Blood pressure reactivity to mental stress task as a determinant of sustained hypertension after 5 years of follow-up

Previous studies have reported an increased risk of developing sustained hypertension (SH) in borderline or mildly hypertensive subjects showing an exaggerated response of blood pressure (BP) to mental stress. The aim of this study was to assess if the response of BP to mental stress tasks is an independent predictor of SH. A total of 89 patients with grade 1 hypertension, aged 18-64 years, 62% males, were included. The mean of follow-up was 5.3 years (s.d. 2.1 years). SH was defined as the development of grades 2-3 hypertension (Systolic BP>or=160 mmHg or diastolic BP>or=100 mmHg) or to be in antihypertensive treatment after follow-up. Two mental stress tasks: mental arithmetic stress task and a stressful interview (SI) were applied at entry. The subjects were classified as hyper-reactors when BP increase was greater than 35 mmHg for systolic BP or greater than 21 mmHg for diastolic BP, according to the results obtained previously in a normotensive control group. In the univariate analysis, the factors associated with the development of SH were age (P=0.0007), office diastolic BP (P=0.014) and hyper-reactivity of BP during a stressful interview (P=0.003). In the Cox regression model, after adjusting for gender, age, and office BP, the hyper-reactivity of BP during SI was an independent predictor of development of SH. In conclusion, the response of BP to mental stress tasks is useful in predicting SH in young and middle-aged subjects with grade 1 hypertension.

East-west differences in reported preventive practices. A comparative study of six European areas of the WHO-CINDI programme

BACKGROUND

Differences have been reported in life expectancy and mortality between Eastern and Western European countries. Also, disparities have been found among different European countries or populations concerning the implementation of preventive practices by health professionals. This study analysed the patterns of reported preventive practices in three Eastern European areas and three Western ones.

METHODS

Health surveys were carried out in particular geographical area of six countries participating in the project (three Eastern European countries; Russia, Poland and Hungary and three Western European countries; Finland, Germany and Spain). All of them are partners in the WHO-CINDI (Countrywide Integration Non-communicable Diseases Intervention) Programme. Three preventive practices are analysed: reported blood pressure and blood cholesterol measurements and reported antismoking counseling during the last year. Data are presented separately for the general population and for people reporting specific chronic conditions (cardiovascular disease, respiratory disease and/or diabetes mellitus).

RESULTS

Blood pressure measurement and antismoking counseling are more frequently reported to be carried out by primary health care physicians in the Eastern European areas while blood cholesterol measurement is more frequently reported in Western European countries. All these preventive activities are more frequently reported to be done among people with chronic conditions than in the population as a whole.

CONCLUSIONS

Major differences have been found in reported preventive practices between Eastern and Western European countries. Great potential exists for chronic disease prevention among them.

Do health behaviour and psychosocial risk factors explain the European east-west gap in health status?

BACKGROUND

Mortality rates are much more favourable in Western European countries than in those of Eastern Europe. Health behaviour and psychosocial factors have been suggested to be important contributors to East-West differences in mortality and health status.

METHODS

To compare reported health status as well as health behaviours and psychosocial factors which may be related to unequal health status in different parts of Europe, standardised postal surveys of representative populations samples were conducted in six Eastern and Western European areas.

RESULTS

Higher mortality in the eastern populations was associated with more reported morbidity and generally more negative health ratings. Health behaviours and psychosocial factors were also more negative in the East. Multivariate analyses suggested that the East-West difference in health status may be partly explained by differences in health behaviours and psychosocial factors.

CONCLUSION

Efforts to promote health in Eastern Europe should concentrate both on the promotion of healthier lifestyles and on improvement of social and economic conditions.

Pharmacoeconomic considerations in the management of hypertension

Hypertension is highly prevalent in developed and developing countries (more than 30% of the adult population when a threshold value of 140/90 mm Hg is selected). It constitutes one of the major cardiovascular risk factors and accounts for more than 5% of total deaths worldwide. The economic impact of hypertension is enormous, representing $US23.74 billion in the US in 1995 and approximately $US1685 million in Spain in 1994. Direct costs amount to more than 50% of the total costs of hypertension, and almost 70% of these are attributable to drug treatment. Furthermore, hypertensive patients use medical services 50% more than normotensive individuals, and hypertension represents one of the 3 leading causes of visits to primary healthcare centres. When considering the cost effectiveness of hypertension treatment, there is no doubt that it is cost effective in comparison with other interventions, although some controversies exist, mainly with respect to mild-to-moderate hypertension and to the long term versus short term benefits. The controversy about the absolute risk of hypertension influences the cost-effectiveness analysis. Because of the limitations of the available cost-effectiveness analyses, it is currently impossible to recommend the use of any particular antihypertensive drug for all patients with hypertension. Consequently, the choice of antihypertensive in any patient should be guided by clinical experience and the recommendations of the present international guidelines.

