Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P <0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg; P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.

Clinical Trial Registration—

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

Suppression of Aldosterone Secretion After Recumbent Saline Infusion Does Not Exclude Lateralized Primary Aldosteronism

Guidelines recommend suppression tests such as the saline infusion test (SIT) to ascertain the diagnosis of primary aldosteronism (PA) in patients with a high aldosterone:renin ratio. However, suppression tests have only been evaluated in small retrospective series, and some experts consider that they are not helpful for the diagnosis of PA. In this study, we evaluated whether low post-SIT aldosterone concentrations do exclude lateralized PA. Between February 2009 and December 2013, 199 patients diagnosed with PA on the basis of 2 elevated aldosterone:renin ratio results and a high basal plasma or urinary aldosterone level or high post-SIT aldosterone level had a selective adrenal venous sampling. We used a selectivity index of 2 and a lateralization index of 4 to interpret the adrenal venous sampling results. Baseline characteristics of the patients were the following (percent or median): men 63%, 48 years old, office blood pressure 142/88 mm Hg, serum potassium 3.4 mmol/L, aldosterone:renin ratio 113 pmol/mU, plasma aldosterone concentration 588 pmol/L. The proportion of patients with lateralized adrenal venous sampling was 12 of 41 (29%) among those with post-SIT aldosterone <139 pmol/L (5 ng/dL) and 38 of 104 (37%) among those with post-SIT aldosterone <277 pmol/L (10 ng/dL). Post-SIT aldosterone levels were not associated with the blood pressure outcome of adrenalectomy. A low post-SIT aldosterone level cannot rule out lateralized PA, even with a low threshold (139 pmol/L). Adrenal venous sampling should be considered for patients who are eligible for surgery with elevated basal aldosterone levels even if they have low aldosterone concentrations after recumbent saline suppression testing.

SFE/SFHTA/AFCE primary aldosteronism consensus: Introduction and handbook

The French Endocrinology Society (SFE) French Hypertension Society (SFHTA) and Francophone Endocrine Surgery Association (AFCE) have drawn up recommendations for the management of primary aldosteronism (PA), based on an analysis of the literature by 27 experts in 7 work-groups. PA is suspected in case of hypertension associated with one of the following characteristics: severity, resistance, associated hypokalemia, disproportionate target organ lesions, or adrenal incidentaloma with hypertension or hypokalemia. Diagnosis is founded on aldosterone/renin ratio (ARR) measured under standardized conditions. Diagnostic thresholds are expressed according to the measurement units employed. Diagnosis is established for suprathreshold ARR associated with aldosterone concentrations >550pmol/L (200pg/mL) on 2 measurements, and rejected for aldosterone concentration<240pmol/L (90pg/mL) and/or subthreshold ARR. The diagnostic threshold applied is different if certain medication cannot be interrupted. In intermediate situations, dynamic testing is performed. Genetic forms of PA are screened for in young subjects and/or in case of familial history. The patient should be informed of the results expected from medical and surgical treatment of PA before exploration for lateralization is proposed. Lateralization is explored by adrenal vein sampling (AVS), except in patients under 35 years of age with unilateral adenoma on imaging. If PA proves to be lateralized, unilateral adrenalectomy may be performed, with adaptation of medical treatment pre- and postoperatively. If PA is non-lateralized or the patient refuses surgery, spironolactone is administered as first-line treatment, replaced by amiloride, eplerenone or calcium-channel blockers if insufficiently effective or poorly tolerated.

SFE/SFHTA/AFCE consensus on primary aldosteronism, part 4: Subtype diagnosis

To establish the cause of primary aldosteronism (PA), it is essential to distinguish unilateral from bilateral adrenal aldosterone secretion, as adrenalectomy improves aldosterone secretion and controls hypertension and hypokalemia only in the former. Except in the rare cases of type 1 or 3 familial hyperaldosteronism, which can be diagnosed genetically and are not candidates for surgery, lateralized aldosterone secretion is diagnosed on adrenal CT or MRI and adrenal venous sampling. Postural stimulation tests and (131)I-norcholesterol scintigraphy have poor diagnostic value and (11)C-metomidate PET is not yet available. We recommend that adrenal CT or MRI be performed in all cases of PA. Imaging may exceptionally identify adrenocortical carcinoma, for which the surgical objectives are carcinologic, and otherwise shows either normal or hyperplastic adrenals or unilateral adenoma. Imaging alone carries a risk of false positives in patients over 35 years of age (non-aldosterone-secreting adenoma) and false negatives in all patients (unilateral hyperplasia). We suggest that all candidates for surgery over 35 years of age undergo adrenal venous sampling, simultaneously in both adrenal veins, without ACTH stimulation, to confirm the unilateral form of the hypersecretion. Sampling results should be confirmed on adrenal vein cortisol assay showing a concentration at least double that found in peripheral veins. Aldosterone secretion should be considered lateralized when aldosterone/cortisol ratio on the dominant side is at least 4-fold higher than contralaterally.

Reappraisal of a 20-year experience with the radial artery as a conduit for coronary bypass grafting

OBJECTIVE

This study aimed at evaluating the clinical and angiographic results of the radial artery (RA) used as a coronary bypass graft over 20 years.

METHODS

Clinical follow-up was obtained in 563 patients at 9.2 years. Angiographic follow-up was obtained in 351 patients with opacification of 1427 conduits, including 629 RA at 7.0 years.

