Change in cardiovascular risk profile by echocardiography in medium-risk elderly hypertensives

Most advisable strategy in search of asymptomatic target organ damage in hypertensive patients

OBJECTIVE

To evaluate the diagnostic potential of seven examinations in order to define the most suitable strategy for target organ damage (TOD) search in hypertensive patients.

METHODS

This is a descriptive, cross-sectional study. 153 consecutive treated and essential hypertensive patients were enrolled. Patients with established cardiovascular or chronic renal disease (stage ≥4) were excluded. TOD search was assessed by: glomerular filtration rate (GFR), albumin/creatinine ratio (ACR), electrocardiogram (ECG), echocardiogram (ECO), ankle-brachial index (ABI), pulse wave velocity (PWV), and carotid ultrasound (intima media thickness and presence of plaques). The rationale of our strategy ought to determine the performance of applying a set of the most widely available tests (GFR, ACR, ABI, ECG) and advise about the optimal sequence of the remaining tests.

RESULTS

The sample was 64.4±7.9 years old, 45.8% males. 82.6% of the sample had any TOD at all. The resulting algorithm found a 37% TOD in relation to GFR, ACR, ABI and ECG values. Adding carotid ultrasound added up to 70% of the studied population and properly classified (TOD+/TOD-) 89% of the cohort. When performing PWV, 78% of the patients had been identified as TOD+ and 96% of the population was correctly identified. Contribution of ECO was minor.

CONCLUSION

After running the more widely available explorations (GFR, ACR, ABI, ECG), a step-by-step strategy that included carotid ultrasound, PWV and ECO could be the best sequence for TOD search in asymptomatic hypertensive patients.

Cardiovascular risk stratification in unselected primary care patients with newly detected arterial hypertension

Cardiovascular risk (CVR) stratification in patients with arterial hypertension is essential. Few data are available on CVR factors (CVRFs), hypertensive target organ damage (TOD) and overall CVR in medical outpatients with newly detected arterial hypertension. General medical patients entering the Medical Outpatient Department of the University Hospital Basel, Switzerland, were screened for elevated office blood pressure (OBP of >140/90 mm Hg). Patients with newly detected arterial hypertension (elevated OBP at two consultations) underwent a work-up that included fundoscopy, urinalysis, ambulatory blood pressure (ABP) monitoring, ECG and echocardiography. CVR was calculated according to the 1999/2003 World Health Organization/International Society of Hypertension (WHO/ISH) guidelines. A total of 2615 outpatients were screened. Of 580 patients with elevated first OPB, 207 were treated for hypertension, 98 refused to participate, 8 were early dropouts and 36 had a normal second OBP. Data from 212 patients were analyzed (mean age 53+/-14 years). The first and second OBP readings were 162+/-6/100+/-6 and 153+/-14/96+/-9 mm Hg, respectively. Mean ABP was 134+/-12/83+/-9 mm Hg, and sustained hypertension was found in 76.9% of patients. Among patients with hypertension according to OPB monitoring, 61.3% had 1 or 2 CVRFs, and 33.0% had >or=3 CVRFs. Evidence of TOD, diabetes or associated clinical conditions (ACCs), such as renal or cardiovascular disease, was found in 26.4, 5.6 and 7.1% of patients, respectively. In terms of CVR, 2.4% of patients were at low risk, 25.9% at medium risk and 71.7% at high risk. No differences existed between white coat and sustained hypertensives regarding CVRFs, TOD or ACCs. Comprehensive analysis in patients with newly detected arterial hypertension revealed a surprisingly high prevalence of CVRFs, TOD and ACCs, indicating high CVR in the majority of these patients.

[High cardiovascular risk due to inadequate control of risk factors in Spanish hypertensive patients seen in the Spanish primary care]

INTRODUCTION

Cardiovascular diseases are the main cause of morbidity-mortality in Spain. Hypertension and the other cardiovascular factors are important in the pathophysiological basis of this fact. Control of the main risk factors in treated hypertensives was evaluated in this study.

PATIENTS AND METHODS

Multicenter study in hypertensive patients treated in Primary Care. Blood pressure, cardiovascular risk factors as well as registered target organ damage and clinical diseases were measured. Finally, global cardiovascular risk was calculated.

RESULTS

Only 17.3% of pharmacologically treated hypertensives were controlled (3.9% of diabetic patients). LDL-cholesterol control deteriorated as the patient's cardiovascular risk pattern increased (90.4% in low risk and 19.9% in high-very high risk). High levels of serum creatinine were detected in 8.3%, microalbuminuria being positive in 15.6%, with 20.8% ventricular hypertrophy. A total of 31% of the patients were diabetic, 59.8% of them having HbA1c > or = 6.5%. Global CV risk was high very high in many subjects (65.4%) when European Society of Hypertension-European Society of Cardiology (ESH-ESC) guidelines were used. This percentage was 3.6% when the Spanish-validated Framingham score was used.

CONCLUSIONS

Blood pressure control as well as main cardiovascular risk factors is poor in this population. Considering this fact plus the number of target organ damage, the global risk is high in many patients according to the European guidelines. Guidelines that do not consider target organ damage do not estimate adequately the risk of this uncontrolled population. This conclusion could explain the clinical tendency of many doctors when attending uncontrolled patients.