Determinants of left ventricular mass in untreated mildly hypertensive subjects: hospitalet study in mild hypertension

The objectives of this cross-sectional study were to identify the determinants of left ventricular mass in untreated mildly hypertensive subjects at the Hypertension Unit, Department of Internal Medicine, Red Cross Hospital, Hospitalet de Llobregat, Barcelona, Spain. One hundred seventy-one untreated mildly hypertensive subjects, with a mean age of 41.1+/-11.8 years (from 18 to 65 years) were sequentially visited in our Unit; 54% were men. Echocardiographic measurements of good quality were obtained in 142 subjects (83%). Two-dimensional guided M-mode echocardiograms were used and left ventricular mass was estimated according to the Penn convention. Left ventricular mass (LVM) was analyzed as a continuous variable. In the bivariate analysis, the variables that significantly correlated with LVM were patient's height (r = 0.42, P<.0005), weight (r = 0.47, P< or =.0005), heart rate (r = -0.22, P = .01), HDLc (r = -0.30, P = .002), hematocrit (r = -0.28, P = .001), urinary sodium excretion (r = 0.23, P = 0.012), and different measurements from the ambulatory blood pressure profile for 24 h. By means of multiple regression analysis, a maximum of 41.2% of LVM variability could be explained from the factors registered in our study. The final model included age, gender, patient's weight, and diastolic night load from ambulatory blood pressure monitoring. When added to different models, weight and diastolic night load showed a similar strength in predicting left ventricular mass. In untreated patients with mild hypertension, traditional factors such as blood pressure levels explain a maximum of 41.2% of LVM variability. More knowledge is needed about factors that may alter cardiac morphology in the evolution of hypertensive patients.

[Relationship in cardiovascular reactivity to mental stress and early involvement of target organs in non-treated mild arterial hypertension. Hospitalet Study]

BACKGROUND

It has been previously reported that an exaggerated response of blood pressure to mental stress tasks is associated to an increased cardiovascular risk. The objective of this cross-sectional study, with sequential inclusion of subjects who met the inclusion criteria, was to asses the relationships between the response of blood pressure and heart rate to two different mental stress tasks and early target organ-damage, defined as abnormalities in the echocardiogram and/or an increase of urinary albumin excretion (UAE) or microalbuminuria, in untreated mild hypertensive subjects.

SUBJECTS AND METHODS

Two hundred and eleven subjects aged 18 to 65 years (56% males) with mild hypertension (SBP between 140-180 mmHg and/or DBP between 90-105 mmHg) were included in Hospitalet Study. One hundred and thirty seven of them accepted to participate in the study of cardiovascular reactivity. Two different tasks were applied in the same day: a stressful interview (SI) and a mental arithmetic stress tasks (MAST). An echocardiogram of good quality was obtained in 123 cases (89.8%) and 24 h UAE was measured in 108 cases (78.8%).

RESULTS

The prevalence of left ventricular hypertrophy was 21.1% (95% CI = 14.3-29.4) and the prevalence of microalbuminuria was 15.7% (95% CI = 9.4-24.4%). After adjusting for the baseline blood pressure, a significant correlation was observed between increase of systolic BP during SI and UAE (r = 0.21; p = 0.03) and between increase of diastolic BP during SI and relative wall thickness (r = 0.32; p < 0.005). When we analyzed the changes of BP during MAST, a significant correlation was observed between increase of diastolic BP (adjusted for baseline diastolic BP) and left atrial size (r = 0.21; p = 0.02). We did not find any significant correlation between the increases of BP (systolic or diastolic) during MAST or increases of heart rate during both tasks and left ventricular mass index or UAE.

CONCLUSIONS

A weak correlation was observed between cardiovascular reactivity of blood pressure during mental stress tasks and early target organ damage in mild hypertension. We did not find any relationship between the response to heart rate during the tasks and early target organ damage.

Target-organ damage and cardiovascular risk profile in resistant hypertension. Influence of the white-coat effect

BACKGROUND

It is difficult to draw definite conclusions about the prevalence and clinical characteristics of patients with resistant hypertension because of the heterogeneity of study designs described in published studies.

OBJECTIVES

To estimate the prevalence of resistant hypertension, the associated cardiovascular risk factors and the degree of target-organ damage, and to analyze the differences between true resistant hypertension (TRH) and white-coat resistant hypertension (WCRH).

DESIGN

Cross-sectional study.

METHODS

Patients who visited the Hypertension Clinic with resistant hypertension were sequentially included. Resistant hypertension was defined as an average of three measurements of systolic blood pressure, >/= 160 mmHg or a diastolic blood pressure >/= 95 mmHg, or both, in patients treated with a triple-drug regimen, over at least 2 months. Twenty-four-hour ambulatory blood pressure monitoring and M-mode bi-dimensional echocardiography were performed. WCRH was defined as a mean daytime ambulatory blood pressure </= 135/85 mmHg; patients with higher values were classified as having TRH.