RESULTS

At 9.2 years, freedom from overall and cardiovascular death was 80.3% and 92.7%, respectively. Symptoms were: acute myocardial infarction: 2.1% (n=12); angina: 17.4% (n=98), and congestive heart failure 10.6% (n=60). Percutaneous revascularization was required in 13.5% (n=76) of cases on: native coronary (n=77), RA conduit (n=21), and other graft (n=7). Reoperation was needed in 2.3% (n=13) of cases for valve replacement (n=10) and redo coronary artery bypass grafting (CABG) (n=3). At 7.0 years, RA patency was 82.8% (521/629) and was lower than that of left internal mammary artery (IMA), 95.5% (491/514) (p<0.001); similar to right IMA, 87.9% (51/58, p=0.32); free IMA, 80.0% (44/55, p=0.60); and vein, 81.9% (140/171, p=0.77). RA patency was lower in the case of myocardial ischemia: 74.0% (174/235) versus 88.1% (347/394) in asymptomatics (p<0.001). RA patency was higher for diagonal (93.1% (95/102)) compared to circumflex (82.5% (274/332, p<0.01)) and right coronary (77.6% (146/188, p<0.001)). Calcium channel blockers had no impact on RA patency. Separating four groups at successive follow-up intervals, RA patency was: 86.2%, 81.9%, 81.4%, and 81.6% at 1.0, 5.4, 8.3, and 13.1 years, respectively.

CONCLUSION

CABG with the RA offered long-lasting clinical benefit. Beyond the first postoperative year during which some attrition was observed, RA patency was remarkably stable for up to 20 years.

[Critical limb ischaemia: endovascular treatment in diabetic patients?]

Endovascular treatment has an increasing role in the treatment of patients with critical limb ischemia, particularly in diabetic patients with a majority of infrapopliteal lesions. The aim of the procedure is to obtain a "straight-line flow to the foot" by treating all the significant stenoses and short occlusions that impair distal vascularization. Stents are indicated when there is a suboptimal results following balloon angioplasty (recoil or dissection). Restenosis rate after primary stenting for long lesion is high. Angioplasty is a safe and effective procedure, allowing limb salvage rate in a majority of the cases with a low mortality and morbidity rate.

Arterial percutaneous angioplasty in upper limbs with vascular access devices for haemodialysis

BACKGROUND

The purpose of this study was to evaluate retrospectively the clinical context and effectiveness of arterial percutaneous transluminal angioplasty (PTA) of arterio-venous fistulae in chronic haemodialysis patients.

METHODS

Between May 1992 and June 1997, arterial PTA was performed in 33 patients with a total of 35 angioaccess devices of the upper limbs (18 arterio-venous fistulae and 17 PTFE grafts). Clinical indications for arterial PTA were unexplained acute thrombosis in 12 patients (34.3%), insufficient blood flow in 13 patients (37.1%), and severe limb ischaemia in 10 patients (28.6%), two of whom had skin ulcerations and one had severe neurological damage. Follow-up periods varied between 1 and 55 months (mean 15.5 months).

RESULTS

PTA was attempted in 22 radial, 10 brachial and seven ulnar arteries. Angioplasty was successful (i.e. residual stenosis of </=30%) in all but one patient. There were no complications. Early re-thrombosis (<1 month) occurred in two of the 12 patients with acute occlusions. All the angioaccesses of patients with insufficient blood flow were improved. Eight of the patients with limb ischaemia became symptom free, and two were failures (one had partial healing of skin ulcerations and one did not improve). Re-stenosis occurred in six cases (27.3% of the 22 angiograms performed) but re-dilatation was performed in only two instances. Primary and secondary patencies were 63.5 and 90.6% at 6 months and 40.8 and 75.6% at 24 months, respectively.

CONCLUSION

Chronic arterial lesions in upper limbs bearing vascular access devices for haemodialysis may lead to thrombosis, ischaemia and insufficient flow for dialysis treatment. PTA is a safe and effective technique with a low rate of re-intervention.

[Glycoprotein IIb/IIIa inhibitors in unstable angina]

During the last ten years we have considerably update our knowledge about the pathogenesis of unstable angina or acute coronary syndromes. The platelet activity have in this settings the central role in development of the thrombotic process. Platelet glycoprotein IIb/IIIa inhibitors block fibrinogen binding to platelets, and the effect of this on the final common pathway of platelet aggregation makes these compounds extremely potent antiplatelet drugs. Three intravenous IIb/IIIa receptor antagonists are approved for clinical use, and this class of therapy has update our pharmacologic armatarium to avoid ischemic complication in the settings of percutaneous coronary revascularization at first and now in medical treatment of acute coronary syndromes. Results of large trials using this drugs suggest that this agents are effective in patient with unstable angina particularly in those presenting a high score of risk for acute ischemic events and those requiring coronary intervention.

Percutaneous transluminal angioplasty of the anomalous circumflex artery

The technical experience reported in the literature concerning angioplasty in patients with anomalous origin of the left circumflex artery is limited. Balloon angioplasty seems to be a favorable approach for revascularization in these vessels, and major determinants of successful angioplasty are angiographic knowledge of their course and structure, appropriate selection of guiding catheter, and the possibility of advancing the balloon into the anomalous vessel. Five consecutive patients with severe atherosclerotic lesions on the anomalous left circumflex artery who underwent coronary angioplasty of the anomalous vessel are reported. Angiographic and clinical success were achieved in three patients with balloon alone and in one with stent implantation.

The radial artery for coronary artery bypass grafting: clinical and angiographic results at five years

OBJECTIVE

The aim of this study was to assess the long-term results of use of the radial artery as a conduit for coronary artery bypass grafting.

