmHg, and the antihypertensive effect, when assessed by ABPM persisted for 24 hours with a trough-to-peak ratio of 76.7%. The frequency of adverse events was quite low in this group, and the long-term incidence of leg edema was approximately four-fold lower than that observed with amlodipine alone. The fixed combination did not change glucose and lipid metabolism in the medium or in the long term.

CONCLUSION

Based on these results, we can say that the combination of amlodipine and losartan--the first fixed combination of a calcium channel blocker and an angiotensin II receptor blocker available in the pharmaceutical market, is an excellent option for the treatment of a wide range of hypertensive patients.

Is the area under blood pressure curve the best parameter to evaluate 24-h ambulatory blood pressure monitoring data?

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) provides relevant data about blood pressure over a 24-h period. The analysis of parameters to determine the blood pressure profile from these data is of great importance.

OBJECTIVES

To calculate areas under systolic and diastolic blood pressure curves (SBP-AUC/DBP-AUC) and compare with systolic and diastolic blood pressure load (SBPL/DBPL) and 24-h systolic and diastolic blood pressure (24-h SBP/24-h DBP) in order to determine which provides the best correlation with left ventricular mass index (LVMI).

METHODS

ABPM measurements (1143 individuals) were analyzed to obtain 24-h SBP/24-h DBP, SBPL/DBPL, and SBP-AUC/ DBP-AUC, using Spacelabs (90207) and CardioSistemas devices. Left ventricular mass was determined using an echocardiograph HP Sonos 5500 and LVMI was calculated.

RESULTS

The correlations between all possible pairs within the group 24-h SBP/SBPL/SBP-AUC and 24-h DBP/DBPL/DBP-AUC were high and statistically significant. The correlations between 24-h SBP/24-h DBP and SBP-AUC/DBP-AUC with SBPL/DBPL close to 100%, were lower than those mentioned above. The correlations of the parameters obtained by ABPM with LVMI were also high and statistically significant, except for blood pressure load between 90 and 100%, and for 24-h SBP of 135 mmHg or less and SBPL higher than 50%.

CONCLUSIONS

SBPL/DBPL and SBP-AUC/DBP-AUC can be used for the evaluation of ABPM data owing to the strong correlation with 24-h SBP/24-h DBP and with LVMI, except when SBPL is close to 100% or 24-h SBP is below 135 mmHg but SBPL is above 50%. SBP-AUC/DBP-AUC, however, are a better alternative because they do not have the limitations of blood pressure load or even of 24-h blood pressure present.

Previous exercise attenuates muscle sympathetic activity and increases blood flow during acute euglycemic hyperinsulinemia

Insulin infusion causes muscle vasodilation, despite the increase in sympathetic nerve activity. In contrast, a single bout of exercise decreases sympathetic activity and increases muscle blood flow during the postexercise period. We tested the hypothesis that muscle sympathetic activity would be lower and muscle vasodilation would be higher during hyperinsulinemia performed after a single bout of dynamic exercise. Twenty-one healthy young men randomly underwent two hyperinsulinemic euglycemic clamps performed after 45 min of seated rest (control) or bicycle exercise (50% of peak oxygen uptake). Muscle sympathetic nerve activity (MSNA, microneurography), forearm blood flow (FBF, plethysmography), blood pressure (BP, oscillometric method), and heart rate (HR, ECG) were measured at baseline (90 min after exercise or seated rest) and during hyperinsulinemic euglycemic clamps. Baseline glucose and insulin concentrations were similar in the exercise and control sessions. Insulin sensitivity was unchanged by previous exercise. During the clamp, insulin levels increased similarly in both sessions. As expected, insulin infusion increased MSNA, FBF, BP, and HR in both sessions (23 ± 1 vs. 36 ± 2 bursts/min, 1.8 ± 0.1 vs. 2.2 ± 0.2 ml·min−1·100 ml−1, 89 ± 2 vs. 92 ± 2 mmHg, and 58 ± 1 vs. 62 ± 1 beats/min, respectively, P < 0.05). BP and HR were similar between sessions. However, MSNA was significantly lower (27 ± 2 vs. 31 ± 2 bursts/min), and FBF was significantly higher (2.2 ± 0.2 vs. 1.8 ± 0.1 ml·min−1·100 ml−1, P < 0.05) in the exercise session compared with the control session. In conclusion, in healthy men, a prolonged bout of dynamic exercise decreases MSNA and increases FBF. These effects persist during acute hyperinsulinemia performed after exercise.

