Optimum and stepped care standardised antihypertensive treatment with or without renal denervation for resistant hypertension (DENERHTN): a multicentre, open-label, randomised controlled trial

BACKGROUND

Conflicting blood pressure-lowering effects of catheter-based renal artery denervation have been reported in patients with resistant hypertension. We compared the ambulatory blood pressure-lowering efficacy and safety of radiofrequency-based renal denervation added to a standardised stepped-care antihypertensive treatment (SSAHT) with the same SSAHT alone in patients with resistant hypertension.

METHODS

The Renal Denervation for Hypertension (DENERHTN) trial was a prospective, open-label randomised controlled trial with blinded endpoint evaluation in patients with resistant hypertension, done in 15 French tertiary care centres specialised in hypertension management. Eligible patients aged 18-75 years received indapamide 1·5 mg, ramipril 10 mg (or irbesartan 300 mg), and amlodipine 10 mg daily for 4 weeks to confirm treatment resistance by ambulatory blood pressure monitoring before randomisation. Patients were then randomly assigned (1:1) to receive either renal denervation plus an SSAHT regimen (renal denervation group) or the same SSAHT alone (control group). The randomisation sequence was generated by computer, and stratified by centres. For SSAHT, after randomisation, spironolactone 25 mg per day, bisoprolol 10 mg per day, prazosin 5 mg per day, and rilmenidine 1 mg per day were sequentially added from months two to five in both groups if home blood pressure was more than or equal to 135/85 mm Hg. The primary endpoint was the mean change in daytime systolic blood pressure from baseline to 6 months as assessed by ambulatory blood pressure monitoring. The primary endpoint was analysed blindly. The safety outcomes were the incidence of acute adverse events of the renal denervation procedure and the change in estimated glomerular filtration rate from baseline to 6 months. This trial is registered with ClinicalTrials.gov, number NCT01570777.

FINDINGS

Between May 22, 2012, and Oct 14, 2013, 1416 patients were screened for eligibility, 106 of those were randomly assigned to treatment (53 patients in each group, intention-to-treat population) and 101 analysed because of patients with missing endpoints (48 in the renal denervation group, 53 in the control group, modified intention-to-treat population). The mean change in daytime ambulatory systolic blood pressure at 6 months was -15·8 mm Hg (95% CI -19·7 to -11·9) in the renal denervation group and -9·9 mm Hg (-13·6 to -6·2) in the group receiving SSAHT alone, a baseline-adjusted difference of -5·9 mm Hg (-11·3 to -0·5; p=0·0329). The number of antihypertensive drugs and drug-adherence at 6 months were similar between the two groups. Three minor renal denervation-related adverse events were noted (lumbar pain in two patients and mild groin haematoma in one patient). A mild and similar decrease in estimated glomerular filtration rate from baseline to 6 months was observed in both groups.

INTERPRETATION

In patients with well defined resistant hypertension, renal denervation plus an SSAHT decreases ambulatory blood pressure more than the same SSAHT alone at 6 months. This additional blood pressure lowering effect may contribute to a reduction in cardiovascular morbidity if maintained in the long term after renal denervation.

FUNDING

French Ministry of Health.

Perindopril/indapamide combination in the first-line treatment of hypertension and end-organ protection

This article examines evidence-based findings in the literature on the efficacy of perindopril 2 mg/indapamide 0.625 mg, a first-line, low-dose antihypertensive drug combination. In regulatory Phase II and III trials, perindopril/indapamide significantly lowered blood pressure compared with other first-line therapies (atenolol, losartan and irbesartan). This was also the case in STRAtegies of Treatment in Hypertension: Evaluation, a postregistration study versus current monotherapies and stepped-care therapy with different classes of antihypertensive agents. The efficacy/safety ratio (both clinical and with regard to laboratory parameters) of perindopril/indapamide was good. Perindopril/indapamide provides additional antihypertensive efficacy compared with each component used alone and with current monotherapies, with major efficacy on systolic blood pressure, an important predictor of cardiovascular risk. It also reduces pulse pressure, an independent cardiovascular risk factor, large-vessel arterial stiffness and microcirculatory alterations. The fixed dosage of a once-daily tablet, ensures optimal ease of use and enhances patient compliance. Perindopril/indapamide also reduces target organ damage in patients at high cardiovascular risk, such as patients with cardiac hypertrophy and Type 2 diabetics with albuminuria. These benefits, together with the good efficacy/tolerability ratio, fulfill the requirements of the European Society of Hypertension and of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines for low-dose, first-line combination therapy in hypertension.

Normotensive incidentally discovered pheochromocytomas display specific biochemical, cellular, and molecular characteristics

CONTEXT

A number of incidentally discovered pheochromocytomas are not associated with hypertension. The characteristics of normotensive incidentally discovered pheochromocytomas (NIPs) are poorly known.

OBJECTIVE

The purpose of this work was to assess the clinical, hormonal, histological, and molecular features of NIPs.

DESIGN

This was a retrospective cohort recruited from 2001 to 2011 in 2 tertiary care medical departments.

PATIENTS AND METHODS

Clinical, biological, and radiological investigations performed in 96 consecutive patients with sporadic unilateral pheochromocytomas were examined; 47 patients had overt pheochromocytomas responsible for hypertension. Among the patients with incidental pheochromocytomas, 28 had hypertension and 21 were normotensive (NIPs). A total of 62 tumors were examined to determine the Pheochromocytoma of the Adrenal Gland Scale Score, and 29 were studied for the expression of 16 genes involved in chromaffin cell function.

RESULTS

Tumor size and metaiodobenzylguanidine (MIBG) scintigraphy results were similar for hypertensive pheochromocytomas (HPs) and NIPs. Patients with NIPs displayed reduced summed levels of urinary catecholamines and metanephrines and, more specifically, reduced levels of adrenaline and metadrenaline compared with those of patients with HPs (P < .001). Urinary metanephrines had 98% diagnostic sensitivity in patients with HPs and only 75% in patients with NIPs (P < .01). Tumor diameter positively correlated with the total amount of urinary concentrations of metanephrines in patients with HPs (P < .001) but not in patients with NIPs. NIPs displayed global decreased chromaffin gene expression (reaching significance for 5 of them) and 2 corresponding proteins (phenylethanolamine N-methyltransferase and secretogranin II) and a significant increase in the cellularity, mitotic activity, and presence of atypical mitosis (P < .05).