METHODS

After revival of the technique in 1989, the radial artery was used as a conduit in 910 patients undergoing coronary artery bypass grafting. A complete follow-up was obtained for the first 102 consecutive patients from 4 to 7 years after the operation (mean 5.27 +/- 1.30 years). Fifty-nine percent of the patients were receiving calcium-channel inhibitors. An electrocardiographic stress test was obtained for 51 patients, with no contraindications found. Routine follow-up angiography was performed in 50 cases, including those of all patients with symptoms. Thus 64 radial artery and 48 left internal thoracic artery grafts were followed up from 4 to 7 years after the operation (mean 5.6 +/- 1.40 years).

RESULTS

The actuarial survival was 91.6% at 5 years, and the actuarial rate of freedom from angina was 88.7% at 5 years. Four patients underwent percutaneous transluminal angioplasty during the period of follow-up, and there were no reoperations for revision of the bypass. The electrocardiographic stress test showed negative results in 73% of cases, electrocardiographic changes alone in 21%, and clinically positive results in 6%. Angiography showed that the patency rate of the radial artery grafts was 83%. The patency rate of the left internal thoracic artery grafts (n = 47) was 91%. The difference in patency could be related to the implantation sites of the grafts, mainly the circumflex artery (51%) for the radial artery grafts and almost exclusively the left anterior descending artery (94%) for the left internal thoracic artery.

CONCLUSION

The use of the radial artery for coronary bypass grafting provides excellent clinical and angiographic results at 5 years. Routine use of the radial artery in combination with the left internal thoracic artery can be recommended.

Percutaneous transluminal angioplasty of radial artery grafts

The radial artery is being used with increasing frequency to replace the saphenous vein as a coronary artery bypass graft, in the belief that it will provide improved long-term patency. Several centers have confirmed that the early results of surgery using the radial artery seem to be better than those obtained with saphenous grafts. Despite these apparent gains, early failure of the radial artery graft can occur and is frequently associated with symptomatic myocardial ischemia. Percutaneous angioplasty is an alternative to reoperation to treat lesions occurring on radial artery grafts. We report on 4 patients who underwent angioplasty of radial artery grafts.

Treatment of hemodialysis access rupture during PTA with Wallstent implantation

PURPOSE

To report the authors' experience in treatment of ruptures complicating percutaneous transluminal angioplasty (PTA) of hemodialysis access with implantation of a Wallstent.

MATERIALS AND METHODS

Between January 1, 1990, and October 1, 1995, the authors performed 2,414 PTAs of angioaccesses. A severe rupture occurred in 40 (1.7%) of these procedures and was treated by means of stent placement. Wallstents were implanted in 37 of these ruptures. The angioaccesses comprised 22 grafts and 15 fistulas. The indications for stent placement were four isolated pseudoaneurysms and 33 cases of bleeding: 15 major leaks, five moderate leaks that persisted despite prolonged inflation at low pressure, seven leaks associated with greater than 50% residual stenosis, four leaks associated with pseudoaneurysm, and two leaks associated with both greater than 50% residual stenosis and pseudoaneurysm. Seventeen ruptures were located on a vein, 19 on the venous anastomosis of a graft, and one on a graft itself.

RESULTS

Stent placement stopped the bleeding immediately in 28 cases and after prolonged inflation within the stent in four cases. Residual bleeding required implantation of a covered Cragg stent within the Wallstent in one case. A pseudoaneurysm was still visible at the end of the intervention in 11 cases. Two complications occurred; one hematoma was drained surgically and one access occluded on day 2. Follow-up angiography showed a small pseudoaneurysm in only one patient with impaired platelet function. The primary and secondary patency of the angioaccesses were 48% and 86% at 1 year, respectively.

CONCLUSION

Wallstent implantation is very effective for both immediate and long-term treatment of rupture of angioaccess during PTA.

New non-ionic contrast: effects on the cardiovascular system

Contrast media cause a variety of effects on the cardiovascular system both hemodynamic and electrophysiologic in nature. These effects are mainly related to the physico-chemical characteristics of the compounds and are less pronounced with low osmolar nonionic than with ionic contrast media. Nonetheless there is still room for further improvement in the features of the nonionic agents. Iomeprol is a new nonionic contrast medium which, with its low osmolality and toxicity and very low viscosity, proved to be safe and well tolerated during clinical trials in cardioangiography.

Percutaneous treatment of acute iliac artery injury after intraaortic balloon counterpulsation

We report on a novel approach to correcting iliac artery occlusions caused by aortic counterpulsation. Two patients who had leg ischemia after retrieval of an intraaortic balloon pump underwent angiograms that showed occlusion of the right external iliac artery because of dissection (one case) or thrombosis (one case). Percutaneous self-expandable stents were implanted in the occluded vessels, and they fully restored normal iliac patency with no complications and satisfactory midterm follow-up results. We conclude that iliac artery occlusion induced by aortic counterpulsation can be safely treated by implanting self-expandable stents in cases of acute iatrogenic dissection.

Self-expandable stents for the treatment of iliac artery obstructive lesions: long-term success and prognostic factors

OBJECTIVE

The purpose of our study was to report long-term (more than 2 years of follow-up) angiographic patency after self-expandable stent implantation in the iliac artery and to identify patient- or procedure-related prognostic factors of angiographic patency.