Left ventricular hypertrophy and cardiovascular risk stratification: impact and cost-effectiveness of echocardiography in recently diagnosed essential hypertensives

BACKGROUND

Echocardiography is more accurate than electrocardiography in the assessment of cardiac target organ damage related to hypertension, thus leading to a more precise stratification of total cardiovascular risk. However, ultrasound examination of the heart on a routine basis remains a matter of debate.

OBJECTIVE

To evaluate the impact and cost-effectiveness of echocardiographic examination on global risk stratification in low and medium-risk hypertensive patients in relation to age and sex.

METHODS

A total of 580 untreated hypertensive individuals (355 men and 225 women, mean age 47.8 +/- 11.4 years), classified at low to medium risk, according to routine clinical work-up suggested by the 2003 European Society of Hypertension/European Society of Cardiology guidelines, were included in the study. Total risk was reassessed by adding the results of ultrasound examination of the heart. Left ventricular hypertrophy (LVH) was defined as a left ventricular mass index of 125 g/m2 or more in men and 110 g/m2 or more in women. The impact of LVH in stratifying risk was assessed according to age (< 50 and > or = 50 years) and sex.

RESULTS

According to routine classification, 16.3% (n = 93) of the 580 patients were considered to be at low added risk and 83.7% (n = 487) at medium added risk. In the whole population, echocardiographic LVH was found in 86 patients (14.8%) who were then reclassified in the high-risk stratum. The prevalence rates of patients reclassified in the high-risk class as a consequence of LVH detection, according to age and sex, were as follows: 8.9% in men under 50 years, 12.3% in women under 50 years, 26.7% in men aged 50 years and over and 15.3% in women aged 50 years and over. The cost per detected case of LVH was 595 euros in patients under 50 years of age and 290 euros in those 50 years of age and older.

CONCLUSIONS

Our findings indicate that the prevalence of LVH, and consequently the probability of upgrading the total cardiovascular risk profile, is highest in the group of old hypertensive men; echocardiography has a limited impact on the risk reclassification in younger patients and an unfavourable cost-effectiveness profile. Our data thus do not support the systematic ultrasound assessment of the heart in all uncomplicated hypertensive individuals.

C-reactive protein and echocardiography have little impact on risk stratification in never-treated hypertensive patients

The aim of this study was to assess the contribution of increased concentrations of high-sensitivity C-reactive protein (hsCRP) and echocardiography to risk stratification according to the 2003 European guidelines for the management of arterial hypertension in patients with untreated hypertension. A total of 207 consecutive medical outpatients with untreated hypertension were included. History and clinical examination, electrocardiography, laboratory analyses including the measurement of hsCRP and echocardiography were performed in all patients. Patients were classified into four risk groups with and without using echocardiography and hsCRP concentrations of at least 10 mg/l according to the 2003 guidelines for the management of hypertension. The majority of the 207 patients (81%) were at moderate or high cardiovascular risk before adding echocardiography and/or hsCRP to the risk stratification process. When echocardiography was included, only three patients were reclassified from the moderate added risk to the high added risk group. Adding hsCRP concentrations of at least 10 mg/l had no impact on risk stratification. Using an hsCRP cutoff level of 3 mg/l, one patient was at moderate instead of low added risk, eight patients were at high instead of moderate added risk and one patient was at very high instead of high added risk. We conclude that hsCRP at the proposed cutoff level of 10 mg/l has no impact on risk stratification in outpatients with untreated hypertension. An hsCRP cutoff level of 3 mg/l may be more suitable for risk stratification. Finally, our data suggest that depending on the population studied, there is minimal impact of echocardiography on risk stratification.

Influence of target organ lesion detection (assessment of microalbuminuria and echocardiogram) in cardiovascular risk stratification and treatment of untreated hypertensive patients

European guidelines indicate the importance of the evaluation of global cardiovascular risk (CVR) to determine the management of the hypertensive patients (EH). However, in primary care, the diagnostic work-up (PCD) only includes the metabolic risk factors. The aim of this study was to assess the importance of microalbuminuria (MA) and echocardiogram (ECHO) in the process of risk stratification, and the number of patients to be treated with drugs at diagnosis. In total, 155 nontreated EH were included in the study. Blood pressure, a lipid profile and plasma glucose (LG) were determined after an overnight fast. MA was evaluated with dipstick MICRALTEST, and in those patients with two positive results, it was measured again in two 24-h urine samples and was considered positive (MA+) if the average was >30 mg/24 h. Left ventricular mass index was calculated and values>125 g/m2 were considered as LV hypertrophy (LVH+). When the patients were stratified according to PCD, 22 had to be treated with drugs. When MA, ECHO and both tests used together were added to the risk evaluation, the number of patients to be treated were 42, 51 and 64, respectively (P<0.001 vs PCD). It is mainly in patients who have moderate cardiovascular risk that risk changes, whereas risk hardly changes in those having low and very high risk. In conclusion, in EH with moderate risk, measurement of MA, due to its easy availability and low cost, seems to be a cost effective screening test to avoid the underestimation of the CVR.