RESULTS

Of 1200 hypertensive subjects who visited the clinic, 60 patients with resistant hypertension were included [mean age 59+/-8 years; 38 women (63%)]. Office blood pressure was 173+/-14/100+/- 8 mmHg. Of 36 patients with a good quality echocardiograph, 18 had left ventricular hypertrophy. Twenty cardiovascular events were recorded in 16 patients. Obesity was present in 43% of patients, diabetes in 28%, and hypercholesterolemia in 47%. Hypoalphalipoproteinemia was detected in 18%of the patients, all of whom had TRH (P = 0.01). Nineteen subjects (32%) had WCRH. The subjects with TRH had a higher office systolic blood pressure, greater frequency of hypoalphalipoproteinemia than those who had WCRH and a greater proportion of clinical target-organ damage.

CONCLUSIONS

Resistant hypertension is uncommon in clinical practice. Resistant hypertension is associated with multiple cardiovascular risk factors, including left ventricular hypertrophy. A third of patients with resistant hypertension achieve adequate control of their blood pressure outside the physician's office. The proportion of patients with clinical target-organ damage is greater in subjects with TRH than in those with WCRH.

[Pathogenesis and epidemiology of arterial hypertension]

The pathogenesis of arterial hypertension is more clearly understood today because of the availability of data enabling identification of a certain number of precipitating factors. From a genetic standpoint, hypertension would appear to be a multifactorial polygenic disorder with a tendency to interact with certain environmental factors. The latter are mainly related to lifestyle and are potentially modifiable. Obesity during childhood and adolescence is the main predictive factor for hypertension. It has been suggested that the underlying mechanism could well be hyperinsulinaemia, which induces hyperactivity of the sympathetic nervous system. The mechanisms of the relationship between hypertension and alcohol are still unclear. However, in many countries, excessive alcohol consumption has been reported to be a significant factor in the development of arterial hypertension. The negative effect of a sedentary lifestyle on blood pressure has been widely demonstrated. In addition, it has also been shown that regular physical exercise under aerobic conditions leads to a reduction in blood pressure levels. An excessive sodium intake is also responsible for inducing arterial hypertension through increases in cardiac output and effects on vascular reactivity and contractility. Similarly, restricting sodium intake leads to a reduction in blood pressure levels. Smoking--namely, certain components of tobacco smoke--would appear to have both short and long term effects on blood pressure. These contributing factors all have specific effects on cardiac output and peripheral resistance in individuals. At the community level, the impact of hypertension is particularly significant. Prevalence is strongly influenced by the type of population studied, although it is generally estimated that this disease affects between 10 and 20% of the adult population and is responsible for 5.8% of all deaths worldwide. The direct and indirect costs of the disease are particularly high and are generally considered to be underestimated since a significant proportion of cardiac disease and stroke should also be included in any cost estimates, giving extremely high final figures. Hypertension-related morbidity and mortality principally result from cardiovascular complications and approximately 35% of atherosclerotic cardiovascular events can be attributed to hypertension. The highest risks are associated with stroke (relative risk: 3.8) and congestive heart failure in individuals with hypertension, in whom the risk is quadrupled. With regard to risk for an individual, the higher the blood pressure the greater the risk for the patient. However, the situation is very different if the entire population is being considered. In this instance, the highest risk is associated with mild hypertension since this involves the largest proportion of the hypertensive population. Similarly, relative risk corresponds to a probability rate that applies to populations rather than individuals. In response to this contradiction, the concept of absolute risk was proposed and corresponds to the prevalence of the disease. The approach to hypertension treatment based on absolute risk has recently been proposed for use in clinical practice. It takes into account lesions of the target organ together with any other risk factors and thus integrates the notion of prevention which remains the principal approach to the problems encountered in the management of hypertension.

Management of the hypertensive patient who smokes

Smoking and arterial hypertension are highly prevalent at the community level. While the coexistence of both risk factors is less frequent, the potentiation of cardiovascular risk when both are present makes the association highly relevant in terms of a preventive approach. There are many interrelationships between smoking and high blood pressure at the clinical, epidemiological and pathophysiological levels. Those demonstrable links compel us to review the usual explanation of the influence of smoking on blood pressure. Pharmacological treatment of the hypertensive patient who smokes must be adapted to the patient's risk profile, using the most efficacious antihypertensive agents. With the exception of nonselective beta-blockers, all the available antihypertensive drugs can be prescribed. Minimal intervention and nicotine replacement constitute the most well tested interventions in helping smokers to quit their habit. Nicotine replacement is currently a well tolerated intervention, even in patients with cardiovascular disease.

Actions implemented to improve hypertension control in Spain

Hypertension prevalence is estimated at approximately 30% of the adult population in Spain, using the 140/90 mm Hg cutoff. This represents a heavy public health burden when compared with other European countries, although the direct cost per person is one of the lowest in Europe. The programs implemented regionally since 1985 are presented here. As a result of them, a decade later the number of hypertensives with controlled blood pressure has increased from 10% in 1986 to 13% in 1995, and cerebrovascular mortality has steadily decreased.

[Smoking prevalence trends in Catalonia, Spain, 1982-1994]

BACKGROUND

Smoking prevalence trends from 1982 to 1994 of adult population in Catalonia (Spain) are described.

