[PASTIS study: Evaluation of an automated office blood pressure measurement]

OBJECTIVE

The evaluation of automated office blood pressure (AOBP) measurement compared to 24-hour ambulatory BP monitoring (ABPM), Home BP measurement and manual BP.

PATIENTS AND METHODOLOGY

A total of 123 hypertensive patients were included. Overall, 68 completed the 4 measurement: Manual BP in the office (Omron 705 CP 3 measurements), ABPM (Spacelab of 96 measurement/per 24hours), Home BP (18 measurement during 3 days), AOBP using the SPRINT methodology: lying patient, isolated with an automatic measurement (Dinamap) every minutes during 8minutes (average of the last 3 measurement). Twenty-two out of 123 patients (26%) did not complete the Home BP measurement.

RESULTS

The average of AOBP measurement using SPRINT is 132±12/69±9mmHg, of ABPM 134±13/79±9, of Home BP: 135±13/70±13 and of manual BP: 138±13/72±11mmHg The Bland & Altman method highlight that the AOBP, the ABPM and home BP measurement are 3 substitutable methods. The confidence interval is smaller between the ABPM and the AOBP than with the home BP.

CONCLUSION

The automated office blood pressure, as the Home BP measurement, can be considered a reliable substitute for the ABPM, when the later is not accessible, and when a repeated therapeutic evaluation is needed, or when the home BP measurement is not done. These results encourage us to use it more frequently as the Canadian Hypertension Education Program recommend it.

[Prevalence and severity of hypertensive emergencies and outbreaks in the hospital emergency department of CHU Timone at Marseille: Follow-up in three months of hospitalized patients]

GOAL

Evaluation of the prevalence and severity of hypertensive emergencies and crisis in an Emergency Service of Timone hospital in Marseille and follow-up of 3 months of hospitalized emergencies.

METHODS

This study was conducted in the Emergency Department between April 1 and June 30, 2015. All patients with BP>180 and/or 110mmHg was recorded and classified in true emergencies (presence of visceral pain) and hypertensive isolated crisis. A phone follow-up patients was organized.

RESULTS

During this period, 170 patients were identified: 95 (56%) hypertensive crisis and 75 (44%) hypertensive emergencies: 25 OAP (33%), 18 ischemic stroke (24%), 15 hemorrhagic stroke (20%), 9 angina (12%) and 8 different. The clinical characteristics of hypertensive emergencies are preferentially dyspnea (27%) motor deficit (36%), and chest pain (16%). The BP of hypertensive emergencies at their admission (3 measurements, oscillometric automatic device) is close to the hypertensive crisis (198.17±19.3 to 96.4±21.2mmHg versus 191±31.6 to 96.12±21). The BP controlled after 15minutes of rest is lower for crisis compared to real emergencies (152±47 to 79±28 vs. 174±31 to 86±26). Age emergency is larger (77±14 vs. 67±17), the number of slightly larger drug (1.79 versus 1.67±1±1). Telephone follow-up was performed after an average period of three months. Ninety-nine patients were contacted by telephone: 46 patients who were admitted for hypertensive emergency patients and 53 for a push. Eighteen deaths have been recorded, including 15 among hypertensive emergencies (9 in hemorrhagic stroke, 5 for ischemic stroke, and 1 for OAP) with 5-hospital deaths within 48hours after admission and 10 within 3 months in patients hospitalized with hypertensive emergency or 33%. Seventy-seven patients out of 99 had been reviewed by their attending physicians. A questionnaire was sent by mail to patients who have not answered the phone contacts, and responses are pending.

CONCLUSION

Hypertensive emergencies hospitalized in Timone Hospital represent 44% of patients hospitalized for emergency HTA. Their gravity is 1/3 since most patients die within three months warranting closer management of these fragile patients by creating a specialized consulting postemergency.