CONCLUSIONS

NIPs differ from pheochromocytomas responsible for hypertension and display features of altered chromaffin differentiation. These tumors may be misdiagnosed with the use of the usual biological diagnostic tools.

Phasing-in plasma metanephrines determination

OBJECTIVES

We set up plasma normetanephrine (pNMA) and metanephrine (pMA) assays as they demonstrated their usefulness for diagnosing phaeochromocytomas. Our scope is to describe some practical laboratory aspects and the clinical relevance of these assays in our endocrinological or cardiological departments.

METHODS

We retrospectively reviewed the results of MA from a population of in- and outpatients over a 7-year period. Subjects (n=2536) from endocrinological or cardiological departments were investigated (66 phaeochromocytomas). Urinary NMA (uNMA) and pNMA, and urinary MA (uMA) and pMA were assayed by HPLC with electrochemical detection.

RESULTS

pNMA and pMA assays are now more frequently requested than uNMA and uMA. This changed our laboratory work load with improved delivery, sensitivity and reliability of plasma assays as well as reduced apparatus maintenance time. The pNMA and pMA upper reference limits (URLs) of subjects with no phaeochromocytoma were 1040 and 430 pmol/l respectively. Sensitivity and specificity based on receiver operating characteristic curves optimal points were 83 and 93% for pNMA at 972 pmol/l and 67 and 98% for pMA at 638 pmol/l. Sensitivity and specificity of paired tests of pMA (positive test: at least one analyte above its URLs) were 100 and 91% respectively.

CONCLUSION

The very low concentration of analytes requires a sustained very good apparatus analytical sensitivity. This can be obtained in an up-to-date laboratory. In terms of clinical performances, assays in plasma or urine are equivalent. Depending on local preferences, populations, strategies or departments, requests for one or the other assay may sustain the need for specifically defined reference ranges.

Impaired baroreflex sensitivity and the risks of new-onset ambulatory hypertension, in an elderly population-based study

BACKGROUND

Impairment of the autonomic nervous system activity may be involved in the development of hypertension. Yet the prognostic values of heart rate variability and baroreflex sensitivity in the risk of new-onset ambulatory hypertension have not been investigated. We sought to assess the relationship between heart rate variability and baroreflex sensitivity parameters and ambulatory hypertension in a community-dwelling elderly cohort.

METHODS

Normotensive subjects were selected from the PROOF study cohort, including 1011 subjects aged 65 years at baseline. The autonomic nervous system activity was assessed through 24-hour heart rate variability and 15-minute spontaneous baroreflex sensitivity at baseline. Incident hypertension was defined with the 24-hour, day-time and night-time ambulatory blood pressure measurements and antihypertensive treatment use, at two-years of follow-up.

RESULTS

At baseline, 13.7% of subjects developed day-time hypertension, 18.2% developed night-time hypertension and 13.6% developed 24-hour hypertension. Reduced baroreflex sensitivity at baseline was associated with onset of hypertension after adjustment for blood pressure level, C-reactive protein levels and depression score (OR = 0.45 [0.23-0.86]). Indices of heart rate variability were not associated with hypertension onset.

CONCLUSION

Baroreflex sensitivity may represent an intermediate goal for prevention of ambulatory hypertension at early stage.

Autonomic activation during sleep and new-onset ambulatory hypertension in the elderly

BACKGROUND

Sympathetic "overactivity" during night is a well recognized factor of hypertension development in adults. However, the deleterious effect of nocturnal autonomic activation in elderly remains controversial.

METHODS

Subjects, all aged 65 years at baseline, were selected from the PROOF cohort study, a prospective observational cohort of subjects. Exclusion criteria were previous myocardial infarction, stroke, heart failure, type-1 diabetes, atrial fibrillation or anti-arrhythmic drug. Normotensive subjects were selected according to: 24-h ambulatory blood pressure (BP) measurements <135/85 mm Hg, absence of self-report antihypertensive treatment. Autonomic activation during sleep was evaluated from night-time ECG Holter recording. According the %VLFI (Very-Low Frequency component of Interbeat Interval Increment evaluated from heart rate variability analysis). Subjects with new-onset ambulatory hypertension were identified after two years when daytime ambulatory blood pressure was higher than 135/85 mm Hg or when they used an antihypertensive treatment.

RESULTS

Among 428 normotensive subjects at inclusion, 62 (14.5%) were considered as hypertensives after two years. Univariate logistic regression model showed a significant association between abnormal %VLFI (>4%) and new-onset hypertension: OR = 1.78 (1.03-3.07). Male gender, increased body mass index and ambulatory systolic BP were also associated with increased risk of hypertension. After adjustment in the stepwise logistic regression, abnormal %VLFI was associated with an 82% increase in odds of new-onset hypertension, independently of systolic ABPM and body mass index.

CONCLUSION

Repeated autonomic activation during sleep, whatever the origin of the phenomenon, may trigger hypertension development in the elderly.

Atrioventricular conduction in the hypertensive patient: influence of aging, pulse pressure, and arterial stiffness

Atrioventricular (AV) conduction time (PR interval) lengthens with age. Hypertension is often presented as an accelerated aging of the heart and arteries. The principal marker of arterial aging is an increase in arterial stiffness and pulse pressure. We were interested to find out whether parameters of blood pressure and arterial stiffness were related to the PR interval and whether they influenced its long-term progression. We examined factors linked to the PR interval at baseline in a cohort of untreated hypertensive patients including office and 24-hr blood pressure and arterial stiffness (QKD(100-60)). Long-term evolution of the PR interval and related factors were obtained during follow-up of this population. Baseline data were obtained in 1,034 untreated hypertensive patients. At baseline, four variables emerged as significantly and independently correlated with PR interval: Gender, age, weight, and heart rate. During follow-up (137 ± 78 months), 328 of these patients were re-examined. In this group, PR increased from 159 ± 20 to 167 ± 25 msec (p<0.001), a mean alteration of 8 ± 19 msec. This change was correlated with the baseline 24 hr PP (r=0.17, p=0.004) and with the duration of follow-up (r=0.13, p=0.02). In the group with baseline evaluation of arterial stiffness (n=141), QKD(100-60) was correlated with the change in PR interval (r= -0.33, p<0.0001) along with the duration of follow-up (r=0.22, p=0.005). This study shows a link between baseline increased pulse pressure or arterial stiffness with the prolongation of the PR interval with aging. Because this link was observed during follow-up, it is possible that increased arterial stiffness favors the increase in the PR interval with age.