SUBJECTS AND METHODS

Ninety-five consecutive patients (101 arteries) underwent Wallstent implantation to treat claudication (n=95 limbs), rest pain (n=2), and nonhealing ulcer (n=3). Another patient was asymptomatic but was treated for acute occlusion of the iliac artery after coronary angioplasty. After implantation of self-expandable stents, we followed up by examining clinical and angiographic records at 6 months, 1 year, and annually thereafter. The Kaplan-Meier survival curve was used to determine primary and secondary patency rates. Primary patency was that achieved after the initial procedure only. Secondary patency was defined as that achieved after one or more successful additional percutaneous procedures within the stent or beyond the stent. Multivariate analysis using the Cox proportional hazard model was performed to identify predictive factors of angiographic failure, defined as restenosis of 50% or greater or occlusion.

RESULTS

Four-year patency rates of 61% (primary) and 86% (secondary) were found (mean follow-up, 29 months). The following five factors were associated with long-term angiographic failure: occlusion of the superficial femoral artery (relative hazard = 5.21), absence of hypertension (relative hazard = 4.85), a stent diameter of less than 8 mm (relative hazard = 4.45), two or more stents implanted (relative hazard = 3.56), and current tobacco consumption (relative hazard = 2.46).

CONCLUSION

Improved patency rates may be obtained by selecting patients for Wallstent implantation in the iliac artery based on five factors shown to be prognostically important.

Outcome of percutaneous intervention in iliac artery stents

PURPOSE

To assess the safety and efficacy of secondary procedures in iliac artery stents.

MATERIALS AND METHODS

Thirty-four patients (36 limbs) underwent one or more interventional procedures in iliac artery stents to treat restenosis (n = 30) or occlusion (n = 6). All patients were followed up by means of clinical and angiographic examination. Primary and secondary patency were assessed with angiography, duplex ultrasound, or both. Primary patency was determined after one interventional procedure, and secondary patency was determined at the end of the study (mean +/- standard deviation, 20.1 months +/- 17.5; range, 1-58 months).

RESULTS

Immediate angiographic success was achieved in all cases. Four complications were observed. The primary and secondary cumulative patency rates were 77.5% +/- 7.6 and 94% +/- 4.1 at 6 months, 73% +/- 8.4 and 89.3% +/- 6 at 12 months, and 51.4% +/- 10.9 and 78.8% +/- 8.8 at 2 years. At the end of the study, 80% of the arteries were still nominally patent.

CONCLUSION

Restenosis and chronic occlusion in iliac artery stents can be treated with percutaneous interventional procedures; however, stenosis can still recur.

[Drug thrombolysis and mechanical recanalization in recent femoro-popliteal arterial occlusions]

Acute femoro-popliteal occlusions (native arteries or bypass grafts) were treated by medical and surgical treatment. Despite improvement in surgical technique, patient mortality was high and limb loss remained frequent. Percutaneous endoluminal treatment of such lesions is feasible using in situ fibrinolysis and/or thromboaspiration singly or in association with balloon angioplasty. Those techniques are effective and are currently the first intention treatment of many of those acute femoro-popliteal occlusion. The advantages and disadvantages of those techniques are discussed, as well as their respective indications, and particularly their place compared to surgical techniques. New devices such as mechanical thrombectomy may increase effectivity and indications of endovascular treatment however such devices need to be better evaluated.

Renal artery stent placement: immediate and midterm technical and clinical results

PURPOSE

The authors report their experience with implantation of self-expandable stents into renal arteries.

PATIENTS AND METHODS

Twenty-five Wallstent endoprostheses were deployed into 18 renal arteries in 18 patients. Atheroma was the cause of the initial renal artery lesion in 15 patients (four ostial, 10 postostial, and one long occlusion). In these 15 patients, indications for stent placement were 12 immediate failures of percutaneous transluminal renal angioplasty (PTRA), two immediate PTRA complications (dissections), and one recurrent stenosis. The other renal artery lesions were three dissections (two spontaneous and one after catheterization).

RESULTS

The procedure was technically successful in all patients, with residual stenosis less than 20%. However, five stents were slightly misplaced and a second stent was implanted to fully cover the lesion. Three complications occurred: one acute thrombosis 15 days after stent implantation that was successfully treated with local fibrinolysis, one asymptomatic occlusion due to early thrombosis or to delayed restenosis, and one segmental renal infarction related to extensive dissection after PTRA and not to stent placement. Following stent implantation, systolic blood pressure (P = .006) and diastolic blood pressure (P = .002) measured at 6 months decreased significantly. Angiographic follow-up was obtained in 16 patients (with intravenous technique in nine and intraarterial digital subtraction angiography in seven) at a mean of 11 months after stent placement, and ultrasonographic follow-up was obtained in the two others after 8 and 25 months, respectively. A normal patent renal artery was demonstrated in 16 patients (89%); there was one restenosis with a 75% reduction in diameter of the renal artery and the asymptomatic occlusion above mentioned.

CONCLUSION

Self-expandable stent implantation is a promising technique in PTRA failures. Wallstent placement is technically feasible. Immediate results were satisfactory and the midterm restenosis rate was low in this series of patients.

Stenoses of renal branch arteries in fibromuscular dysplasia: results of percutaneous transluminal angioplasty

PURPOSE

To evaluate percutaneous transluminal renal angioplasty (PTRA) in the treatment of renal branch artery stenoses caused by fibromuscular dysplasia.

MATERIALS AND METHODS

The authors retrospectively studied the files of 20 consecutive hypertensive patients with 25 branch artery stenoses associated with 10 main renal artery lesions. Results at clinical and angiographic follow-up were assessed by means of life-table analysis.