O conhecimento de profissionais da área da saúde sobre a medida da pressão arterial

Avaliou-se o conhecimento teórico e prático de 110 auxiliares de enfermagem, 44 médicos e 25 enfermeiros, por meio de 15 questões de múltipla escolha e pela observação do procedimento da medida da pressão arterial. O percentual de acerto quanto ao conhecimento teórico foi de 32%±12% para os auxiliares de enfermagem, 44%±14% para os enfermeiros e 56%±13% para os médicos, sendo que todos foram estatisticamente diferentes entre si (p<0,05). Quanto ao conhecimento prático, este foi de 41%±6% para os auxiliares de enfermagem, 44%±10% para os enfermeiros e 50%±12% para os médicos, sendo que os médicos apresentarem resultados significativamente superiores (p<0,05). Conclui-se que o conhecimento foi pouco satisfatório.

Blood pressure measurement in obese patients: comparison between upper arm and forearm measurements

BACKGROUND

It is well known that blood pressure measurement with a standard 12-13 cm wide cuff is erroneous for large arms.

OBJECTIVE

To compare arm blood pressure measurements with an appropriate cuff and forearm blood pressure measurements (BPM) with a standard cuff, and both measurements by the Photopletismography (Finapres) method.

METHODS

One hundred and twenty-nine obese patients were studied (body mass index=40+/-7 kg/m2). The patients had three arm BPM taken by an automatic oscillometric device using an appropriate cuff and three forearm BPM with a standard cuff in the sitting position after a five-minute rest. Data were analysed by the analysis of variance. The correction values were obtained by the linear regression test.

RESULTS

Systolic and diastolic arm BPM with an appropriate cuff were significantly lower (p<0.05) than forearm BPM with a standard cuff. The measurements obtained by Finapres were significantly lower (p<0.05) than those found for forearm systolic and diastolic blood pressures and upper arm diastolic blood pressure. The equation to correct BPM in forearm in obese patients with arm circumference between 32-44 cm was: systolic BPM=33.2+/-0.68 x systolic forearm BPM, and diastolic BPM=25.2+0.59 x forearm diastolic BPM.

CONCLUSION

This study showed that forearm blood pressure measurement overestimates the values of arm blood pressure measurement. In addition, it is possible to correct forearm BPM with an equation.

Amlodipine 2.5???mg once daily in older hypertensives: a Brazilian multi-centre study

OBJECTIVES

The use of low-dose amlodipine has not yet been well established in the elderly. This study therefore aimed to evaluate the efficacy and tolerability of low-dose amlodipine in elderly patients with Joint National Committee VI stage I or II hypertension.

PATIENTS AND METHODS

Sixty-five hypertensive individuals (aged 66.3 +/- 5.3 years) received amlodipine 2.5 mg per day for 12 weeks before and after two periods of 4 weeks of placebo. At weeks 0, 12 and 16, patients were submitted to office, 24 h ambulatory blood pressure monitoring and home blood pressure measurement.

RESULTS

Office systolic and diastolic blood pressure showed decreases at weeks 8 (153 +/- 17, 90 +/- 9 mmHg) and 12 (152 +/- 16, 90 +/- 9 mmHg) compared with weeks 0 (164 +/- 16, 99 +/- 6 mmHg) and 16 (162 +/- 19, 95 +/- 9 mmHg). During ambulatory monitoring, a decrease was observed in the average 24 h systolic and diastolic pressure at week 12 (143 +/- 13, 86 +/- 7 mmHg) compared with weeks 0 (155 +/- 15, 93 +/- 6 mmHg) and 16 (152 +/- 16, 92 +/- 8 mmHg). A daytime and night-time reduction in systolic and diastolic pressure was observed on home blood pressure monitoring at week 12 (146 +/- 16/88 +/- 8, 144 +/- 16/93 +/- 8 mmHg) compared with weeks 0 (159 +/- 17/94 +/- 8, 161 +/- 19/93 +/- 8 mmHg) and 16 (153 +/- 16/93 +/- 8, 154 +/- 17/92 +/- 8 mmHg). Adverse reactions were infrequent.

CONCLUSIONS

Amlodipine at a dose of 2.5 mg per day showed efficacy and good tolerability in elderly hypertensives.