Domestic activities after myocardial infarction. Their impact is underestimated

BACKGROUND

Although aptitude for resumption of work is usually evaluated after myocardial infarction, the return home often entails significant daily obligations whose cardiovascular implications are poorly described and may well be underestimated.

AIM

The aim of this study was to evaluate the consequences of domestic activities on blood pressure and heart rate in patients with recent myocardial infarction

DESIGN

This was an observational study.

SETTING

Inpatients, at the end of a three week period of cardiovascular rehabilitation.

POPULATION

Patients with recent myocardial infarction.

METHODS

We studied patients who had benefited from a three-week period of cardiovascular rehabilitation after a myocardial infarction, all treated with beta-blockers. At the end of the rehabilitation period, patients were submitted to a standardized exercise test with measurement of V.O2. They also carried out, on a separate day, four standardized domestic tasks in a random order along with an automated measurement of blood pressure and heart rate.

RESULTS

We included 16 men and 11 women, aged 35 to 74 years. Vacuum cleaning led to a much greater increase in the product of heart rate and systolic blood pressure (DP) than did window cleaning, bathroom cleaning or ironing. It also led to an increase in heart rate to 70-90% of maximum heart rate during the exercise test and 47-65% of the maximal DP on the exercise test. Although the women were more accustomed to these tasks than the men, they did not appear to benefit from any training effect. The average level of DP observed in some patients during domestic tasks was comparable to that of a maximum exercise test indicating that they were not adequately prepared for a return to household activities.

CONCLUSION

Domestic tasks should not be underestimated as they can lead to a significant increase in DP. They tend not to be taken into account in the rehabilitation of patients after a myocardial infarction.

CLINICAL REHABILITATION IMPACT

The traditional methods of rehabilitation are not well adapted for resumption of domestic life, especially for women who are most involved in these activities. We recommend an individual approach involving performance of real life tasks taking account of the personality of the patients, their lifestyle and home environment.

[Surgical excision of subclinical cortisol secreting incidentalomas: Impact on blood pressure, BMI and glucose metabolism]

OBJECTIVES

To compare clinical, vascular and metabolic parameters before and after surgery in patients with subclinical cortisol secreting incidentalomas.

PATIENTS AND METHODS

Eight patients were investigated before and 12 months after removal of the mass on hemodynamic (blood pressure by MAPA procedure), anthropometric (body weight, body mass index), and metabolic parameters (glucose level, HbA(1c)).

RESULTS

In the whole group, 75% of patients displayed decrease in blood pressure (cessation of at least one hypotensive medication) and 33% of them were definitely cured of hypertension. Seventy-one percent of patients lost body weight and 37.5% lost more than 5%. In the whole group of patients, glucose level decreased by 1.1% and medical treatment was discontinuated in two of three diabetic patients.

CONCLUSION

Subclinical cortisol secreting adrenal incidentalomas are associated with cardiovascular risk factors that may be corrected after removal of the mass. Therefore, surgery may be an appropriate choice in patients with subclinical Cushing's syndrome to improve hypertension, body weight and impaired glucose level. Controlled studies comparing surgical treatment to a medical follow-up including optimal cardiovascular risk factors treatment are needed to define the usefulness of surgery in hypertensive patients with subclinical cortisol secreting incidentalomas.

Magnitude of the early morning blood pressure surge in untreated hypertensive patients: a pooled analysis

OBJECTIVES

A post hoc analysis was performed to assess the magnitude of the early morning blood pressure surge (EMBPS), which is associated with peak cardiovascular risk, in untreated hypertensive patients enrolled in two sister studies (Prospective, Randomised Investigation of the Safety and efficacy of MICARDIS vs. ramipril using ambulatory blood pressure monitoring I and II) with identical design.

METHODS

In adults with a mild-to-moderate primary hypertension and no significant comorbidities, 24-h ambulatory blood pressure monitoring was conducted after a 2- to 4-week placebo run-in period and before treatment initiation. Individual blood pressure measurements at 20-min intervals were analysed.

RESULTS

In 1419 hypertensive patients with normal sleeping times, blood pressure displayed a typical circadian rhythm, with a mean EMBPS of 29/24 mmHg. An EMBPS of >or= 25 mmHg was observed in around 60% of patients. The surge was significantly increased with smoking, alcohol consumption, longer sleep, later waking times, and increased blood pressure variability during waking and sleeping. The magnitude of the EMBPS was significantly reduced in Black vs. White patients. The surge was not affected by gender, body mass index or duration of hypertension. Further analysis showed that ethnicity, alcohol consumption and smoking were all found to have a significant impact on surge around waking and age, sleep duration and sleep blood pressure variability were all found to have an effect on the prewake surge.

CONCLUSIONS

In untreated hypertensive patients, the magnitude of the EMBPS is significant when compared with the 24-h mean and is affected by individual patient characteristics. In light of these findings, physicians should understand the importance of 24-h blood pressure control and the modification of certain lifestyle factors as ways of reducing the EMBPS.

Acoustic videodensitometric parameters correlate with abnormalities of left ventricular filling in hypertensive patients assessed via Doppler Tissue Imaging

PURPOSE

Using a videodensitometric technique developed in our center we investigated whether the amplitude of variation of gray levels in the interventricular septum was related to functional parameters, especially ventricular filling as studied by doppler tissue imaging (DTI) in hypertensive patients.