SUBJECTS AND METHODS

Four population surveys have been carried out periodically using the same questionnaires and definitions for smoking status. Surveys in 1982, 1986 and 1990 have been implemented taking samples of Catalonia population through a multistage sampling with random stratified selection by province and habitat. Individuals were chosen through a random route process. In 1994, a survey with a complex probabilistic sample design with 8 geographical areas (health regions) and 2 basic units (towns and individuals) was implemented.

RESULTS

Among the 15-64 years old adults, a decrease of 6.9% in smoking prevalence has been observed. The initial prevalence in 1982 was 37.9% (CI 95%: 35.4; 40.3); in 1994 this prevalence was 35.3% (CI 95%: 34.4; 36.2). In 1994, the prevalence of current smokers in population over 14 years old was 30.6% (CI 95%: 29.8; 31.4). We have observed a significant decrease in smoking prevalence in all age groups among male population (-20.6% for the 12-year period) whereas prevalence has increased among female (+28.0%) mainly among those between 25 and 54 years old. The main percentual decrease in smoking prevalence has been observed among young people aged 15-24 years old for both genders. The proportion of former smokers has remained stable (11.4% in 1982, 12.9% in 1994) during the period studied. The proportion of former smokers increases with age among man over 25 years.

CONCLUSIONS

Smoking habit is still very prevalent in Catalonia, even higher than in other Western European countries. In spite of the increase among women, the significant dectines of smoking prevalence among men and youngsters (of both genders) could represent encouraging findings in order to pursue the efforts aimed at reducing the morbi-mortality burden of smoking in our society.

[Frequency of white coat arterial hypertension in mild hypertension. Profile of cardiovascular risk and early organic involvement]

BACKGROUND

The aim of the present was to study the frequency and characteristics of white coat hypertension (WCH) in a series of individuals with slight hypertension (SH) consecutively attended, as well as to evaluate the degree of organic involvement and the presence of other cardiovascular risk factors.

METHODS

One hundred six subjects [mean age 43 +/- 12 years, 51 males (48%)] with SH (diastolic pressure between 90-104 mmHg) who were not receiving pharmacologic treatment and did not have severe organic involvement were included in the study. Systolic/diastolic blood pressure (BP) was (x +/- SD) 150 +/- 12/96 +/- 4mmHg. The basic protocol of the Hypertension Unit was applied with out patient monitorization of BP for 24 hours with a Spacelabs 90202 monitor and a two-dimension echocardiogram with measurements according to the recommendations of the American Society of Echocardiography. WCH was defined as a mean diurnal BP (07:00-23:00 h) under 134/90 mmHg.

RESULTS

The frequency of WCH was 46%, being more frequent in those over the age of 40 years [OR: 3.08 (IC 95% 1.26-7.62) p = 0.006]. WCH was associated with total cholesterol >or= 5.2 mmol/l [OR: 2.8 (IC 95% 1.14-6.91)]. No significant associations were observed with cholesterol HDL, LDL, triglycerides, glycemia, family history of high blood pressure, body mass index and smoking. Left ventricular hypertrophy (LVH) was less frequent in WCH (6%) than in maintained hypertension (MH) (18%) (NS), while concentric remodelling was more frequent in WCH (22% and 5%, respectively [p < 0.03]). Microalbuminuria was observed in 50 individuals being >or= 30 mg/24 h in 15% of the WCH and in 30% of the MH.

CONCLUSIONS

The frequency of white coat hypertension in subjects with slight hypertension is high. The profile of cardiovascular risk among the patients with white coat hypertension and moderate hypertension is similar.

Cigarette smoking as a risk factor for tuberculosis in young adults: a case-control study

SETTING

The association between smoking and pulmonary tuberculosis has not often been studied.

OBJECTIVE

To assess the influence of cigarette smoking on the development of active pulmonary tuberculosis in young people who were close contacts of new cases of smear-positive pulmonary tuberculosis.

DESIGN

A case-control study in which 46 'cases' (patients with active pulmonary tuberculosis: isolation of Mycobacterium tuberculosis or clinical and/or radiographic evidence of current pulmonary tuberculosis, with a positive tuberculin skin test) and 46 'controls' (persons with positive tuberculin reaction, negative bacteriological test and without clinical and/or radiological evidence of pulmonary tuberculosis) were included. Smoking habits were investigated by questionnaire. Univariate and multivariate analysis was performed, and odds ratio (OR) was adjusted for age, gender and socio-economic status.

RESULTS

Statistically significant differences were found in active smokers (occasional and daily smokers) (OR: 3.65; 95% CI, 1.46 and 9.21; P < 0.01), daily smokers (OR: 3.53; 95% CI, 1.34 and 9.26; P < 0.05), and individuals who were both passive and active smokers (OR: 5.10; 95% CI, 1.97 and 13.22; P < 0.01) and passive and daily smokers (OR: 5.59; 95% CI, 2.07 and 15.10; P < 0.001). There was a dose-response relationship between the number of cigarettes smoked daily and the risk of active pulmonary tuberculosis.