The influence of patient's consciousness regarding high blood pressure and patient's attitude in face of disease controlling medicine intake

OBJECTIVE

To assess the relation between blood pressure control and the following: the Morisky-Green test, the patient's consciousness regarding high blood pressure, the patient's attitude in face of medicine intake, the patient's attendance at medical consultations, and the subjective physician's judgment.

METHODS

We studied 130 hypertensive patients with the following characteristics: 73% females, 60 +/- 11 years, 58% married, 70% white, 45% retired, 45% with incomplete elementary schooling, 64% had a familial income of 1 to 3 minimum wages, body mass index of 30 +/- 7 kg/m , consciousness regarding the disease for a mean period of 11 +/- 9.5 years, and mean treatment duration of 8 +/- 7 years.

RESULTS

Only 35% of the hypertensive individuals had blood pressure under control and a longer duration of treatment (10 +/- 7 vs 7 +/- 6.5 years; P<0.05). The retiree predominated. The result of the Morisky-Green test did not relate to blood pressure control. In evaluating the attitude in face of medicine intake, the controlled patients achieved significantly higher scores than did the noncontrolled patients (8 +/- 1.9 vs 7 +/- 2, P<0.05). The hypertensive patients had higher levels of consciousness regarding their disease and its treatment, and most (70%) patients attended 3 or 4 medical consultations, which did not influence blood pressure control. The physicians attributed significantly higher scores regarding adherence to treatment to controlled patients (6 +/- 0.8 vs 5 +/- 1.2; P<0.05).

CONCLUSION

Consciousness regarding the disease, the Morisky-Green test, and attendance to medical consultations did not influence blood pressure control.

Effect of indapamide SR on microalbuminuria--the NESTOR study (Natrilix SR versus Enalapril Study in Type 2 diabetic hypertensives with micrOalbuminuRia)--rationale and protocol for the main trial

In type 2 diabetic hypertensive patients, microalbuminuria can be due to hypertension and/or diabetic nephropathy. Angiotensin-converting enzyme (ACE) inhibitors act preferentially on microalbuminuria due to diabetic nephropathy. The objective is to demonstrate the efficacy of a thiazide-like diuretic, indapamide sustained release (SR), at reducing microalbuminuria in hypertensive type 2 diabetic patients in comparison with an ACE inhibitor, enalapril. The study is an international multicentre, 12-month, randomized, double-blind, controlled, two parallel group study of type 2 diabetic patients with hypertension (140 mmHg < or = systolic blood pressure <180 mmHg and diastolic blood pressure <110 mmHg) and microalbuminuria. Intervention is after a 4-week placebo period, patients with microalbuminuria > or = 20 and < or = 200 microg/min are randomized to indapamide SR 1.5 mg or to enalapril 10 mg once a day for a one-year treatment period. An additional label treatment by amlodipine 5-10 mg (1st step) and atenolol 50-100 mg (2nd step) a day is permitted after 6 weeks of treatment based upon blood pressure response. The main outcome measures are microalbuminuria expressed as urinary albumin to creatinine ratio, albumin fractional clearance, and albumin excretion rate evaluated on overnight urine collections. Secondary criteria are supine and standing systolic, diastolic and mean blood pressure; and biological and clinical safety. This study will complete the knowledge of the efficacy of indapamide SR in hypertension and target organ damage and will provide valuable information on the management of type 2 diabetic hypertensives with microalbuminuria.

Assessment of the DIXTAL DX-2710 automated oscillometric device for blood pressure measurement with the validation protocols of the British Hypertension Society (BHS) and the Association for the Advancement of Medical Instrumentation (AAMI)

OBJECTIVE

To assess the Dixtal DX2710 automated oscillometric device used for blood pressure measurement according to the protocols of the BHS and the AAMI.

METHODS

Three blood pressure measurements were taken in 94 patients (53 females 15 to 80 years). The measurements were taken randomly by 2 observers trained to measure blood pressure with a mercury column device connected with an automated device. The device was classified according to the protocols of the BHS and AAMI.

RESULT

The mean of blood pressure levels obtained by the observers was 148+/-38/93+/-25 mmHg and that obtained with the device was 148+/-37/89+/-26 mmHg. Considering the differences between the measurements obtained by the observer and those obtained with the automated device according to the criteria of the BHS, the following classification was adopted: "A" for systolic pressure (69% of the differences < 5; 90% < 10; and 97% < 15 mmHg); and "B" for diastolic pressure (63% of the differences < 5; 83% < 10; and 93% < 15 mmHg). The mean and standard deviation of the differences were 0+/-6.27 mmHg for systolic pressure and 3.82+/-6.21 mmHg for diastolic pressure.