METHODS AND RESULTS

We included 35 hypertensive patients from whom we recorded a two dimensional sequence of the left ventricle from the short axis parasternal view and a doppler tissue scan of the mitral ring. Two-dimensional sections were then analyzed with Iodp software to measure variations in levels of gray in the septum. We observed significant correlations between these variations and the velocity of the Ea wave on DTI of the lateral wall (r = 0.49, p < 0.002). On dividing this population into three sub-groups according to the Appleton classification of ventricular filling, we noted a tendency to a reduction in amplitude of variations of gray of the septum in cases with abnormalities of relaxation. This was even more marked in cases with a restrictive or pseudo-normal profile.

CONCLUSION

These observations point to the interest of sonographic videodensitometry in the evaluation of hypertensive cardiopathy. Further studies will be required to determine whether it can define the extent of the abnormalities of myocardial structure and the degree of fibrosis.

Arterial stiffness predicts severe progression in systemic sclerosis: the ERAMS study

OBJECTIVE

The ERAMS study addressed the value of arterial stiffness in predicting the severity of systemic sclerosis.

METHODS

ERAMS was a prospective multicentre cohort study including patients with definite systemic sclerosis. Arterial stiffness was measured by the standardized non-invasive QKd 100-60 method. Clinical evaluation, biological measurements, functional respiratory tests and cardiac Doppler echography were performed at inclusion then each year until 3 years' follow-up was completed. Progression was defined as mild (articulations, muscle, oesophagus or skin involvement) or severe (lung, heart or kidney involvement) by a critical event committee. The prediction of severe progression was studied for QKd 100-60 as well as clinical and biological data at baseline by univariate and multivariate analysis.

RESULTS

Ninety-nine patients were included (81 women, 18 men, mean age 57 years, standard deviation 12.5). Although their blood pressure profile was normal, half the patients had increased arterial stiffness (QKd 100-60<200 ms). There was a significant relationship between age-adjusted arterial stiffness and decrease in carbon dioxide diffusion (P<0.03) or haemoglobin rate (P<0.01). By univariate analysis, severe progression after 3 years was predicted by age (P=0.04), lung involvement (P=0.04), diffusion of lung carbon oxide (DLCO) (P<0.01), skin score (P=0.02), haemoglobin (P<0.01) and baseline Qkd 100-60 divided into two classes according to the median (P<0.01). By multivariate analysis, only haemoglobin rate [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.2-0.9] and QKd 100-60 (OR 19.6, 95% CI 1.2-308.2) predicted severe progression of systemic sclerosis.

CONCLUSION

The measurement of arterial stiffness by the QKd method is a useful objective method for assessing the prognosis of systemic sclerosis independently from other data.

The effect of telmisartan and ramipril on early morning blood pressure surge: a pooled analysis of two randomized clinical trials

OBJECTIVES

The period of early morning blood pressure surge is associated with a higher incidence of cardiovascular events than at other times of the day. Antihypertensive medication given once daily in the morning may not protect against this surge if its duration of action is too short. We compared telmisartan, an angiotensin II receptor blocker with a trough-to-peak ratio >90%, with ramipril, an angiotensin-converting enzyme inhibitor with a trough-to-peak ratio of around 50%.

METHODS

Data from two prospective, randomized, open-label, blinded endpoint studies comparing telmisartan force titrated to 80 mg once daily and ramipril 10 mg once daily were pooled. Patients had mild-to-moderate hypertension and were assessed using 24-h ambulatory blood pressure monitoring at baseline and endpoint. Early morning blood pressure surge was defined as the difference between mean blood pressure within 2 h after arising and night-time low. Patients were grouped into quartiles according to their baseline systolic surge.

RESULTS

Data from 1279 patients were analyzed. Telmisartan changed the overall mean (SE) systolic surge by -1.5 (0.47) mmHg, and ramipril by +0.3 (0.47) mmHg (P=0.0049). The magnitude of surge reduction was greatest in the quartile with highest baseline systolic surge: telmisartan -12.7 (0.91), ramipril -7.8 (1.02) mmHg (P=0.0004). Telmisartan also reduced the surge compared with ramipril in dippers, but there were no differences between the two groups in nondippers.

CONCLUSIONS

Telmisartan significantly reduced the early morning systolic blood pressure surge compared with ramipril. A reduction in this surge may help to reduce cardiovascular events in the morning period.

Ambulatory blood pressure in hypertensive patients with left ventricular hypertrophy: efficacy of first-line combination perindopril/indapamide therapy

BACKGROUND

Ambulatory blood pressure (BP) is more sensitive than office BP and is highly correlated with the left ventricular mass (LVM) of hypertensive patients with left ventricular hypertrophy (LVH).

METHODS

In this prospectively designed ancillary study of the PICXEL trial, the effects of first-line combination perindopril/indapamide on ambulatory BP were compared with those of monotherapy with enalapril in 127 patients. Hypertensive patients with LVH received once daily either perindopril 2 mg/indapamide 0.625 mg (n = 65) or enalapril 10 mg (n = 62) for 52 weeks. Dose adjustments were allowed for uncontrolled BP. Twenty-four-hour ambulatory BP and echocardiographic parameters were measured at baseline, week 24, and week 52.

RESULTS

At study end, both treatments significantly improved ambulatory BP compared with baseline (p < or = 0.01). Perindopril/indapamide treatment reduced 24-hour and daytime systolic BP (SBP) and pulse pressure (PP) significantly more than enalapril treatment (p < 0.01). No significant between-group differences were noted for diastolic BP (DBP) or for night-time measurements. Trough/peak ratios were higher with perindopril/indapamide than with enalapril (88.5 vs 65.8 for SBP and 86.7 vs 63.9 for DBP, respectively). The global smoothness index was higher with perindopril/indapamide than with enalapril (6.6 vs 5.2 for SBP and 5.6 vs 4.9 for DBP, respectively). With perindopril/indapamide treatment, LVM index was significantly reduced (-9.1 g/m2 from baseline; p vs baseline <0.001). More patients required dose increases with enalapril (87%) than with perindopril/indapamide (71%). No unusual safety elements were noted.

CONCLUSIONS

First-line perindopril/indapamide combination decreased ambulatory SBP and PP, and LVM more effectively than enalapril.