CONCLUSIONS

The data studied show that cigarette smoking is a risk factor for pulmonary tuberculosis in young people, with a dose-response relationship with the number of cigarettes consumed daily.

[Smoking cessation program using nicotine patch among physicians and pharmacists of Catalonia: results after 3-12 months]

Smoking abstinence rates of a group of 300 physicians and pharmacists of Catalonia (Spain) who participated in an open non-controlled follow-up design study with nicotine patch, are presented. Were eligible all the individuals who regularly smoke more than 15 cigarettes/day and get Fagerström Test score of 5 or more. Those who smoke more than 20 cig/day were offered a 3-month 24-hour transdermal nicotine treatment (30-20-10 schedule) and those smoking between 15 and 20 cig/day, received the 20-20-10 schedule. A follow up of participants was carried out at 3, 6, 9 and 12 months. After one year, 12 participants (4%) were dropped out. The overall abstinence rates at 3, 6, 9 and 12 months were respectively 55.9% (IC95%: 50.2-61.6), 42.7% (IC95%: 37.0-48.4), 35.4% (IC95% 29.9-40.9), 33.7% (IC95%: 28.2-39.2). Among predictive cessation variables, only those who had mad 1 to 3 previous attempts and those with only "cold turkey" (or slow reduction) quit experience, obtained statistically better results at 3 months. These results seem to be as good as or even better than those obtained in other similar studies with nicotine patch.

Adverse effects of direct-acting vasodilators

Direct-acting vasodilating agents enter the vascular smooth muscle cell to cause vasodilatation. For long term treatment of hypertension, the use of these drugs as monotherapy is accompanied by activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system. These counteracting mechanisms limit the antihypertensive efficacy of these drugs, and cause adverse effects such as tachycardia and fluid retention. These adverse effects require treatment with beta-blockers and diuretics. However, there is still an important role for intravenous vasodilator therapy in hypertensive emergencies. In the treatment of chronic heart failure, vasodilator therapy has been an important advance. Combination therapy with hydralazine and nitrates is efficacious in improving survival, but ACE inhibitors have an incremental benefit on survival over this combination.

[The association between arterial hypertension, obesity and hypercholesterolemia in a sample of the adult population of Catalonia]

BACKGROUND

The Framingham's study has demonstrated that the incidence of cardiovascular diseases increases when several risk factors are present. In this study, the association between the main cardiovascular risk factors has been studied in a random sample from the adult population of Catalonia.

METHODS

A random sample was obtained (n = 314) from the adult population of Catalonia and univariate and multivariate statistical procedures were used to analyze the association between the following risk factors: HDL, hypertriglyceridemia, obesity, diabetes and tobacco consumption.

RESULTS

A simple correlation was observed between most of the risk factors. The multiple linear regression analysis showed that both the diastolic and systolic arterial pressures were correlated with total levels of cholesterol, body mass index and age (r = 0.65 for SAP and r = 0.48 for DAP); levels of total cholesterol were correlated with levels of triglycerides and age (r = 0.57); levels of triglycerides were correlated with levels of total cholesterol and cholesterol-HDL, body mass index and age (r = 0.61); body mass index was correlated with levels of triglycerides, total cholesterol, cholesterol-HDL and age (r = 0.52) (p < 0.001). The prevalence of hypercholesterolemia, obesity and diabetes was higher and the prevalence of tobacco consumption was lower among the hypertensives (SAP > 140 and/or DAP > 90 mm Hg) than among normotensives, being the odds ratio 3.56 (2-6.33) for hypercholesterolemia; 3.65 (1.66-8.09) for obesity; 3.70 (1.06-13.45) for diabetes and 0.40 (0.22-0.72) for tobacco consumption. The adjusted odds ratio derived from multiple logistic regression analysis was 2.52 (1.38-4.64) for hypercholesterolemia; 2.40 (1.05-5.46) for obesity, 1.74 (0.50-6.04) for diabetes and 0.63 (0.33-1.20) for tobacco consumption, being statistically significant in the case of hypercholesterolemia (p = 0.002) and obesity (p = 0.038).

CONCLUSION

We have observed an association between the cardiovascular risk factors analyzed. This association may be attributed to several physiological mechanisms and life-styles, which may influence the development of atherosclerosis and increase the cardiovascular risk.

[Response of arterial pressure to mental stress in young patients with high or mild arterial hypertension. Does it reflect the changes in arterial pressure observed during its ambulatory monitoring?]

BACKGROUND

The use of cardiovascular reactivity tests in the laboratory is based on their probable capacity to predict blood pressure response in stress situations of everyday life. These responses may be estimated from the values obtained by out patient monitorization or blood pressure (OPMBP).

METHODS

OPMBP was carried out over 24 hours by Spacelabs 90202 monitor in 57 subjects from 18-40 years of age with high or slightly high blood pressure (mean blood pressure diagnosed 143 +/- 12/91 +/- 8 mmHg) with a Quetelet index of 25.8 +/- 9 kg/m2. Two mental stress tests were applied: the mental arithmetic test (MAT) and a structured interview (SI) in 38 patients with high or slightly high blood pressure (HBP) and to 18 healthy normotense subjects of the same age group.