RESULTS

PTRA was technically successful in 21 of the 25 renal branch artery stenoses (84%). One of the technical failures was treated by means of selective embolization. Nine of the 10 associated main renal artery lesions were successfully dilated, and the 10th was improved. Immediately after PTRA, at 6-month follow-up, and at long-term follow-up, 70%, 76%, and 68% of the patients, respectively, were cured and 25%, 24%, and 16% were improved. Stenosis recurred in 9% of the branch arteries and was associated with clinical relapse; these arteries were redilated, and all patients were considered cured at the second 6-month follow-up.

CONCLUSION

PTRA should be considered the first-line treatment for hypertension due to renal branch artery stenosis in fibromuscular disease.

[Use of the radial artery for coronary artery bypass. A new experience after 20 years]

Twenty years after its first introduction by A. Carpentier, the use of the radial artery (RA) for coronary bypass was reinvestigated because of unexpected good long term results in some patients. Since July 1989, 158 patients (pts) underwent myocardial revascularization using 189 RA grafts (31 pts received 2 grafts). The left internal mammary artery (LIMA) was concomitantly used as a pedicled graft in 151 cases and the right internal mammary artery (RIMA) in 31 cases, a free IMA graft was used in 29 cases and a saphenous vein graft in 40 cases. A mean of 2.8 graft/pt was performed. The target artery receiving the RA was: circumflex (n = 93), diagonal (n = 39), right coronary (n = 47) and LAD (n = 10). Two patients died (1.3%) and three presented a perioperative myocardial infarct (2.5%). Sternal wound infection was noted in three cases of double IMA implant. No ischemia of the hand was observed. All patients received diltiazem started intraoperatively and continued after discharge. In addition, aspirin (100 mg/day) was given at discharge. Early angiographic controls (< 3 weeks) were obtained in the first 60 consecutive patients and revealed: 73/73 patent RA grafts, 58/58 patent LIMA grafts, 16/16 patent RIMA grafts, 15/19 patent free IMA grafts and 10/11 patent vein grafts. Six patients presented a localized narrowing of the RA conduit unrelated to the anastomotic lines (spasm). Late angiographic control (6 to 24 months) was obtained after a mean follow-up of 11 months in 37 patients: 42/46 RA grafts were patent (91.3%) and free of spasm and 4 were occluded.(ABSTRACT TRUNCATED AT 250 WORDS)

[Early angiographic evaluation of coronary bypass using arterial grafts]

The aim of this study was to evaluate the early postoperative angiographic features of arterial coronary bypass grafts in 83 asymptomatic patients referred consecutively from the surgical unit. The patients aged 33 to 78 years (average 62 years) were operated between August 1989 and March 1992 and received only arterial coronary bypass grafts: 209 arteries bypassed (121 internal mammary including 10 sequential grafts, 46 radial, 36 epigastric including 4 sequential grafts and 6 gastroepiploic arterial grafts), an average of 2.4 bypass grafts per patient. Selective angiography of the arterial grafts was performed systematically between the 7th and 15th postoperative days in patients with uncomplicated recoveries. The native coronary arterial network was opacified only when a graft was "non-functional": haemodynamic (> 70%) stenosis or occlusion. 3.8% of pediculated mammary grafts were occluded. On the other hand, 16.6% of free internal mammary grafts were occluded. None of the radial artery grafts were occluded, but 8% were stenotic. Finally, 30% of epigastric and 50% of the gastroepiploic grafts were occluded. These results confirm the good function of in situ mammary artery grafts by suggest that systematic multiple arterial grafts should be used with caution. Radial artery grafts give very encouraging results which require long-term evaluation. Early postoperative evaluation of coronary arterial grafts provides important information and should be considered a routine procedure.

Infrarenal aortic stents: initial clinical experience and angiographic follow-up

From March 1990 to May 1991, arterial stents were placed in seven patients because of a tight stenosis (five patients) or a total chronic occlusion (two patients) located in the infrarenal aorta. In one case, the aortic occlusion extended to both common iliac arteries. After balloon dilatation, aortic stents were successfully positioned in all cases. Bilateral common iliac recanalization and stent placement were performed in one case. No complications occurred in any of the patients. No complications occurred in any of the patients. Follow-up data were derived from clinical assessments and angiographic results. After a 15.1-month mean follow-up period (range 12-24 months), the seven aortic stents remained patent. Three iliac artery procedures were performed in two of the patients as well. Claudication recurred in three of the seven patients which was related to a common iliac occlusion (one case) or distal progression of atherosclerosis (two cases). Aortic stents seem to be suitable for treating failed angioplasty of aortic lesions but the procedure remains technically difficult when there is associated severe atherosclerosis of the proximal common iliac arteries. Nevertheless, considering the morbidity rate (0%) and the patency rate in this series, this technique could become an alternative to surgical treatment for infrarenal aortic occlusive lesions.

Decision to treat mild hypertension after assessment by ambulatory monitoring and World Health Organisation recommendations

OBJECTIVE

To determine if one ambulatory blood pressure recording over 12 hours could detect those patients with mild hypertension who needed treatment according to the World Health Organisation-International Society of Hypertension (ISH) guidelines based on the causal measurement of diastolic blood pressure at successive visits to a clinic.

DESIGN

Comparison of decision to treat based on one ambulatory measurement over 12 hours and standard blood pressure measurements over six months in the same patients.

SETTING

Outpatient hypertension clinic.

SUBJECTS

130 men and women with diastolic blood pressure of 90-104 mm Hg at second visit to clinic.