Cardiac safety in cluster headache patients using the very high dose of verapamil (≥720 mg/day)

Use of high doses of verapamil in preventive treatment of cluster headache (CH) is limited by cardiac toxicity. We systematically assess the cardiac safety of the very high dose of verapamil (verapamil VHD) in CH patients. Our work was a study performed in two French headache centers (Marseilles-Nice) from 12/2005 to 12/2008. CH patients treated with verapamil VHD (≥720 mg) were considered with a systematic electrocardiogram (EKG) monitoring. Among 200 CH patients, 29 (14.8%) used verapamil VHD (877±227 mg/day). Incidence of EKG changes was 38% (11/29). Seven (24%) patients presented bradycardia considered as nonserious adverse event (NSAE) and four (14%) patients presented arrhythmia (heart block) considered as serious adverse event (SAE). Patients with EKG changes (1,003±295 mg/day) were taking higher doses than those without EKG changes (800±143 mg/day), but doses were similar in patients with SAE (990±316 mg/day) and those with NSAE (1,011±309 mg/day). Around three-quarters (8/11) of patients presented a delayed-onset cardiac adverse event (delay ≥2 years). Our work confirms the need for systematic EKG monitoring in CH patients treated with verapamil. Such cardiac safety assessment must be continued even for patients using VHD without any adverse event for a long time.

[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.

[Evaluation of patient compliance among hypertensive patients treated by specialists]

OBJECTIVES

To evaluate compliance with antihypertensive therapy by a self-report in patients referred to hypertension specialists.

METHODS

We studied 484 treated hypertensive subjects referred to several hypertension clinics and who were treated since at least one year. Patients were asked to fill in the Compliance Evaluation Test (CET), a questionnaire with 6 questions previously validated to assess factors that could affect medication compliance. We defined patients as "good compliant" when "No" was answered to the 6 items, as "minor noncompliant" when 1 or 2 "Yes" were answered, and as "noncompliant" when 3 or more "Yes" were answered. A good agreement was demonstrated between CET score and compliance evaluated by the number of pills missed during the previous month according to patient interview.

RESULTS

We observed 8% of "noncompliant", 53% of "minor noncompliant" and 39% of "good compliant". [table: see text] Logistic regression analysis including age, sex, education level, blood pressure level and the number of antihypertensive tablets confirm the statistical differences observed.

CONCLUSIONS

In clinical practice, a method of assessing medication compliance is to ask the patient for a self-report interview. We demonstrated that the compliance evaluation test is able to detect factors usually associated with poor compliance (young age, elevated blood pressure, number of tablets per day). The use of the compliance evaluation test may help physicians to face the problem of nonadherence among their hypertensive patients.

[Evaluation of blood pressure control by repeated ambulatory automatic blood pressure measurements]

The aim of this study was to compare the evaluation of blood pressure control in using an automatic blood pressure device (ABPD) and an ambulatory blood pressure measurement (ABPM).

METHOD

41 patients with essential hypertension (HTA) were screened prospectively from April to June 2000 (22 men and 19 female) mean age 63 years old, 2.6 antihypertensive drug per patient). The blood pressure was randomly measure by 2 physicians with an automatic blood pressure device OMRON 705 CP, 3 times. All the patients had a 24 hours ABPM in the month before and after this measure, without change in medication.

RESULTS

The mean blood pressure measured was 151/81 mmHg by the first physician, 149/85 mmHg with the physician observer and 131/81 mmHg with the ABPM. The percentage of patient who have an optimal control was significantly less in the ABPD estimation (27% < 140/90 mmHg) than ABPM (Day ABPM < 135/85 mmHg = 51%). In conclusion, the control of hypertension still remains insufficiency even if the utilisation of ABPM may increase the accuracy of that estimation.

[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.

[New requirements in the primary treatment of arterial hypertension: why do we need fixed low-dose combination therapy?]

The latest results of studies and therapeutic trials have shown the following: Present therapeutic strategies for arterial hypertension have a certain efficacy, but appear to have reached a plateau. Arterial hypertension essentially affects older subjects who can benefit from the advantages of antihypertensive treatment as much as, if not more than, younger subjects. A better evaluation of the cardiovascular risk of the patient is essential: This should include all the components of arterial hypertension (diastolic and systolic blood pressures and pulse pressure), risk factors, associated pathologies, and target-organ damage. Such an evaluation will help fix therapeutic objectives tailored to individual patientsí needs. The limitations of monotherapy in achieving this objective: They are demonstrated in clinical practise, as well as in large-scale trials. In this context, new strategies based on the first-line use of fixed very-low-dose combination therapies appear to be both useful and promising, as well as being in line with the latest recommendations.

[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.