RESULTS

The increases in systolic BP (SBP) and diastolic BP (DBP) observed during MAT and SI were similar: r = 0.88 and r = 0.68, respectively (p < 0.0001, both). The percentage of hyperreactive subjects, defined as those presenting an absolute increase in SBP > or = 25 mmHg and/or an increase of DBP > or = 15 mmHg was greater between those with slightly high blood pressure (70%) and high blood pressure (43%) in both tests than among the normotense subjects of the control groups (28%) (p < 0.05). Upon study of the relation between response to BP during the mental stress tests and the values of BP obtained with OPBPM, a positive correlation was found between the increase in DBP in MAT and the SI and mean 24 hour DBP (r = 0.39 and r = 0.45, p < 0.025 and p < 0.01, respectively).

CONCLUSIONS

The correlation of the absolute increase in systolic and diastolic blood pressure during two different mental stress tests in young subjects with high or slightly high blood pressure is very high. The correlation between the increase in blood pressure to mental stress in the laboratory and the blood pressure values obtained during non invasive out patient monitorization was found to be only intermediate for diastolic blood pressure nad null for systolic blood pressure in this study.

Mortality in hypertensive patients in Hospitalet de Llobregat, Barcelona (Spain)

A retrospective cohort study was carried out on 729 hypertensive patients (male and female 40 years and older) in Hospitalet de Llobregat (Barcelona, Spain) to assess possible differences between the mortality of this group of hypertensives and the general population of the same area matched by age and sex. Patient mortality was assessed during a six year period, resulting in a mean follow-up of 2.6 years at the end of the study. The results reflect an increased risk of dying among hypertensives compared with the general population, with standardised mortality ratio by age and sex of 1.88 (95% confidence interval 1.21-2.44). Cardiovascular mortality was significantly higher for males, while noncardiovascular mortality was significantly higher for females. The study also shows that the presence of smoking habit, diabetes or hyperglycaemia, uncontrolled hypertension and age > or = 60 years can increase the risk of dying among hypertensive patients. Although a higher level of BP control is achieved in hypertension hospital clinics than in the primary health care system, the study shows that hypertensives have an excess of mortality than expected considering their own general population by age and sex.

Cardiovascular mortality trends in Spain and Catalonia. Comparisons with Europe

Cardiovascular mortality trends in Spain during the last 15 years have been reviewed and compared with those observed in other European countries. Future coronary heart disease (CHD) mortality trends in Catalonia have been estimated, and its expected evolution with intervention programmes on the prevalence of hypercholesterolaemia is discussed. The main conclusions are: (a) a reduction in stroke and no changes in CHD mortality in Spain and Catalonia has been observed during recent years; (b) this evolution was similar to that observed in other European countries; (c) Spain, like other Mediterranean countries, shows a peculiar cardiovascular mortality pattern with predominance of stroke over CHD; (d) no spectacular changes in CHD mortality trends during the next few years can be expected in Catalonia, but reductions in the prevalence of hypercholesterolaemia may contribute to modify the stable CHD mortality trends.

Epidemiology of cardiovascular disease risk factors in Catalonia (Spain)

Cardiovascular disease is one of the most important public health problems in developed countries. We have studied the epidemiology of the following cardiovascular disease risk factors in a random sample (n = 704) of the adult population of Catalonia (Spain): hypercholesterolemia (> or = 6.1) mmol/l or 240 mg/dl), hypertension (SBP > or = 160 and/or DBP > or = 95 mmHg), low HDL-cholesterol concentrations (< 0.9 mmol/l or 35 mg/dl), hypertriglyceridemia (> 2.8 mmol/l or 250 mg/dl), obesity (BMI > 30), smoking and history of diabetes and coronary heart disease. Two percent of participants had hypertriglyceridemia, 3% had a history of coronary heart disease, 4% a history of diabetes, 6% low HDL-cholesterol concentrations, 12% were obese, 20% had hypertension, 24% had hypercholesterolemia and 36% were smokers. 58% of hypertensive individuals had been previously detected, 46% were currently on treatment, and 21% had their blood pressure controlled (SBP < 160 and DBP < 95 mmHg). Correlation and multiple regression analyses were used to investigate the association between cardiovascular risk factors. Multiple linear regression analysis showed independent correlations between risk factors. Prevalence of hypercholesterolemia, obesity and diabetes was higher and prevalence of smoking was lower in hypertensives than normotensives. The odds ratio was 3.68 (95% CI = 2.07-6.54) for hypercholesterolemia, 3.26 (95% CI = 1.52-7.02) for obesity, 3.81 (95% CI = 1.09-7.02) for diabetes and 0.40 (95% CI = 0.22-0.70) for smoking. The adjusted odds ratio was statistically significant for hypercholesterolemia (OR = 2.74, 95% CI = 1.01-3.75). The prevalence of cardiovascular risk factors was similar to that observed in other Mediterranean communities.(ABSTRACT TRUNCATED AT 250 WORDS)

[Lipid distribution in the adult population of Catalonia]

BACKGROUND

High concentrations of total and LDL-cholesterol and low concentrations of HDL-cholesterol are related to morbidity and mortality due to cardiovascular diseases. In this study, lipid concentration, prevalence of hypercholesterolemia and the association between hypercholesterolemia and other cardiovascular risk factors was investigated in a random sample of adult population of Catalonia (Spain).