MAIN OUTCOME MEASURES

Blood pressure measurements over six months. Measurement from ambulatory monitoring. Decision to treat.

RESULTS

Of the 130 patients included, 108 were followed up over the six months. Treatment was started according to WHO-ISH criteria in 44 (13 at the third visit, 13 at the fourth, 18 at the fifth). According to the selected criteria for ambulatory blood pressure monitoring 41 patients would have been treated. Both methods agreed that the same 27 patients required treatment and the same 50 did not, but they did not agree in 31 patients. When calculated at the optimal diastolic blood pressure threshold determined by a receiver operating characteristic curve, the sensitivity, specificity, and positive predictive value of ambulatory blood pressure monitoring were 71% (95% confidence interval 57% to 84%), 82% (72% to 92%), and 66% (51% to 81%), respectively.

CONCLUSION

If the WHO-ISH criteria are accepted as the standard for deciding to treat patients with mild hypertension the predictive value of one ambulatory blood pressure recording over 12 hours is too low to detect with confidence those patients who need treatment when managed according to these criteria.

Revival of the radial artery for coronary artery bypass grafting

Eighteen years after its first introduction for coronary artery revascularization, the radial artery (RA) was reinvestigated because of unexpected good long-term results in the early series. Since July 1989, 104 patients underwent myocardial revascularization using 122 RA grafts (18 patients received two grafts). The left internal mammary artery (IMA) was concomitantly used as a pedicled graft in 100 cases and the right IMA in 19 cases; a free IMA graft was used in 29 cases and a saphenous vein graft in 24 cases. A mean of 2.8 grafts per patient were performed. Nine patients underwent associated procedures: carotid endarterectomy (3), aortic valve replacement (3), Bigelow procedure (1), and mitral valve repair (2). The target artery receiving the RA was the circumflex (n = 59), diagonal (n = 29), right coronary (n = 27), and left anterior descending (n = 7). One patient died (0.96%) and 2 had perioperative myocardial infarct. Sternal wound infection was noted in 3 cases of double IMA implantation. No ischemia of the hand was observed. All patients received diltiazem started intraoperatively and continued after discharge. In addition aspirin (100 mg/day) was given at discharge. Early angiographic controls (less than 2 weeks) were obtained in the first 50 consecutive patients and revealed 56 of 56 patent RA grafts, 48 of 48 patent left IMA grafts, 11 of 11 patent right IMA grafts, 14 of 18 patent free IMA grafts, and 8 of 9 patent vein grafts.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intraluminal angioplasty in renovascular arterial hypertension. 104 cases]

Between January 1, 1985 and January 1, 1988, 104 patients with arterial hypertension and renal artery stenosis were treated by percutaneous transluminal angioplasty (PTA). The procedure was justified by the resistance of hypertension to other treatments in 50 patients with atheromatous stenosis and 38 patients with fibrodysplasic stenosis. In the remaining 16 patients, who had severe atheroma, PTA was made necessary by ischaemic renal failure. Out of 52 PTAs (including 2 bilateral in one stage) performed in atheroma patients without renal failure, 48 (92 per cent) were immediate technical successes. In 44 patients arterial pressure measurements after 7.5 months (2-24) showed cure in 6 cases (13 per cent), improvement in 29 cases (66 per cent) and failure in 9 cases (21 per cent). Control arteriography of 40 arteries showed success in 28 cases (70 per cent), residual stenosis in 9 (22 per cent) and restenosis in 3 cases (8 per cent) (2 secondary successes of PTA). In patients with fibrodysplastic stenosis, 42 PTAs (4 bilateral) resulted in immediate angiographic success in 81 per cent. In 34 patients arterial pressure measurements after 8.2 months (2-35) showed cure in 2 cases (65 per cent), improvement in 10 cases (29 percent) and failure in 2 cases. Angiography of 34 arteries showed success in 31 (91 per cent) and restenosis in 3 (2 bypasses). In 13 of the 16 patients with renal failure, the renal function was stabilized by PTA, but 5 patients needed surgery and 2 were put on chronic dialysis. It is concluded that the immediate and medium term success rates of renal angioplasty confirm the value of this recanalization procedure in fibrodysplasia and atheroma.

Influence of age on the outcome of percutaneous angioplasty in atheromatous renovascular disease

We compared the efficacy and safety of percutaneous transluminal renal angioplasty for the treatment of renovascular disease in 66 patients. Thirty-four were aged less than 60 years, and 32 more than 60 years. The younger patients had a shorter known duration of hypertension and higher levels of diastolic pressure (6.4 +/- 9 years and 109 +/- 15 mmHg) than the older patients (12.8 +/- 8 years and 101 +/- 11 mmHg, P less than 0.01 for both comparisons). They also had higher creatinine clearance rates (78 versus 46 ml/min, P less than 0.01) and less severe renal artery disease. A total of 70 percutaneous transluminal renal angioplasties were performed in 70 arteries with a technical success rate of 100% in the younger group versus 67% in the older group (P less than 0.01); complications occurred more frequently in the older group. Our data indicate that, when technically successful, percutaneous transluminal renal angioplasty improves blood pressure to a similar extent in both younger and older patients. However, in patients over 60 years, the safety of the procedure is limited by more severe age-associated atheroma of renal and extrarenal arteries.

