Late Post-Dissection Dynamic Intermittent Malperfusion of the Aortic Arch in Association with a Rare Heterogenous LOX Gene Variation

Late ischaemic consequences of type A aortic dissection are rare. We present a 6-year late complication of type A aortic dissection treated by Bentall surgery in a 41-year-old patient. The patient presented with several episodes of lipothymia associated with hypertensive attacks with anisotension, cervicalgia, hemicranial headache, abdominal pain and lower limb slipping initially on exertion and later at rest. On dynamic examination, we diagnosed an intermittent dynamic occlusion of the aortic arch and rare LOX gene variation, which is considered to be associated with aneurysm or dissection of the ascending aorta in young patients. Surgical treatment by replacement of the ascending aorta and the aortic arch with reimplantation of the brachiocephalic trunk (BcTr) allowed the symptoms to resolve.

Abdominal Aortic Calcifications Influences the Systemic and Renal Hemodynamic Response to Renal Denervation in the DENERHTN (Renal Denervation for Hypertension) Trial

Background

The DENERHTN (Renal Denervation for Hypertension) trial confirmed the efficacy of renal denervation (RDN) in lowering daytime ambulatory systolic blood pressure when added to standardized stepped‐care antihypertensive treatment (SSAHT) for resistant hypertension at 6 months.

Methods and Results

This post hoc exploratory analysis assessed the impact of abdominal aortic calcifications (AAC) on the hemodynamic and renal response to RDN at 6 months. In total, 106 patients with resistant hypertension were randomly assigned to RDN plus SSAHT or to the same SSAHT alone (control group). Total AAC volume was measured, with semiautomatic software and blind to randomization, from the aortic hiatus to the iliac bifurcation using the prerandomization noncontrast abdominal computed tomography scans of 90 patients. Measurements were expressed as tertiles. The baseline‐adjusted difference in the change in daytime ambulatory systolic blood pressure from baseline to 6 months between the RDN and control groups was −10.1 mm Hg (P=0.0462) in the lowest tertile and −2.5 mm Hg (P=0.4987) in the 2 highest tertiles of AAC volume. Estimated glomerular filtration rate remained stable at 6 months for the patients in the lowest tertile of AAC volume who underwent RDN (+2.5 mL/min per 1.73 m²) but decreased in the control group (−8.0 mL/min per 1.73 m², P=0.0148). In the 2 highest tertiles of AAC volume, estimated glomerular filtration rate decreased similarly in the RDN and control groups (P=0.2640).

Conclusions

RDN plus SSAHT resulted in a larger decrease in daytime ambulatory systolic blood pressure than SSAHT alone in patients with a lower AAC burden than in those with a higher AAC burden. This larger decrease in daytime ambulatory systolic blood pressure was not associated with a decrease in estimated glomerular filtration rate.

Clinical Trial Registration

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

Hospital and out-of-hospital mortality in 670 hypertensive emergencies and urgencies

Long-term mortality in patients with acute severe hypertension is unclear. The authors aimed to compare short-term (hospital) and long-term (12 months) mortality in these patients. A total of 670 adults presenting for acute severe hypertension between January 1, 2015, and December 31, 2015, were included. A total of 57.5% were hypertensive emergencies and 66.1% were hospitalized: 98% and 23.2% of those with hypertensive emergencies and urgencies, respectively (P = .001). Hospital mortality was 7.9% and was significantly higher for hypertensive emergencies (12.5% vs 1.8%, P = .001). At 12 months, 106 patients died (29.4%), mainly from hypertensive emergencies (38.9% vs 8.9%, P = .001). Median survival was 14 days for neurovascular emergencies and 50 days for cardiovascular emergencies. Patients with hypertensive emergencies or urgencies had bad long-term prognosis. Short-term mortality is mainly caused by neurovascular emergencies, but cardiovascular emergencies are severe, with high mortality at 12 months. These results justify better follow-up and treatment for these patients.

Paraganglioma of the organ of Zuckerkandl associated with a somatic HIF2α mutation: A case report

Paragangliomas of the organ of Zuckerkandl (OZ-PGL) are rare tumors that, in >70% of cases, occur in association with succinate dehydrogenase complex iron sulfur subunit B (SDHB) or SDHD gene mutations. The aim of the current study was to determine whether a somatic genetic defect in the hypoxia-inducible factor 2α (HIF2α) gene was present in a case of sporadic OZ-PGL. A 32-year-old African female presented with uncontrolled hypertension during the first trimester of pregnancy. A diagnostic hysteroscopy was performed 3 months after delivery, precipitating a hypertensive crisis. Thereafter, the patient was diagnosed with noradrenaline-secreting OZ-PGL. A complete blood count identified mild normocytic anemia of an inflammatory origin. Surgical removal of the tumor resulted in normalization of plasma and urinary normetanephrine levels. Genetic testing for germline mutations (including large deletions) in the von Hippel-Lindau tumor suppressor, SDHB, SDHC and SDHD genes was normal. However, a heterozygous missense mutation (c.1589Cys>Tyr) was detected in exon 12 of HIF2α, which results in a substitution of alanine 530 with valine (Ala530Val) in the HIF2α protein. A germline mutation was excluded based on the negative results of blood DNA testing. A three-dimensional homology model of Ala530Val was constructed, which showed impaired HIF2α/VHL interaction and decreased HIF2α ubiquitination. ¹H-high-resolution magic-angle-spinning nuclear magnetic resonance spectroscopy detected low succinate levels and high α and β glucose levels. To the best of our knowledge, the present case represents the first of its kind to associate a somatic HIF2α gain-of-function mutation with OZ-PGL. It is therefore recommended that patients without germline SDHx mutations should be tested for HIF2α mutations.