Can ambulatory blood-pressure monitoring provide reliable indices of arterial stiffness?

BACKGROUND

The use of ambulatory recordings of blood pressure (BP) was proposed to estimate arterial stiffness (AS). We compared the relative value of the ambulatory AS index (AASI), and of the slope of pulse pressure (PP) according to mean BP (MBP) obtained from 24-h ambulatory BP monitoring, to the monitoring of the arrival time of Korotkoff sounds (QKD interval) in the prediction of cardiovascular (CV) events.

METHODS

Twenty-four-hour ambulatory BP and QKD monitoring were recorded at baseline, before antihypertensive treatment of hypertensive patients in our Bordeaux cohort. From these recordings, the AASI, the PP/MBP slope, and the theoretical value of the QKD for a systolic pressure of 100 mm Hg and a heart rate of 60 beats/min (QKD100-60) were calculated. The patients were then given antihypertensive treatment and followed by their family physicians, who were unaware of the QKD, AASI, and PP/MBP slope results. Regular updates on patients were obtained. The reproducibility of measurements was studied in 38 normal subjects evaluated on two occasions.

RESULTS

The reproducibility of the AASI and the PP/MBP slope was less than that of BP over 24 h and of QKD100-60. The cohort comprised 469 patients. With an average follow-up of 70+/-39 months, 62 CV complications, including 13 deaths, were recorded. In the monovariate analysis, age, PP over 24 h, QKD100-60, AASI, and the PP/MBP slope were significantly related to the occurrence of complications. In the multivariate analysis, when age and PP over 24 were included in the model, only QKD100-60 remained significantly linked to CV events.

CONCLUSIONS

Our data support the value of the AASI as an indirect estimate of AS and as an element in the evaluation of CV risk in hypertensive patients. However, the reproducibility of this index is less, and its predictive value for complications is poorer, than that of QKD100-60, a parameter that we believe is more closely linked to AS.

A review of telmisartan in the treatment of hypertension: blood pressure control in the early morning hours

Measurement of blood pressure in the clinic may provide a false impression of blood pressure control. Ambulatory blood pressure monitoring (ABPM) allows the automatic recording of the circadian variation in blood pressure and evaluation of the efficacy of antihypertensive medication throughout the dosing interval. Ambulatory blood pressure provides more effective prediction of cardiovascular risk; blood pressure control at the time of heightened risk in the early morning after waking and before taking the next dose of medication is becoming important in order to improve long-term prognosis. To achieve blood pressure control in the early morning, a long-acting antihypertensive agent is essential. Telmisartan, an angiotensin II receptor blocker, as well as having a terminal elimination half-life of 24 h, has a large volume of distribution due to its high lipophilicity. The efficacy of telmisartan 80 mg monotherapy has been demonstrated using ABPM, with superior reduction in mean values for the last 6 h of the dosing interval compared with ramipril 10 mg and valsartan 80 mg. In addition, telmisartan 80 mg provides superior blood pressure control after a missed dose compared with valsartan 160mg. When combined with hydrochlorothiazide (HCTZ) 12.5 mg, telmisartan 40mg and 80mg is more effective than losartan/HCTZ (50/12.5 mg) at the end of the dosing interval. Furthermore, greater reductions in last 6 h mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) are achieved with telmisartan/HCTZ (80/12.5 mg) than with valsartan/HCTZ (160/12.5 mg) in obese patients with type 2 diabetes and hypertension. Recent data from a large group of patients show that telmisartan 80 mg controls the early morning blood pressure surge more effectively than ramipril 5-10 mg and, thus, may have a greater beneficial effect on long-term cardiovascular risk. This supposition is being tested in the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) programme.

Different effects of ambulatory blood pressure monitoring on subjective and objective sleep quality

OBJECTIVE

To determine whether ambulatory blood pressure monitoring affects objective and subjective sleep quality in patients tested at home.

METHODS

Seventy consecutive patients (40 women and 30 men, aged 53+/-15 years), having ambulatory blood pressure monitoring to monitor the efficacy of antihypertensive treatment or to distinguish between hypertension or white-coat hypertension had an evaluation of their sleep quality on a first night with ambulatory blood pressure monitoring and the three following nights without ambulatory blood pressure monitoring. Ambulatory blood pressure monitoring was performed with an auscultatory device with a measure every 15 min during 24 h. Sleep evaluation criteria were both subjective (sleep quality score and sleep questionnaire) and objective (wrist actigraphy monitoring). Sleep parameters during night 1 with ambulatory blood pressure monitoring were compared with those during night 4 without ambulatory blood pressure monitoring. Usual quality of sleep of the patients was assessed by the mean sleep quality score over 7 consecutive days.

RESULTS

The sleep quality score was significantly higher for night 4 than for night 1 (7.3+/-2.1 vs. 5.3+/-2.3; P<0.0001). In contrast, actigraphy parameters (actual sleep time, mean activity score, and fragmentation index) were similar on night 1 and night 4 (6.7+/-1.2 vs. 6.9+/-1.2, 13.2+/-9.8 vs. 12.1+/-8.4, and 31.0+/-14.5 vs. 29.9+/-14.3, respectively). Subjective sleep quality was significantly altered by ambulatory blood pressure monitoring in good sleepers (mean sleep quality score > or =7, 73% of patients) but not in poor sleepers. The effect of ambulatory blood pressure monitoring on subjective sleep quality did not differ between dippers and nondippers.

CONCLUSIONS

Objective sleep quality as assessed by wrist actigraphy is not significantly altered by ambulatory blood pressure monitoring, whereas subjective sleep quality is adversely affected in good sleepers.

Early Morning Blood Pressure Surge

Alterations in the circadian rhythm of blood pressure, whether a loss of the nighttime dip or an exaggeration of the early morning increase that occurs upon rising, indicate increased cardiovascular risk. Estimates of the magnitude of the blood pressure surge on rising vary depending on technique and population, but it is usually around 10-30 mm Hg systolic and 7-23 mm Hg diastolic. The magnitude of the surge increases with age, alcohol consumption, and smoking and is greater in whites. Blood pressure variations and morning plasma aldosterone are closely correlated. A high morning surge is linked to increased target organ damage as well as strokes and other cardiovascular complications. Therapeutic options exist to reduce the magnitude of the morning blood pressure surge-notably, the use of drugs with a long duration of action, the use of medications that specifically antagonize the morning surge (such as alpha blockers), and the administration of drugs upon awakening but before rising.