[Reference values of ambulatory arterial pressure in activity and during the night. Multicenter study of 394 normotensive subjects at rest]

The blood pressure pattern and variability were assessed in a population of 394 normotensive subjects (OMS) stratified by age (20 to 75 years) and sex. Ambulatory blood pressure measurements were performed with an automatic device (Spacelabs 5200) every 15 min. from 6 a.m. to 12 p.m., and every 30 min. from 0 a.m. to 6 a.m. The analysis was effected during normal daily activities (from 9 a.m. to 7 p.m.) and during night (from 11 p.m. to 7 a.m.). Blood pressure levels were higher in males than females. During daytime and nighttime, diastolic blood pressure rose with age until 59 years while SBP was not affected, except for the females older than 60 years. After this age, diastolic blood pressure decreased. No epidemiological study has provided a measure of the cardiovascular risk related to ambulatory blood pressure, so that we were unable to define true normal values. However, reference population values provided from two statistical methods: limit of the 95th upper confidence interval for the mean of limit of the 90th percentile value for the total data. These blood pressure distributions according to age and sex may allow a better approach to borderline hypertensive patients.

[Iodo-methyl norcholesterol scintigraphy in the localization of primary hyperaldosteronism]

The aim of the study was to investigate the accuracy of iodomethyl norcholesterol, a new adrenal isotopic scanning agent, in the strategy of aldosteronism localization. Among 1499 patients examined in the clinic in 1987, 49 presented with primary aldosteronism. Nine were explored by adrenal scintigraphy (SCI). Mean age was 50 +/- 10 ans, blood pressure was 188 +/- 26/110 +/- 17 mmHg. Initial serum kalemia was 3.2 +/- 0.4 mMol/l, urinary potassium 67 +/- 39 mMol/d; standing plasma active renin was 9.9 +/- 5.0 pg/ml (20 less than N less than 50), supine plasma aldosterone was 316 +/- 200 pg/ml (50 less than N less than 150) and aldosterone excretion rate was 49 +/- 27 microgr/day (N less than 17). Adrenal CT-scan correctly predicted unilateral adenoma in 7 patients (size from 5 to 15 mm). CT-scan was negative twice. Adrenal vein aldosterone sampling and phlebography confirmed adenoma in the 8th patient. 7 patients underwent surgery, with pathological confirmation of the diagnosis. The diagnosis of adrenal hyperplasia (AH) was made in the 9th patient. (table; see text) When compared to CT-scan, SCI is unuseful if a tumor (greater than or equal to 10 mm) is detected on CT-scan (2 SCI false-negative/5 CT-scan tumors). At the opposite, when CT-scan is negative, SCI localizes 2 tumors in 4 patients (2 adenomas).

CONCLUSION

SCI should not be used as first step diagnosis procedure in the localization of primary aldosteronism.

Epithelioid sarcoma of soft tissues: a case of extrarenal renin-secreting tumour

The case of a young woman presenting with a renin-secreting soft tissue sarcoma is described. The primary extrarenal tumour as well as metastatic disease were associated with severe hypertension and both required surgical treatment. The location of these rare malignant tumours and their association with renin-dependent hypertension is discussed. In cases of this type, reappearance of hypertension suggests tumour recurrence.

[Malignant adrenal cortex carcinoma revealed by an isolated picture of primary hyperaldosteronism]

Adrenocortical carcinoma (ACC) is a rare disorder with an estimated incidence of only 0.023 percent of all malignancies. In most cases, Cushing's syndrome and virilization or feminization due to abnormal steroid production by the tumor rapidly lead to the diagnosis. Occasionally, the tumor produces an excessive amount of mineralocorticoids only and ACC can be revealed by an isolated syndrome of primary aldosteronism. Out of 100 cases of tumoral primary aldosteronism studied from 1977 to 1987, we observed 4 ACC and 96 Conn's adenomas (CONN). When primary aldosteronism was diagnosed, ACC and CONN had same clinical features, although hypokalemia in ACC was more profound: 2.2 +/- 0.76 mmol/l (1.4 to 3.2) compared to 2.9 +/- 0.5 (1.6 to 4.2) in CONN. Mean supine plasma aldosterone levels, plasma renin and aldosterone responses to the upright posture or to serum saline infusion, cortisol at 8 a.m. were not different in patients with ACC from those observed in patients with CONN. 24 hours urinary cortisol excretion and 17-ketosteroids excretion were highly increased in three out four patients with ACC. Clinical, biological and hormonal investigations were therefore not sufficient to diagnose malignant tumoral primary aldosteronism. Systematic computed tomographic scanning allowed to differentiate carcinomas from adenomas on the following criteria: ACC showed enlarged tumor size that was always above 30 mm in diameter, whereas the largest CONN measured 20 mm.ACC appeared as an heterogeneous tumor with the presence of internal calcifications in each case of ACC, that were diagnosed both on ultrasound and CT scan, whereas none of the CONN showed any calcification, using the same screening procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transluminal angioplasty in renovascular hypertension with renal insufficiency]