A specific training on hypertension guidelines improves blood pressure control by more than 10% in hypertensive patients: the VALNORM study

VALNORM was designed to assess the impact on blood pressure (BP) control of a specific training in new European Society of Hypertension-International Society of Hypertension (ESH-ISH) guidelines for hypertension management. It was an 8-week prospective, randomized, open, blinded end points design study. General practitioners (GPs) located in France were randomized in two groups: group 1 (G1) without training to the guidelines and free attitude for the prescription whereas group 2 (G2) received a specific training in ESH guidelines. The primary efficacy criteria was strict BP control at week 8 (systolic BP/diastolic BP [SBP/DBP] <140/90 mm Hg and/or SBP/DBP <130/80 mm Hg if diabetes or renal insufficiency). All physicians used the same treatment (valsartan 80 or 160 mg once daily alone or in fixed combination with hydrochlorothiazide 12.5 or 25 mg once daily). BP was measured in the GPs' office with an electronic device. The groups GPs included 4,436 patients with essential uncontrolled hypertension (G1: 595 physicians, 2,308 patients; G2: 502 physicians, 2,128 patients). Patients' main characteristics were: age = 61 +/- 13 years, 52% female, BP = 160 +/- 13/92 +/- 9 mm Hg. No difference was observed between the two groups. The primary efficacy criteria showed in G2: 47.8% of BP control vs. G1: 44.7%, P = .005. Subgroup analysis according to age, body mass index (BMI), previous diabetes, and antihypertensive treatment showed that higher efficacy in G2 was more significant in these high-risk subgroups: age >60 years (G1: n = 1,150, G2: n = 1,035), BMI >/=25 kg/m(2) (G1: n = 1540, G2: n = 1430), diabetes (G1: n = 267, G2: n = 290), no previous antihypertensive treatment (G1: n = 1,111, G2: n = 1,005). The percentage of patients with controlled BP in each subgroup was: diabetes: G1 11.2% vs. G2 17.9% (P = .001), age >60 years: G1 40.3% vs. G2 43.7% (P = .022), BMI >/=25 kg/m(2): G1 43.2% vs. G2 45% (P = .165), untreated: G1 48.2% vs. G2 52.4% (P = .005). Specific training on the guidelines showed a positive impact on BP control, highly significant in patients at high cardiovascular risk such as diabetic hypertensive patients.

[Assessment of antihypertensive monotherapies effectiveness by home blood pressure self-measurement in hypertensive patients]

OBJECTIVE

To evaluate the blood pressure (BP) control and the efficacy of antihypertensive monotherapy using home BP self-measurement in a French population of treated hypertensive subjects in 2007 2009 and 2010.

METHODS

The French League Against Hypertension Surveys (FLAHS) are conducted among a representative sample of individuals aged 35 years and older living in France. For the 2007, 2009 and 2010 surveys, a sample of 1467 subjects who owned a BP self-measurement device and performed three consecutive morning BP measurements were included. Among the 60% of subjects who reported taking at least one antihypertensive drug, we analyzed subjects treated with one of the following antihypertensive monotherapy, i.e., beta-blocker (BB), ACE inhibitors, calcium channel blocker (CCB) and angiotensin receptor blockers (ARB).

RESULTS

Among treated hypertensive subjects (n=886), 66% (n=586) had home BP below the 140/90mmHg threshold and 50% (n=449) below 135/85mmHg. Three hundred two subjects were treated with a single antihypertensive drug, 33% had ARB, 25% BB, 19% CCB and 13% ACE inhibitors. Age (years) for each treatment group is different (P<0.01) CCB (72.1±9.3), BB (65.6±9.8), ARB (68.6±8.9) and ACEI (67.3±10.2). The mean systolic/diastolic BP (mmHg) is not comparable between monotherapy 130.7/76.1 (ARB), 130.7/78.7 (BB), 134.0/75.2 (CCB) and 139.1/80.3 (ACEI) for ARB, BB, CCB and ACE inhibitors respectively. Compared to ACE inhibitors, BP was significantly lower with ARB (P<0.01). The proportion of subjects with a BP below 140/90mmHg was 73% for ARB, 52% for BB, 68% for CCB and 47% for ACE with a statistical significance (P=0.03) for ARB vs. ACEI and CCB vs. ACEI.

CONCLUSION

Among subjects treated for hypertension who owned a BP self-measurement device, 50 to 66% had a controlled BP (depending on the threshold used). It is observed differences between antihypertensive efficacy of monotherapy with a larger number of patients controlled with ARB or CCB.