The prospective, randomized investigation of the safety and efficacy of telmisartan versus ramipril using ambulatory blood pressure monitoring (PRISMA I)

OBJECTIVE

To compare the efficacy and safety of once-daily telmisartan and ramipril on blood pressure (BP) reductions during the last 6 h of the dosing interval.

PATIENTS AND METHODS

In a prospective, randomized, open-label, blinded-endpoint study using ambulatory BP monitoring, 801 patients with mild-to-moderate hypertension were randomly assigned to once-daily treatment with telmisartan 80 mg for 14 weeks or ramipril 5 mg for 8 weeks and then force titrated to ramipril 10 mg for the last 6 weeks. Primary endpoints were the reduction from baseline in the last 6-h mean ambulatory systolic BP (SBP) and diastolic BP (DBP). Secondary endpoints included changes in 24-h, morning, daytime and night-time mean ambulatory BP and ambulatory BP response rates.

RESULTS

Telmisartan 80 mg produced greater reductions in the last 6-h mean ambulatory SBP and DBP compared with ramipril 5 mg (P < 0.0001) and 10 mg (P < 0.0001), and was superior to ramipril for all secondary ambulatory SBP and DBP endpoints (P < 0.05). Ambulatory BP response rates (24-h mean ambulatory SBP/DBP < 130/80 mmHg or reduction from baseline > or = 10 mmHg) were greater with telmisartan 80 mg (P < 0.01) than with ramipril 5 and 10 mg. Ramipril was associated with a higher incidence of treatment-related cough (5.7 versus 0.5% for telmisartan).

CONCLUSIONS

Telmisartan was significantly more effective than ramipril in reducing BP throughout the 24-h dosing interval and particularly during the last 6 h, a time when patients appear to be at greatest risk of cerebro- and cardiovascular events. Both drugs were well tolerated, although ramipril was associated with a higher incidence of cough.

Perindopril/indapamide combination more effective than enalapril in reducing blood pressure and left ventricular mass: the PICXEL study

OBJECTIVE

Few data are available comparing the effects of monotherapy and combination therapy on target organ damage. The PICXEL study compared the efficacy of a strategy based on first-line combination with perindopril/indapamide versus monotherapy with enalapril in reducing left ventricular hypertrophy (LVH) in hypertensive patients.

METHODS

In this 1-year multicentre randomized double-blind study, patients received an increasing dosage of perindopril/indapamide (n = 284) or enalapril (n = 272). Changes in blood pressure and echocardiographic measures of LVH were assessed from baseline to the end of treatment. Reading of the echocardiograms was central and blinded for therapy, patient and sequence.

RESULTS

Systolic and diastolic blood pressure decreased significantly more in the perindopril/indapamide than in the enalapril group (P < 0.0001 and P = 0.003). The left ventricular mass index decreased by 13.6 +/- 23.9 g/m(2) (mean +/- SD) with perindopril/indapamide (P < 0.0001) and 3.9 +/- 23.9 g/m(2) with enalapril (P < 0.005); these decreases were significantly different (P < 0.0001). The left ventricular internal diameter, posterior and interventricular septal wall thickness decreased significantly with perindopril/indapamide (P < or = 0.0001); the interventricular septal wall thickness decreased significantly with enalapril (P < 0.001). Both treatments were well tolerated.

CONCLUSION

A strategy based on first-line combination with perindopril/indapamide achieved better blood pressure decrease with a significantly greater degree of LVH reduction than a strategy based on monotherapy with enalapril in hypertensive patients with LVH.

Arterial stiffness and plasma creatinine in untreated hypertensive patients

BACKGROUND

Increased arterial stiffness is a common feature of hypertensive subjects with renal failure, independently of age, office blood pressure (BP), and traditional cardiovascular risk factors including atherosclerosis but not diabetes mellitus. Recently a reduction in creatinine clearance was shown to be associated with increased arterial stiffness in patients with normal or elevated BP and mild renal failure, and the association was noted to be stronger in subjects <55 years of age. We wanted to study this relationship in a population of newly recognized hypertensive subjects with preserved renal function using another method to assess arterial stiffness and to see whether it was independent of 24-h BP.

METHODS

In 263 untreated hypertensive subjects with plasma creatinine <135 micromol/L, 24-h ambulatory BP was measured before any treatment using a validated device enabling automatic measurement of arterial stiffness in parallel. The age median was 48 years in this population. Accordingly the population was split into two groups: those < 48 and those > or =48 years of age.

RESULTS

Arterial stiffness and plasma creatinine were positively and significantly correlated, independently of age, height, gender, traditional risk factors and 24-h BP measurements. A significant correlation was observed whether subjects were younger (< 48 years) or older (> or =48 years).

CONCLUSIONS

In untreated hypertensive subjects with preserved renal function, arterial stiffness and plasma creatinine were found to be positively related, independent of age and ambulatory BP, suggesting an independent link between the two parameters at an early phase of hypertensive vascular disease.

[Prognostic value of QKD interval corrected by QRS duration in hypertensive patients]

OBJECTIVES

The QKD interval is measured between the onset of QRS on the ECG and detection of last Korotkoff sound by a microphone placed on the brachial artery while measuring BP. It is the sum of preejection time and pulse transmission time and thus is correlated to pulse wave velocity (PWV). This interval is automatically monitored with BP and HR every 15 minutes during 24 h with an ambulatory blood pressure monitoring device (Diasys integra, Novacor, France). The 96 measurements obtained allow to automatically calculate the QKD(100-60), QKD value for 100 mmHg SBP and 60 bpm HR. This indice of arterial stiffness has been shown to be linked to future cardiovascular (CV) events, independently of 24 h BP. However this interval may be abnormally prolonged in case of left bundle branch blocks (LBBB).