CONCLUSION

The Dixtal DX2710 device was approved according to the international recommendations.

Salt supresses baseline muscle sympathetic nerve activity in salt-sensitive and salt-resistant hypertensives

The objective of our study was to evaluate the role of the baroreflex control of peripheral sympathetic nervous system on the increase of muscle sympathetic nerve activity (MSNA) in salt-sensitive (SS) and salt-resistant (SR) hypertensives under low salt diet. In phase I mild-to-moderate hypertensive patients (n=5) received three diet periods: a first regular salt (RS1), a low salt (LS=20 meq Na+/day), followed by a second regular salt diet (RS2) with a 7-day duration of each. At the end of each period, sympathetic and heart rate baroreflex control were recorded. Baseline MSNA varied (P<0.005) from 18+/-8 (RS1) to 32+/-9 (LS) and to 14+/-9 (RS2) bursts per minute (bpm). In phase II additional patients (n=6) were included to have baseline MSNA, sympathetic and heart rate baroreflex control evaluated at the end of the LS and RS2. For all patients (n=11), there was a significant decrease of MSNA from 36+/-4 to 20+/-8 bpm on day 7 of LS to RS2 (P<0.05). The response of MSNA to a salt restriction was similar for SS and SR patients, who showed a change from 32+/-6 to 18+/-11 and from 36+/-9 to 17+/-7 bpm for SS and SR on day 7 of LS and RS2 diets, respectively (P<0.05). MSNA baroreflex gain was similar during phenylephrine infusions at day 7 of LS and RS2 (5.1+/-1.6 and 6.1+/-2.9 bpm/mmHg), but it was reduced under LS during sodium nitroprusside infusion (19.5+/-4.9 vs 8.9+/-0.7 bpm/mmHg) (P<0.05) for the whole group. Baroreflex control of MSNA was also similar during phenylephrine infusions under LS and RS2 diets for SS (4.0+/-0.9 and 3.3+/-0.2 bpm/mmHg) and for SR patients (10.1+/-2.5 and 5.6+/-1.5 bpm/mmHg). During nitroprusside infusion, baroreflex gain was significantly greater under RS2 for SR patients (19.5+/-2.6 bpm/mmHg) when compared to LS (11.2+/-5.2 bpm/mmHg) and the same significant difference was observed among SS patients (14.4+/-4.7 and 9.1+/-3.6 bpm/mmHg under RS2 and LS diets, respectively). There was no difference in heart rate baroreflex gain between LS and RS2 diets. Data support the hypotheses that (1) sodium supresses baseline MSNA in SS and SR hypertensives and (2) sodium restriction may impair baroreflex control of MSNA in SR and SS mild-to-moderate hypertensive patients during blood pressure reductions.

Devices and techniques for blood pressure measurement and criteria for hypertension adopted by Brazilian physicians: exploratory study

OBJECTIVE

To determine technical procedures and criteria used by Brazilian physicians for measuring blood pressure and diagnosing hypertension.

METHODS

A questionnaire with 5 questions about practices and behaviors regarding blood pressure measurement and the diagnosis of hypertension was sent to 25,606 physicians in all Brazilian regions through a mailing list. The responses were compared with the recommendations of a specific consensus and descriptive analysis.

RESULTS

Of the 3,621 (14.1%) responses obtained, 57% were from the southeastern region of Brazil. The following items were reported: use of an aneroid device by 67.8%; use of a mercury column device by 14.6%; 11.9% of the participants never calibrated the devices; 35.7% calibrated the devices at intervals < 1 year; 85.8% measured blood pressure in 100% of the medical visits; 86.9% measured blood pressure more than once and on more than one occasion. For hypertension diagnosis, 55.7% considered the patient's age, and only 1/3 relied on consensus statements.

CONCLUSION

Despite the adequate frequency of both practices, it was far from that expected, and some contradictions between the diagnostic criterion for hypertension and the number of blood pressure measurements were found. The results suggest that, to include the great majority of the medical professionals, disclosure of consensus statements and techniques for blood pressure measurement should go beyond the boundaries of medical events and specialized journals.