[Renal artery stenosis after abdominal radiotherapy]

INTRODUCTION

Renal artery stenosis represented 1 to 5% of all arterial hypertensions and is the leading cause of secondary hypertension. Renovascular hypertension is more common among women less than 30 years old (fibrodysplasia, 33%) and men older than 50 years old (66% atherosclerosis). Other causes are rare, especially radiation-induced renal artery stenosis.

MATERIALS AND METHODS

We report the case of Mr. D., 49 years old, with severe high blood pressure (230/125 mmHg) seven years after abdominal radiotherapy for Hodgkin's disease. Echo-Doppler was performed and found a subocclusive right ostial renal artery stenosis probably radiation-induced taking into account the history of the patient. Renal angiography confirmed this diagnosis and percutaneous transluminal renal artery angioplasty was performed with a final acceptable result (residual stenosis<50%).

DISCUSSION

Radiation-induced renal artery stenosis is rare (0.5/1000 to 1%). Most of the cases are proximal and the median time from radiation to referral is nine years. Radiation-induced nephritis disease was often referred to occurrence high blood pressure after abdominal radiotherapy but various data shows that radiation can also cause damage to larger vessels sizes (such as renal arteries) induced by atherosclerosis radiation. Patients should be successful treated by percutaneous intervention, as demonstrated by Fakhouri et al. [Am J Kidney Dis 38 (2001) 302-309] in a study of 11 patients.

CONCLUSION

This case shows that radiation-induced renal artery stenosis may occur many years after initial treatment, and patients developing severe arterial hypertension after abdominal radiation should be investigated for renal artery stenosis.

Predictive factors for masked hypertension within a population of controlled hypertensives

CONTEXT

Prevalence of masked hypertension (MH) is far from negligible reaching 40% in some studies. The SHEAF study (Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-Up) and others clearly showed that masked hypertension (MH) as detected by home blood pressure measurement (HBPM) is associated with poor cardiovascular prognosis.

OBJECTIVE

Systematic HBPM to detect MH is not yet routine. The aim of this work is to better define the clinical profile of masked hypertensives within a population with controlled office blood pressure (BP) and the factors associated with a higher prevalence of MH.

MATERIALS AND METHODS

BP was measured at the clinic by the doctor and at home by the patient himself. Risk factors for MH were analysed in a cohort of 1150 treated hypertensive patients over the age of 60 (mean age 70 +/- 6.5, 48.9% men) with controlled office BP. (SBP < 140 mmHg and DBP < 90 mmHg).

RESULTS

463 patients (40%) were masked hypertensives (SBP > or = 135 mmHg or DBP > or = 85 mmHg at home). Three parameters were associated with MH (odds ratio OR): office SBP (OR = 1.110), male gender (OR = 2.214) and age (OR = 1.031). Decision trees showed a 130 mmHg SBP was an efficient threshold to propose HBPM with a higher probability to detect MH. Subsequent variables were male gender and age over 70 in males.

CONCLUSION

To detect masked hypertension, it would be logical to first of all select patients whose office SBP is between 130 and 140 mmHg.

Amlodipine and valsartan combined and as monotherapy in stage 2, elderly, and black hypertensive patients: subgroup analyses of 2 randomized, placebo-controlled studies

Patients with difficult to control hypertension typically require 2 or more agents to achieve goal blood pressure (BP) levels. Fixed-dose combination therapies with lower doses generally are well tolerated and more effective than higher-dose monotherapy. The authors performed prespecified and post hoc subgroup analyses of 2 double-blind, randomized, placebo-controlled trials that assessed the efficacy and safety of amlodipine and valsartan, alone and in combination, in patients with mild to moderate hypertension. Patients were randomized to amlodipine (study 1: 2.5 or 5 mg/d; study 2: 10 mg/d), valsartan (study 1: 40, 80, 160, or 320 mg/d; study 2: 160 or 320 mg/d), combination therapy across the same dose ranges, or placebo. Analyses were performed on changes from baseline in mean sitting systolic and diastolic BP and the occurrence of adverse events in specific subgroups of patients (ie, those with stage 2 hypertension [post hoc], the elderly [65 years or older], and blacks [both prespecified]). Amlodipine + valsartan combination therapy was associated with greater BP-lowering effects in the subgroups compared with each respective monotherapy and placebo. These findings were consistent with the primary efficacy analysis results from the overall study populations. Combination regimens were generally well tolerated by all patient subgroups.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pulse pressure monitoring of open antihypertensive therapy

BACKGROUND

Pulse pressure (PP) >60 mm Hg is an independent predictor of cardiovascular (CV) risk. Controlled studies showed that, unlike systolic and diastolic blood pressure (BP), PP responds minimally to placebo or no treatment.