METHODS

A random sample of adult population of Catalonia aged 16 or more years was obtained. The sample was of 314 individuals, 156 men and 158 women. Serum total cholesterol, LDL-cholesterol, HDL-cholesterol and triglyceride concentrations were determined. Other cardiovascular risk factors were investigated: hypertension, smoking, body mass index, history of diabetes, and history of coronary heart disease.

RESULTS

Total and LDL-cholesterol levels were similar in both sexes, with a mean of 211 mg/dl for the first 140 mg/dl for the latter. In contrast, triglyceride levels were higher in men (95 mg/dl) than in women (70 mg/dl), and HDL-cholesterol levels were higher in women (60 mg/dl) than in men (51 mg/dl) (p < 0.001). Total cholesterol, LDL-cholesterol and triglycerides concentration increased with age in both sexes. Total cholesterol values were > or = 240 mg/dl in 25% of men and 24% of women. Individuals with hypercholesterolemia had a higher prevalence of hypertension, obesity and diabetes was than normocholesterolemic individuals. The odds ratio was 3.68 for hypertension, 1.89 for obesity and 1.99 for diabetes. The adjusted odds ratio was statistically significant for hypertension (OR adj. = 2.77).

CONCLUSION

The distribution of lipid values observed in the adult population of Catalonia was similar to that observed in other Mediterranean populations.

[The cost of arterial hypertension in Spain]

BACKGROUND

High blood pressure has a high incidence and produces a high morbidity and mortality due to associated diseases: cerebrovascular disease, ischemic cardiopathy, and cardiac failure. The socioeconomic impact of high blood pressure in Spain was estimated during 1985 in primary, hospitalary and pharmaceutical health care, to provide a framework for decision making and to determine strategies for reducing the costs of this entity.

METHODS

The methodology of analysis of the cost of the disease was followed with the aim of quantifying the socioeconomic consequences of an entity, disease or risk factor with prevalence being the focus of the study.

RESULTS

The socioeconomic impact estimated was situated between 95,000 and 124,000 millions of pesetas according to the different hypothesis adopted in the analysis of sensitivity. The direct health care costs represented between 2.6 and 3.9% of the global health care costs for Spain in 1985. Health care funding consumed by high blood pressure in primary health care was higher (between 4.5 and 6.7%) than hospital attendance (between 1.0 and 1.5%) and pharmaceutical care (between 2.3 and 3.5%), with respect to the total costs of each category.

CONCLUSIONS

The reduction of the costs related with high blood pressure in Spain must be obtained from improvement of efficacy of interventions carried out in health care education and primary health care. The economic evaluation of the primary and secondary prevention programs may aid in determining more cost-effective strategies.

[Epidemiology of obesity among the adult population of Catalonia]

Several epidemiological studies have shown that obesity is related to the mortality from cardiovascular disease. In this study, the epidemiology of obesity and the correlation between body mass index and other cardiovascular risk factors was studied in a representative sample of the adult population of Catalonia. It was obtained a random sample (n = 704) of the adult population of Catalonia aged 15 or more years. Height and weight were measured and body mass index (BMI) was calculated (height in Kg/weight2 in m2). Obesity was defined as a BMI greater than 30, and overweight as a BMI from 25 to 30. In the first 314 participants, it was determined the concentration of total cholesterol, cholesterol-HDL and triglyceride, and it was measured the blood pressure. The correlation between BMI and other cardiovascular risk factors was analysed. The study was carried out in 1989. The mean of BMI increased with age in both sexes. BMI was significantly higher in men (26 kg/m2) than women (25 kg/m2). The prevalence of obesity was of 12% in both men and women, and the prevalence of overweight was of 48.5% in men and 38% in women. The prevalence of arterial hypertension, hypercholesterolemia and diabetes was greater individuals with obesity, with differences statistically significant for hypertension (odds ratio of 3.26). The multiple logistic regression analysis showed that the association between obesity and hypertension was not statistically significant (OR adj. = 2.09), when the effect of the other risk factors, the age and sex were controlled.(ABSTRACT TRUNCATED AT 250 WORDS)

[Epidemiology of arterial hypertension in the adult population of Cataluña]

BACKGROUND

The arterial hypertension is one of the most prevalent cardiovascular diseases. In this study the epidemiology of hypertension was investigated in a random sample of the adult population of Catalonia (Spain).