METHODS

We tested the effects of simply removing QRS duration from QKD(100-60) value on the prediction of CV events in a population of 412 hypertensives (247 males: age = 53 +/- 14 years; office BP = 158 +/- 19/97 +/- 11 mmHg; 24 h BP = 133 +/- 17/86 +/- 11 mmHg) followed prospectively.

RESULTS

Mean follow up was 65 months, 32 pts were lost, 49 CV events occurred including 11 deaths. Cox model showed that baseline QKD(100-60) (m = 202 +/- 19; 142-254 ms) was significantly (p < 0.05) associated to events independently of age, 24h SBP and other traditional risk factors. Removing QRS duration (m = 85 +/- 10: 61-158 ms) improves the relation to events (monovariate khi2 = 38 vs 30).

CONCLUSION

Removing QRS duration from QKD(100-60) improves its predictive value of future CV events and allows using this method in patients with LBBB.

[Arterial rigidity of patients operated successfully for coarctation of the aorta without residual hypertension]

In patients successfully operated for coarctation of the aorta, the prevalence of hypertension is higher than that observed in the general population although the exact mechanism is not known. The hypothesis of increased arterial rigidity despite satisfactory correction of the coarctation has been proposed. The authors undertook 24 hour ambulatory blood pressure monitoring coupled with measurement of the QKD interval (pulse wave velocity) in order to evaluate the rigidity of the large arteries. These results were compared with those obtained in control patients paired with respect to gender, age, height and weight. Twenty-six patients with an average age of 14.5 +/- 2.9 years were included (age at time of surgery 6.3 +/- 3.7 years). The statistical data confirmed a higher systolic blood pressure (p<0.05) in the operated patients compared with controls. The results confirm the hypothesis of increased residual arterial rigidity in children operated for coarctation of the aorta which could predispose to secondary hypertension, especially on effort. In the long term, this could be an unquestionable cardiovascular risk factor explaining the increased cardiovascular morbid-mortality compared with the general population.

Left ventricular hypertrophy as a predictor of cardiovascular risk

Left ventricular hypertrophy (LVH) is a potent, independent predictor of cardiovascular events, particularly in hypertension, in which it dramatically increases the risk of stroke, coronary heart disease and heart failure. LVH is predominantly a surrogate marker for the effects of other risk factors integrated over time, but it may also contribute directly to cardiovascular disease through pathological changes in cardiac structure. The influence of blood pressure is central to LVH pathology, with 24-h blood pressure being more predictive of LVH than single clinic measurements. Blood pressure variation throughout the day is also emerging as an important correlate of LVH, and a strong association has been found between the early morning blood pressure rise and increased left ventricular mass. Antihypertensive treatment can reverse LVH, and preliminary studies suggest that this improves cardiovascular outcome and long-term prognosis. Most classes of antihypertensive agent show some effect on LVH regression, with the notable exceptions of minoxidil and hydralazine. However, many of the data regarding LVH regression come from small, poor-quality trials or from meta-analyses of these studies. In the few well-conducted studies that are available, certain classes of antihypertensive drugs are more effective than others. Those that target angiotensin II, such as the angiotensin II receptor blockers, appear to have a specific action on LVH that is independent of blood pressure reduction. Further high-quality studies are needed to define how LVH predicts cardiovascular risk, which agents are most effective at eliciting LVH regression and how such reversal can affect cardiovascular outcome.

Arterial stiffness evaluated by measurement of the QKD interval is an independent predictor of cardiovascular events

BACKGROUND

The QKD interval is the time between the QRS wave on the electrocardiogram (ECG) and the detection of the last Korotkoff sound during BP measurement. Measurement of the QKD interval during ambulatory blood pressure (BP) monitoring provides an automatic evaluation of arterial stiffness. The objective of this longitudinal study was to examine the relationship between arterial stiffness assessed by this method and the occurrence of cardiovascular complications in a cohort of initially untreated hypertensive patients.

METHODS

The initially untreated hypertensive patients were included in the cohort of hypertensives recruited to our center between January 1992 and December 1999. All benefited from ambulatory measurement of the QKD interval and BP over 24 h. Most of these patients were given antihypertensive treatment and were followed up by their family physicians, who were unaware of the QKD results. Their outcome was evaluated in 2003 by inquiring of the patients themselves or of their family physicians.

RESULTS

The initial population comprised 412 patients. At the end point, 33 had been lost to follow-up. We recorded 49 cardiovascular events in this population with an average follow up of 65 +/- 36 months. In a Cox model, the arterial stiffness assessed by the QKD(100-60) as a percentage of the height-predicted normal value was significantly associated with the occurrence of cardiovascular complications, independent of age and mean 24-h BP.

CONCLUSIONS

This study using ambulatory measurement of the QKD interval showed that an increase in arterial stiffness was a marker of cardiovascular risk. We show for the first time that its value persists after taking account of the mean systolic pressure over 24 h.

[Biochemical detection of Conn's adenoma: definition of criteria and reference values]

Primary hyperaldosteronism is a diagnosis which should be considered in refractory hypertension even in the absence of any hypokalaemia. Its detection relies above all on the levels of renin and aldosterone. The aldosterone/renin ratio has been proposed as the most sensitive criterium. The reference values used for the diagnosis of primary hyperaldosteronism are very variable in the literature, depending not only on the method used but also on the criteria used for their determination. In this study we evaluated the defined reference values prospectively by studying a population of patients with a Conn's adenoma treated surgically. The study included an initial retrospective period which allowed identification of 29 cases of Conn's adenoma treated surgically, and a 9 month prospective period during which 212 reports were collected. During this prospective period a further 9 cases of Conn's adenoma were detected, which were successfully treated with surgery. Analysis to discriminate the 38 Conn's adenomata from the rest showed that 3 parameters contributed significantly and independently to the diagnosis: supine plasma renin activity (ARPc), supine aldosteronaemia and the erect aldosterone/renin ratio, allowing correct classification in 88% of the cases. The reference ranges of these 3 parameters were calculated in order to give a sensitivity of 100% and the best possible specificity, therefore allowing a combined criterium involving all 3 parameters to be defined: ARPc < 0.45 ng/ml/h, supine aldosteronaemia >417 pmol/l, and erect aldosterone/renin >1180.