METHODS

The aim of this study was to evaluate PP as a parameter of BP control in general practice. This open multicenter study involved 1841 primary care physicians with postinclusion visits at months 3, 6, and 9. Six thousand one hundred ten hypertensive patients participated in this study. They had a baseline PP >60 mm Hg and were divided into five antihypertensive therapy categories: 1) no antihypertensive therapy; 2) antihypertensive therapy incorporating neither an angiotensin-converting enzyme inhibitor (ACEI) nor a diuretic; 3) ACEI but no diuretic; 4) diuretic but no ACEI; and 5) ACEI + diuretic. In each category, any other antihypertensive agent could be added to lower the PP below 60 mm Hg. The PP was calculated from systolic and diastolic BP using a semiautomatic oscillometric sphygmomanometer; new CV events were assessed.

RESULTS

At 9 months, 95% of patients were receiving the ACEI + diuretic combination versus <10% at inclusion. During this period PP decreased below 60 mm Hg in 48% of the patients, and persisted above 80 mm Hg in less than 5%. New CV events occurred in 221 patients and were predicted by a positive CV history and age <50 years (odds ratio [OR]: 2.49; 95% confidence interval [CI]: 1.46-4.55). In patients without a CV history, the only predictor of decreased CV events was ACEI + diuretic combination (OR: 0.50; 95% CI: 0.30-0.90). In the overall population, age <50 years and PP <60 mm Hg predicted a lack of new CV events (OR: 0.55; 95% CI: 0.32-0.88).

CONCLUSIONS

The PP is an appropriate tool for evaluating open chronic antihypertensive therapy, and help to predict, under an ACEI + diuretic combination, the occurrence of new CV events.

Cardiovascular prognosis of "masked hypertension" detected by blood pressure self-measurement in elderly treated hypertensive patients

CONTEXT

Blood pressure (BP) measurement in clinicians' offices with a mercury sphygmomanometer has numerous drawbacks. In contrast, the use of home BP measurement improves measurement precision and reproducibility. However, data about its prognostic value are lacking.

OBJECTIVE

To assess the prognostic value of home vs office BP measurement by general practitioners in a European population of elderly patients being treated for hypertension.

DESIGN, SETTING, AND PARTICIPANTS

Office and home BP and cardiac risk factors were measured at baseline in a cohort of 4939 treated hypertensive patients (mean age, 70 [SD, 6.5] years; 48.9% men) who were recruited and followed up by their usual general practitioners without specific recommendations about their management. The cohort was then followed up for a mean of 3.2 (SD, 0.5) years. The thresholds defining uncontrolled hypertension were at least 140/90 mm Hg for office BP and 135/85 mm Hg for home BP.

MAIN OUTCOME MEASURES

The primary end point was cardiovascular mortality. Secondary end points were total mortality and the combination of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, transient ischemic attack, hospitalization for angina or heart failure, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery.

RESULTS

At the end of follow-up, clinical status was known for 99.9% of patients. At least 1 cardiovascular event had occurred in 324 (incidence, 22.2/1000 patient-years). For BP self-measurement at home, each 10-mm Hg increase in systolic BP increased the risk of a cardiovascular event by 17.2% (95% confidence interval [CI], 11.0%-23.8%) and each 5-mm Hg increase in diastolic BP increased that risk by 11.7% (95% CI, 5.7%-18.1%). Conversely, for the same increase in BP observed using office measurement, there was no significant increase in the risk of a cardiovascular event. In a multivariable model with patients having controlled hypertension (normal home and office BP) as the referent, the hazard ratio of cardiovascular events was 1.96 (95% CI, 1.27-3.02) in patients with uncontrolled hypertension (high BP with both measurement methods), 2.06 (95% CI, 1.22-3.47) in patients with normal office BP and elevated home BP, and 1.18 (95% CI, 0.67-2.10) in patients with elevated office BP and normal home BP.

CONCLUSIONS

Our findings suggest that home BP measurement has a better prognostic accuracy than office BP measurement. Blood pressure should systematically be measured at home in patients receiving treatment for hypertension.

[The best of hypertension in 2002]

This year, the writing of "Best of hypertension 2002" was completed by the coordinators of 4 working groups of the French Society of Hypertension, in various domains: (a) the working group on BAroreflex and VARiability (BAVAR): it appeared mandatory to evaluate the influence of calculation methods on the values of spontaneous baroreflex sensitivity, through an european study (The EuroBaVar collaboration study); (b) the working group on Blood Pressure Measurement, was first involved in the establishment of an international protocol for the validation of self blood pressure measurement, then validated, according to this procedure and in collaboration with the French Medicine Agency, several apparatus dedicated to the French market; (c) the working group on epidemiology: after the publication of the IHPAF study (Incidence de l'hypertension dans la population active française), which unmasked the influence of social and professional determinants on blood pressure control, this group settled down ancillary studies in French Indias, the INAPAG study (INcidence de l'hypertension artérielle dans la population Antilles-Guyane), and the PHAPPG study (Prévalence de l'hypertension artérielle dans la population précaire guadeloupéenne); finally (d) the working group for continuous medical education settled down a national diploma, entitled "Hypertension and renal and cardiovascular risk".

Is "isolated home" hypertension as opposed to "isolated office" hypertension a sign of greater cardiovascular risk?