METHODS

It was obtained a random sample (n = 704) of the adult population of Catalonia aged 15 or more years. The blood pressure was measured and hypertension was defined as a systolic blood pressure (SBP) equal or greater to 160 and/or a diastolic blood pressure (DBP) equal or greater to 95 mmHg. The borderline hypertension was defined as a SBP of 140-159 and/or a DBP of 90-95 mmHg. It was studied the association between hypertension and the following cardiovascular risk factors: hypercholesterolemia, obesity, diabetes and smoking. The study was carried out in 1989.

RESULTS

The prevalence of hypertension observed was of 20%. The prevalence increased to 28% when the individuals with borderline hypertension were included. 87 of 144 detected hypertensives (58%) were known hypertensives, 67 (46.5%) received antihypertensive medication, and 30 (21%) were treated and had their blood pressures under control. Individuals with hypertension or borderline hypertension had a greater prevalence of hypercholesterolemia, obesity and diabetes, and a lower prevalence of smoking than normotensive persons. The odds ratio (hypertensive vs. normotensive persons) was of 3.68 for hypercholesterolemia, 3.26 for obesity, 3.81 for diabetes, and 0.40 for smoking. Nevertheless, the adjusted odds ratio was only statistically significant for the hypercholesterolemia (OR adj = 2.74).

CONCLUSIONS

Arterial hypertension is one of the most important public health problems in Catalonia. The percentage of detected, treated and controlled hypertensives should be increased in the following years.

Ecological association between hypertension and stroke in Catalonia (Spain): development and use of an ecological regression model

The objectives of this paper were to study the association between the prevalence of uncontrolled hypertension (PUHT) and stroke mortality at the ecological level, in nine geographical areas of Catalonia (Spain); to develop an ecological regression model and to assess its ability to predict crude stroke mortality rate (CMR) from the PUHT. The regression equation obtained for the population older than 25 yrs was CSMR x 10(3) = 0.67035 + 4.94752 PUTH x 10(-2). The ecological risk ratio was 8.38 and the ecological attributable proportion 71.1%. The CSMR estimation obtained by applying the model in a concrete case was close to that observed. The results support an ecological association between the studied variables. The ecological model can be useful in the assessment of observed changes in health problems and risk factor levels in the community. It could also be used in the evaluation of intervention programmes.

Detection, treatment and control of hypertension in Spain

Attitudes and practices with regard to hypertension were the subject of a survey conducted in 1987 among 2,500 Spanish general practitioners. Their responses showed almost complete use of diagnostic criteria adhering to WHO recommendations and guidelines, the wide prescription of diuretics as first-step medication and beta-blockers as the drug of choice in second-step treatment, and a non-compliance rate of 25% attributed to inadequate information and bureaucracy, similar to other countries.

Antihypertensive strategy: a current and prospective review

The efficacy of antihypertensive therapy in reducing cardiovascular complications has been clearly demonstrated in the last 20 years. Antihypertensives are particularly useful in the reduction of cerebrovascular complications which decrease by 60% on average in clinical trials on the treatment of mild and severe hypertension. After the first clinical trials, the 1978 World Health Organization Experts Committee recommended the classic stepped-care (SC) approach with diuretics and beta blockers as first-step agents. Other antihypertensive drugs, such as reserpine, centrally acting agents and vasodilators could be used in the next steps if blood pressure control was not achieved. Both diuretics and beta blockers have been widely used and the SC regimen has contributed to the better control of arterial hypertension in the community. The SC regimen has given general practitioners easy guidelines with which to treat hypertensive patients. There are many reasons for modifying the classic SC approach. Prescription of antihypertensive drugs at high doses should be avoided and the use of new agents, such as calcium antagonists and angiotensin-converting enzyme inhibitors, is recommended. Demographic trends have brought about an increase in the aged population and, consequently, an increase in the proportion of elderly hypertensives. These patients present particular problems in long-term management, among which are a high frequency of other associated diseases and an important number of adverse effects caused by the classic antihypertensive drugs. Nevertheless, diuretics are still useful in the treatment of hypertension, either as a monotherapy regimen or in association with other drugs. New diuretics, such as indapamide, have a very interesting pharmacologic profile with considerably fewer metabolic side effects on plasma cholesterol and glucose levels.

[Multicenter study of atenolol, combined with hydralazine and bendroflumethiazide in the treatment of essential, mild, and severe, arterial hypertension]

The aim of the present study was to determine both the effectiveness and tolerance of a preparation constituted by the combination at fixed doses of a betablocker (atenolol, 100 mg), a diuretic (bendroflumethiazide, 5 mg) and a vasodilator (hydralazine, 50 mg). The study was carried out on a sample formed by 46 patients with moderate or severe essential hypertension who received this preparation as a single antihypertensive therapy during 2 months. As for the hypotensive effectiveness of the product, obtained results demonstrate that arterial blood pressure (BP) levels were normalized in 89% of the patients with moderate essential hypertension and in 9/10 patients with severe hypertension. Tolerance was excellent in most of the cases. Although new studies should be performed in order to enlarge the number of available case-studies, the above presented data allow us to conclude with a positive opinion about the studied combination.