Serial echocardiographic assessment of left ventricular mass

OBJECTIVES

In addition to the interest of mixing the sequence of echo-exam in a central blinded review, we studied the effect that might result from group-analysis of all echocardiograms simultaneously for each patient, with their sequence kept blind. A priori, this method of reading has the potential of decreasing measurement variability.

METHODS

We included 630 echocardiograms from 210 hypertensive patients participating in a randomized clinical trial comparing two antihypertensive agents for regression of left ventricular (LV) hypertrophy. Three echocardiograms per patient [selection (4 weeks before; W-4), at inclusion (week 0; W0), and the end of treatment (week 52; W52)], were read twice, according to two methods, blind to centre, patient numbers and sequence of visits: (1) examination of individual serial echocardiograms, (2) examination of all-patient mixed echocardiograms. The first method was expected to increase the power of treatment comparison by reducing variability of measurements of left ventricular mass (LVM).

RESULTS

Pooling echocardiograms of all patients reduces variability of LVM change under treatment: absolute LVM (W52 - W0) standard deviation was reduced by 22%. Nevertheless, despite a good between-methods agreement for LVM values at each visit (intra-class coefficient of correlation from 0.88 to 0.92), LVM change under treatment was reduced even more, by 41%. Thus, the slight decrease of variability induced by gathering the echocardiograms is associated with an even greater reduction of LVM change.

CONCLUSIONS

According to these findings, the 'full-blind' methodology for a central blinded review in clinical trials appears to produce the maximum power of the study with the lowest sample size.

Blood pressure surge on rising

OBJECTIVES

Since cardiovascular complications tend to occur more often in the morning, it is tempting to link this to the surge in blood pressure (BP) on rising. Our objective was to measure BP and heart rate (HR) on rising and compare values with those recorded immediately beforehand and seek variables related to marked changes in the two parameters in a cohort of initially untreated hypertensives.

METHODS

The 24-h ambulatory BP measurement along with an accurate measurement of the BP on rising (either manually or automatically from the device coupled with a position sensor) was obtained in untreated hypertensives. Left ventricular mass was measured with echocardiography at baseline. Patients were then treated and followed by their general physician and news was obtained at regular intervals.

RESULTS

A total of 507 patients with adequate recordings were included. Rising led to a mean increase of 14 mmHg in systolic blood pressure (SBP) and a 13 beats per minute (bpm) increase in HR. This elevation in BP on rising in the morning differed from the alteration in BP on normal changes in position. It was associated with left ventricular hypertrophy at baseline and an increased risk of future cardiovascular complications.

CONCLUSIONS

Our study confirms the surge in BP on rising in the morning. This elevation in BP is accompanied by an acceleration in cardiac rhythm with no significant correlation between the two parameters. The increase in BP on rising was linked with the overall variability in BP, but was independent of the mean BP over 24 h. It was associated with an increased risk of cardiovascular complications independently of age and average 24-h SBP.

[Malignant hypertension. Case series of 42 patients]

One could expect that malignant hypertension would belong to the history. Unfortunately, this complication has not been eradicated even though many physicians have already forgot it. The hypertension care units are still confronted to it, and even the arrival of the renin-angiotensin system blockers have changed the prognosis of those patients, an adequate management on emergency remains mandatory in order to avoid in particular the evolution to renal failure. By reporting a series of 42 patients included in a period of 7 years, we aimed to remind the presentation of this severe pattern of hypertension and the basics of its management.

Effects of perioperative alpha1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma

BACKGROUND

Laparoscopic surgery for phaeochromocytoma can cause excessive catechol amine release with severe hypertension and sinus tachycardia. i.v. calcium antagonists may be used to prevent increases in blood pressure during phaeochromocytoma resection. We investigated the effects of perioperative alpha(1) adrenergic block with urapidil on intraoperative haemodynamic events. The aim was to block the alpha(1) adrenergic receptors before any acute catecholamine release, to prevent any severe rise in blood pressure.

METHODS

Eighteen patients with a phaeochromocytoma received a continuous i.v. infusion of urapidil 10-15 mg h(-1) for 3 days before surgery and until the adrenal gland had been removed. Plasma catecholamine concentrations were measured before surgery, after induction of anaesthesia, at the end of pneumoperitoneal insufflation, during gland manipulation, after gland resection, and in the recovery room after extubation. Arterial pressure was recorded concomitantly. Hypertensive events were treated with boluses of nicardipine with or without esmolol.

RESULTS

All patients had the adrenal tumour removed without any severe rise in blood pressure or other complication. Creation of a pneumoperitoneum and adrenal gland manipulation induced significant catecholamine release associated with hypertension in 6 and 12 patients, respectively. No correlation was found between hypertensive events and plasma catecholamine levels suggesting alpha(1) receptor block with urapidil is efficacious.

CONCLUSIONS

Perioperative alpha(1) block using i.v. urapidil is a safe and efficient alternative during surgical management of phaeochromocytoma.

Validation of a two-axis accelerometer for monitoring patient activity during blood pressure or ECG holter monitoring

OBJECTIVES

The aim of the study was to evaluate the efficiency of a position/activity monitoring system based on a dual-axis accelerometer strapped to the subject's thigh and a position sensor located within a monitor placed on the subject's belt.

METHODS

Twenty-six subjects wearing two monitors (one accelerometer on each thigh) were submitted to various activities and positions under the control of an observer. An analysis of each tracing was performed both manually by a technician and automatically by dedicated software before being compared with the information gathered during the study.

RESULTS

The accelerometer allowed accurate discrimination between the standing versus the sitting and lying positions. The sitting and lying positions were correctly detected by the built-in position sensor provided the unit was firmly attached. Walking was adequately detected by the accelerometer. The activity score was well correlated with treadmill speed. Changes in position and activity were detected with a mean error of less than 3 s.

CONCLUSIONS

The combination of an accelerometer placed on the subject's thigh and a position sensor located at the subject's waist appeared to be a suitable system for position/activity monitoring during ambulatory ECG and blood pressure monitoring.