BACKGROUND

The SHEAF (Self-Measurement of Blood Pressure at Home in the Elderly: Assessment and Follow-up) study is an observational study (from February 1998 to early 2002) designed to determine whether home blood pressure (BP) measurement has a greater cardiovascular prognostic value than office BP measurement among elderly (> or =60 years) French patients with hypertension. The objective of this present work is to describe the baseline characteristics of the treated patients in the SHEAF study from February 1998 to March 1999, placing special emphasis on "isolated office" and "isolated home" hypertension.

METHODS

Baseline office BP measurement was assessed using a mercury sphygmomanometer. Home BP measurement was performed over a 4-day period. A 140/90-mm Hg threshold was chosen to define office hypertension, and a 135/85-mm Hg threshold to define home hypertension.

RESULTS

Of the 5211 hypertensive patients in the SHEAF study with a valid home BP measurement, 4939 received treatment with at least 1 antihypertensive drug. Patients with isolated office hypertension represented 12.5% of this population, while patients with isolated home hypertension represented 10.8%. The characteristics of the patients with isolated office hypertension were similar to those of patients with controlled hypertension. However, patients with isolated office hypertension had fewer previous cardiovascular complications. In contrast, rates of cardiovascular risk factors and history of cardiovascular disease in patients with isolated home hypertension resembled those in patients with uncontrolled hypertension.

CONCLUSIONS

This retrospective analysis suggests that patients with isolated home hypertension belong to a high-risk subgroup. The 3-year follow-up of these patients will provide prospective data about the cardiovascular prognosis of these subgroups.

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

OBJECTIVE

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

[The feasibility of at-home self-monitoring blood pressure in elderly hypertensive patients]

The goal of the SHEAF study is to determine whether self blood pressure measurement (SBPM) has a better cardiovascular prognostic value than office blood pressure (OBP) among French elderly (> or = 60 y) hypertensive patients (pts) followed-up by general practitioners. Baseline SBPM was performed over a 4-day period: every day a series of 3 consecutive measurements was requested in the morning (8:00 am) and in the evening (8:00 pm), using a validated device OMRON 705 CP. Measurements performed out of predefined morning and evening time (outside the 4:00-12:00 am range or the 4:00-12:00 pm range) were discarded as well as aberrant values. Pts were included in the study only if they exhibited at least 15 valid measurements with at least 6 in the morning and 6 in the evening. 5,649 pts were selected. 186 pts were excluded for age < 60 years. Thus SBPM analysis was performed for 5,463 pts: 2,687 men (49%) and 2,776 women (51%) aged 70 +/- 7 years. Only 252 pts (5%) were excluded for non valid SBPM (207 pts < 15 measurements, 106 pts < 6 measurements in the morning and 205 pts < 6 measurements in the evening). 5,211 pts (95%) with valid SBPM were included. The distribution of pts according to the number of measurements performed is the following: [table: see text] The number of measurements performed in the morning is highly related to the number of measurements performed in the evening. None of the following variables is significantly associated with the poor compliance of measurement protocol: age, gender, CV history, CV risk factors, hypertension duration. In a large cohort of elderly hypertensive living in the community, SBPM is easily performed both in the morning and in the evening by most of the pts. If the SHEAF study demonstrates the prognostic value of SBPM, this would provide the basis for the use of this measurement method by a majority of elderly hypertensives.

[Effectiveness of the treatment of arterial hypertension in a specialized service. An audit using the automatic measurement of arterial blood pressure]

The ineluctable fade out of mercury sphingomanometer pressure device involve the necessity in using automatic blood pressure systems. In parallel the recent PHARE II study witness of a lack in the control of hypertension in general practice. In the basis of an automatic blood pressure device measure, we had try to know the efficiency of blood pressure contrôl (BPC) in a specialised consultation.

METHOD

100 patients with essential systolo-diastolic hypertension (HTA) were screened. An independent physician measured the blood pressure level with an OMRON 705 CP device 3 times. The acceptable BPC was considered less than 160/95 mmHg and the optimal BPC less than 140/90 mmHg. There was 70 man, 30 female (mean age = 67 year old). The initial mean blood pressure was 169/104 mmHg.

RESULTS

The final blood pressure measured was 137/80 mmHg. The percentage of patients who have an acceptable contrôl (< 160/95) was 91% and an optimal contrôl (< 140/90) 66%. 12% of these 66 maintain a height cardio-vascular risk. The mean number of medication used was 2 and it's paradoxally not differ between the optimal blood pressure control group and the other patients who need probably an intensive medication. In conclusion these study shows us the importance in understanding our patients particularity in order to increase the treatment efficiency.

[How to diagnose hypertension in the elderly?]

The management of hypertension in the elderly requires careful diagnosis, which is not always easy in this population because of the increased variability of blood pressure. The practitioner is faced with three questions in this diagnostic approach: how to evaluate the patient's real blood pressure level, how to assess the degree of cardiovascular impairment and concomitant disease and finally how to evaluate the subject's global cardiovascular risk. Self-monitoring of blood pressure, which allows measurement of blood pressure by the patient himself in his usual environment, provides a better assessment of the elderly patient's real blood pressure level.

Use of electronic pill boxes to assess risk of poor treatment compliance: results of a large-scale trial

The objective of the present study was to determine the predictive factors of treatment compliance in hypertensive patients. This was an open large-scale multicenter study where mild to moderate essential hypertensive patients received trandolapril (2 mg) once daily for 30 to 60 days in addition to their usual treatment. Trandolapril was packed in electronic pill boxes that registered date and time of each opening. The main compliance parameters were the percentage of missed doses, the percentage of delayed doses, and the percentage of correct dosing periods. Predictive factors of poor compliance (correct dosing periods < 80%) were determined using a multivariate stepwise logistic regression analysis. Two thousand one hundred seventy-three patients aged 60 +/- 12 years were analyzed. Of the total patients 37% were poor compliers; 29% of patients forgot more than 10% of doses and 36% of patients delayed more than 10% of doses. Ranked predictive factors of poor compliance were: age < 60 years (odds ratio [OR], 1.80 [1.49 to 2.17], P = .0001), the Paris area (OR, 1.70 [1.32 to 2.19], P = .0001), smokers (OR, 1.65 [1.29 to 2.11], P = .0001), monotherapy (OR, 1.40 [1.14 to 1.72], P = .0012), and baseline diastolic blood pressure > or = 100 mm Hg (OR, 1.21 [1.01 to 1.46], P = .044). Therefore, we conclude that young hypertensives, large city dwellers, and smokers are more likely to be poor compliers. The presence of some of these characteristics might incite the physician either to encourage patient compliance or to prescribe antihypertensive drugs that have an effect that persists even beyond 24 h.

[Cardiovascular risk and the measurement of arterial pressure]

Clinical measurement of the blood pressure associated with assessment of the other cardiovascular risk factors: cholesterol, smoking, age, sex, diabetes and cardiovascular heredity, allow appreciation of the cardiovascular risk of hypertensive patients after the results of the Framingham study. There is no consensus about the optimal clinical blood pressure with treatment and about the control of treated hypertensives which remains low in population studies (28% in France, 27% in the United States). New methods of blood pressure measurements such as ambulatory blood pressure monitoring and self-measurement of the blood pressure are better correlated to cardiovascular events and morbi-mortality than measurement of the blood pressure during consultation in hypertensive patients. Ambulatory blood pressure recording also seems to be more predictive of regression of left ventricular hypertrophy. Therefore, the latest recommendations, especially the American consensus, advise using these techniques when the physician is in doubt about the value of the clinical blood pressure measurement of hypertensive patients, especially in the case of apparent antihypertensive drug resistance. Finally, what does good blood pressure control imply in 1988: normal clinical blood pressure measurements compared with ambulatory blood pressure monitoring or self-measurement of the blood pressure? Does it mean control of the patient's absolute cardiovascular risk? The answers to these questions can only be obtained by future prospective studies.

Short-term effects of withdrawing angiotensin converting enzyme inhibitor therapy on home self-measured blood pressure in hypertensive patients

The aim of this study was to compare blood pressure rise after interruption of two angiotensin converting enzyme (ACE) inhibitors in hypertensive patients. After a 2-week placebo run-in period, hypertensive patients were treated with either trandolapril 2 mg once daily or perindopril 4 mg once daily for 4 weeks in a double-blind design. A placebo was then administered for 1 week. Three periods of 1-week home self-measured blood pressure (SMBP) were programmed: end of placebo run-in period, end of treatment period, and final withdrawal placebo period. Every day, three consecutive measurements were requested both in the evening and in the morning. Individual reversion to baseline BP level was studied in the subgroup of patients responding to therapy (evening diastolic SMBP decrease > or =6 mm Hg). The ratio (R) of mean post-drug DBP lowering (residual effect) over evening on-drug DBP lowering (full effect) was used to study reversion to baseline. Patients exhibiting a lower value than the median of this ratio were called Reverters, whereas others were called Nonreverters. One hundred-nineteen patients entered the analysis. During the treatment period, mean SMBP decreased significantly, from 150 +/- 14/97 +/- 7 mm Hg to 139 +/- 15/91 +/- 9 mm Hg (all P < .001). The on-drug BP level was similar in the evening in the two treatment groups. However, both systolic and diastolic morning SMBP levels were significantly lower in the trandolapril group. After drug discontinuation, the mean BP level significantly rose to 144 +/- 14/94 +/- 9 mm Hg (all P = .01) but remained lower than the baseline BP values (P = .003 for SBP and P = .002 for DBP). The post-drug BP level was significantly lower in the trandolapril group than in the perindopril group. Seventy-four patients were responders to therapy. In this subgroup, the median of the R ratio used to analyze reversion to baseline after drug discontinuation was 44%. Nonreverters were characterized by a sustained on-drug BP decrease, compared to Reverters. We therefore conclude that ACE inhibitor treatment withdrawal is accompanied by a rapid rise in BP (within 48 h), followed by a 5-day BP plateau that is lower than the initial level. Reverters to baseline after drug discontinuation were more likely to be insufficiently controlled during therapy, particularly in the morning. The longer duration of action of trandolapril was associated with a lower BP level during both the morning during the active treatment phase and the 1-week posttreatment phase.

[Ambulatory measurement of blood pressure and efficacy of diltiazem. Influence of the timing of drug ingestion and initial blood pressure level]

Clinical and 24-hour ambulatory measurements were made in 46 patients with mild to moderate essential hypertension in order to confirm that the efficacy and safety of sustained-release diltiazem LP 300 mg were the same regardless of the time of day at which it was taken. After two weeks of placebo, patients were randomly assigned double-blind to take diltiazem LP 300 mg either morning or evening for four weeks. Diltiazem LP 300 mg significantly lowered diastolic and systolic blood pressure in both groups by clinical or 24-hour ambulatory measurement, and without any difference according to whether diltiazem LP 300 mg was administered morning or evening. A lesser fall in blood pressure during the night in both groups led to study of the effect of diltiazem LP 300 mg according to initial ambulatory diastolic blood pressure level. Diltiazem brought about a greater fall in blood pressure when patients had an ambulatory diastolic pressure of 90 mmHg or more. Clinical, laboratory and electrocardiographic parameters were all satisfactory, regardless of the time at which the drug was taken.

[Evaluation of hypertrophic cardiomyopathy in treated essential hypertensive patients]

Assessment of left ventricular hypertrophy (LVH) in 231 essential hypertensive patients (61 year'old) treated in a department of internal medicine. Incidence of LVH defined by echocardiography: 34%. Better relationship between LVH and ambulatory blood pressure (BP) monitoring than with casual BP. Influence of age and obesity in the occurrence of LVH.

Comparison of angiotensin-converting enzyme inhibitors and calcium antagonists in the treatment of mild to moderate systemic hypertension, according to baseline ambulatory blood pressure level

This study was aimed at determining whether baseline ambulatory blood pressure (BP) levels influence the efficacy of angiotensin-converting enzyme inhibitors and calcium antagonists in the same manner. Accordingly, the ambulatory BP recordings of 236 mild to moderate hypertensive patients who had previously entered a clinical trial and had received either a calcium antagonist (n = 121) or an angiotensin-converting enzyme inhibitor (n = 115) were reviewed. The inclusion criterion was a clinic diastolic BP between 95 and 115 mm Hg at the end of the placebo period. Patients were classified according to the difference between their observed and predicted ambulatory BP (the latter assessed by regressing the observed ambulatory BP on the clinic BP). Reduction in ambulatory systolic and diastolic BP seemed to be greater (p less than 0.0001, p = 0.01) in patients receiving an angiotensin-converting enzyme inhibitor than in those who were given a calcium antagonist. However, analysis of variance showed (1) there was a significant interaction (F = 6.37 p = 0.01) between the pharmacologic class and the baseline systolic ambulatory BP; and (2) the difference in diastolic ambulatory BP reduction between both classes was no longer significant when adjusted for baseline diastolic ambulatory BP. In patients with higher than predicted ambulatory BP levels, angiotensin-converting enzyme inhibitors and calcium antagonists had roughly a similar effect (reduction in systolic BP, 9 +/- 8% vs 7 +/- 6%, p = not significant; reduction in diastolic BP, 11 +/- 8% vs 8 +/- 6%, p = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

[Non-invasive ambulatory recording of blood pressure. Current data]

Recent advances in medical technology have made it possible to non invasively record ambulatory blood pressure over 24 hours. This new method of measurement has a lot of advantages over the classic way: it enables a satisfactory approach of blood pressure circadian rhythm; it seems to be more reliable than clinic readings of blood pressure, which may be subjects to some confounding variables (e.g. observer bias, digit preference, defence reaction...); it appears to be better at predicting cardiovascular prognosis of hypertensive patients and is more closely correlated with target organ damage; finally, in some instances, it may help the physician to determine whether or not antihypertensive treatment should be initiated or adjusted. The limits and drawbacks of the method are also pointed out and, from a practical point of view, some recommendations are given to perform it only in most relevant circumstances.

[Non-invasive ambulatory blood pressure measurement over 24 hours: effects of labetalol on the rise of blood pressure in the early morning]

Three french specialist centers have included 19 hypertensive patients in an open cooperative study of the effect of labetalol (L = 200 to 400 mg b.i.d.) on the 24 hour blood pressure (24 h - B.P.) recording by a non invasive method (Spacelabs - Squibb Medical Systems), with a particular assessment of the early morning rise of BP. Each patient was subjected to 2 assessments at the end of a 14 days' placebo period and of a 28 days' treatment period. At the end of the study, the systolic (SBP) and diastolic (DBP). B.P. were significantly decreased at rest (p less than 0.001) and on the 24 hours recording (p less than 0.001). The reduction of B.P. was also significant on day period from 7 a.m. to 22 p.m. (p less than 0.001) and night period from 22 a.m. to 7 a.m. (p less than 0.05) as well as on the early morning period, 3 hours before and after waking (p less than 0.001). The heart rate was significantly reduced during the day (p less than 0.05) and was not on the night. The slope of the early morning rise of B.P. was marked after placebo and significantly decreased after labetalol with a reduction of 52% for SBP and 49% for DBP (p less than 0.001). These results show that labetalol has an antihypertensive effect over 24 hours with a marked effect on the early morning rise of B.P.

[Study of the placebo effect in using the non-invasive ambulatory measurement of blood pressure]

The aim of this study is to evaluate the antihypertensive effect of placebo assessed by 24 hr non invasive blood pressure monitoring. 20 patients (16 males, 4 females, 55 +/- 10 years old) with primary hypertension (WHO stage I or II) were included with a diastolic blood pressure greater than or equal to 100 mmHg (mean blood pressure from three clinical readings). Casual blood pressure and blood pressure monitoring (Spacelabs - 4 measurements per hour during a 24 hr period) were established before and at the end of the placebo run in period (one placebo tablet given once daily at 8 h-8 h 30 a.m. for 15 days). Overall sample data: There was no antihypertensive effect of the placebo with casual BP (167 +/- 16-109 +/- 6 mmHg before and 167 +/- 16-109 +/- 7 mmHg after placebo) and with 24 hr B.P. monitoring (142 +/- 14-96 +/- 8 mmHg before and 141 +/- 14-96 +/- 8 mmHg after placebo). The circadian curves were similar. Individual patient data: A clinical placebo effect (B.P. decrease of at least 10 mmHg) was found in 5 patients for the systolic B.P. and in 2 for diastolic B.P. A significant ambulatory placebo effect (p less than 0.05) was found in 5 patients for the 24 hr systolic B.P. and in 4 patients for the 24 hr diastolic B.P. However, patients with clinical placebo effect were not the same as those with ambulatory placebo effect. There was no correlation between the clinical and the ambulatory response to placebo treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Antihypertensive therapeutic effect. Comparison of their evaluation using clinical and ambulatory measurements of arterial pressure. Preliminary study]

The aim of this preliminary report is to compare the evaluation of the antihypertensive drug effect, during a controlled trial, using casual measurements and 24 hr B.P. monitoring. 20 patients (16 males, 4 females 55 +/- 10 years old) with primary hypertension (WHO stage I or II) were included with a diastolic blood pressure greater than or equal to 100 mmHg (mean blood pressure from three clinical readings). Casual B.P. and B.P. monitoring (Spacelabs - 4 measurements per hour during a 24 hr period) were established before and after the end of the placebo run in period (one placebo tablet given once daily at 8 h-8 h 30 a.m. for 15 days). Overall sample data: The clinical B.P. decrease (167 +/- 16-109 +/- 7 before and 147 +/- 17-97 +/- 11 after treatment) is higher that the ambulatory B.P. decrease (148 +/- 15-101 +/- 8 before and 138 +/- 21-94 +/- 14 after treatment). Individual patient data: A clinical B.P. decrease (of at least 10 mmHg) was found in 17 patients for systolic B.P. and in 15 patients for diastolic B.P. A significant ambulatory B. P. drop decrease (p less than 0.05) was found in 11 patients for 24 hr systolic and diastolic B.P. The clinical and ambulatory responses to the treatment are in line in 14 patients, but differ in 3 instances. There is a little correlation (for the diastolic B.P.) and no correlation (for the systolic B.P.) between the clinical and the ambulatory B.P. decreases after treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of once and twice daily administration of captopril plus hydrochlorothiazide on 24 h blood pressure levels

The anti-hypertensive effect of captopril 50 mg plus hydrochlorothiazide 25 mg, given once or twice daily, was investigated by 24 h monitoring in hypertensive patients in a controlled, randomized, double-blind, cross-over trial. Ten patients with blood pressure (BP) greater than 160 and/or 95 mm Hg after a 15 day placebo period, were randomly assigned to one of two treatments, in which they either received the combination once daily in the first month, twice daily in the second and once daily in the third (Treatment Group A) or twice daily in the first month, once daily in the second month and twice daily in the third month (Treatment Group B). The anti-hypertensive effect of the drug combination was assessed by 24 h monitoring using a Dinamap 845 to establish mean BP levels and circadian curves. After 1 month the twice daily administration was more effective than the once daily, but after 2 months, and throughout the third month, there was no difference in the anti-hypertensive efficacy of the combination given either once or twice daily.

[Compression of the right pulmonary artery by a dissecting aneurysm of the ascending aorta. Apropos of a case occurring long after aortic valve replacement]

The authors report the case of a dissecting aneurysm of the ascending aorta compressing the right pulmonary artery in a 62 year old man, 6 years after aortic valve replacement. The clinical presentation was that of pulmonary embolism. The diagnosis was confirmed by angiopneumography and CT scanning. The ascending aorta was successfully replaced with a Dacron prosthesis. One other case was found in a review of the literature. After discussing the predisposing factors of aortic dissection during cardiac surgery, the authors underline the diagnostic value of CT scanning in cases of suspected aneurysms of the thoracic aorta.