From 1985 to 1986, 71 patients with renovascular hypertension were treated by percutaneous transluminal angioplasty (PTA). Among them, 13 (mean age 67 +/- 7 years) had a hypertension refractory to drug therapy (blood pressure: 194 +/- 33/103 +/- 15 mmHg) associated with an impaired renal function (creatinine clearance: 33 +/- 20 ml/mn). Ten had a stenosis in a solitary functioning kidney and a contralateral renal artery thrombosis. Three had bilateral renovascular stenosis. All patients had severe diffuse atherosclerotic disease, i.e. coronary heart disease (n = 7), carotid artery stenosis (n = 6), abdominal aortic aneurysm (n = 3) or arteritis (n = 5). Among these 13 patients, PTA could not be performed in one patient (failure to catheterize the stenosis) and two immediate renal artery dissections were observed: the first was accompanied by a thrombosis of the renal artery which could be successfully treated in emergency by surgical revascularization. The second occurred in a segmental renal branch and did not require surgery since it did not induced further impairment of renal function. Among the 10 remaining patients, nine PAT were classified as immediate angiographic success. One incomplete result required a second PTA 6 months later. Three important inguinal hematomas were observed and blood transfusion was required in 2. Seven patients have been reevaluated after a follow-up of 3 to 22 months. Restenosis occurred in two patients, 6 and 20 months respectively after PTA. A successful surgical revascularization was performed in these 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Validation of an self-measurement blood pressure device]

The aim of this study was to test the self-blood pressure (Self-BP) measurement device Copal UA-251 (Philips). This device uses auscultatory method for BP measurement. It was compared to reference methods: intraarterial and Hawksley Random Zero in 38 patients, selected in two groups: group RO (n = 18), compared Copal to Random Zero. 20 simultaneous measurements were recorded, with devices inversion at eleventh BP measurement, in 18 treated or untreated hypertensive patients. Group IA (n = 20) included 20 patients and compared Copal to intra-aortic measurement. Three simultaneous measurements were recorded, before a coronarography was performed, in 20 normo or hypertensive patients.

RESULTS

(Table: see text). 1) A significant difference was recorded for SBP evaluated by Copal versus RO and for DBP measured by Copal versus IA. 2) A significant correlation was assessed between the different methods of measurement. 3) Differences between couples of RO-Copal values are not correlated to BP level, neither for SBP (r = 0.07), nor DBP (r = 0.05). Same results occur for IA-Copal values (SBP: r = 0.36, DBP: r = 0.30). 4) No order effect was found; no discrepancy between arms occurred in BP measurement.

CONCLUSION

comparing intraaortic measure, Copal is efficient for SBP measurement, but overestimate DBP. Compared to R0, Copal overestimates SBP, but is efficient for DBP measurement. Regarding these results, a self-BP measurement is possible with this device.

[Comparison of 3 methods of blood pressure measurement in obesity]

Arm girth and circumference often leads to difficulties in Blood Pressure (BP) measurement in obese patients. In order to assess the best method of BP measurement, we have compared in a triplicate study, Intra-arterial Pressure (INTRA) to indirect measurements: Mercury Sphygmomanometer (SPH) and oscillometric device Bard Sentron (SEN). SPH and SEN were successively connected to the same cuff (inflatable bladder 14 x 31 cm). Cuff was positioned on contralateral arm to arterial puncture. 19 subjects were studied (18 female); mean age was 51.3 +/- 9 years (extremes: 37-69), mean weight 104 +/- 19 kg (84-147), weight index 40 +/- 4.7 kg/m2 (34-49), and brachial circumference 39 +/- 4 cm (33-47). First out-patient mean blood pressure measurement was 182/104 mmHg (148-264/80-132). Mean SPH BP were 158 +/- 34/91 +/- 3 (98-230, 72-112) and mean INTRA: 171 +/- 37/85 +/- 5 (122-256/56-118). Mean systolic and diastolic differences (S, D, mmHg) were: (Table: see text). 1) SPH systolic BP underestimates HUM systolic BP. 2) Mean SEN measurements are very closed to HUM values. 3) A great intra-individual variability occurs since more than 50 per cent systolic SPH values show discrepancy of more than 10 mmHg for systolic and diastolic HUM BP; the same discrepancies occur for SEN vs HUM. 4) Differences between couples of values (HUM-SEN, HUM-SPH) are not correlated to BP level, neither for systolic nor for diastolic BP. 5) No significant correlation occurs when BP deltas are compared to weight index or arm circumference.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro studies in primary aldosteronism: baseline steroid production and aldosterone responses to ACTH and angiotensin II

The spontaneous glucocorticoid production in control adrenal cells (N = 10) and in the adenoma cells (N = 15) exhibited comparable geometric mean values: 1.896 nmol/ml/4-5 x 10(5) cells per 2 h (confidence limits: 0.428-8.391) and 1.852 nmol/ml (0.326-12.241), respectively. The same results were obtained for the three samples of nodular hyperplasia cells. When cortisol and corticosterone were measured separately, there was no significant difference between the outputs for control cells and those for pathological cells. Baseline aldosterone production in control cells showed a geometric mean of 2.525 pmol/ml (0.236-27.192). In the 15 adenomas, spontaneous production was extremely important: 57.297 pmol/ml (3.357-976.692). The difference was highly significant (P less than 0.0005). Aldosterone levels in the 3 samples of nodular hyperplasia cells were not different from the control values. In 9 out of the 15 adenomas, aldosterone responses to 10(-10) mol/l ACTH, expressed as stimulated/basal production, were above normal: 3.58 +/- 0.86 (SEM) against 1.48 +/- 0.08 (P less than 0.025). In the remaining 6 and in the 3 samples of nodular hyperplasia cells, there was a slight or no response. Angiotensin II (AII) stimulated both adenoma and nodular hyperplasia cells to varying degrees, without any obvious difference between these two categories. A combination of ACTH (10(-12) mol/l) and AII (10(-12) mol/l) had a synergistic action on aldosterone production in cells classed in the adenoma group. These findings demonstrate that despite the abnormal rate of aldosterone formation in adenoma cells, the production rate of corticosterone and cortisol remains normal. They unmask two functional categories with regard to ACTH in the adenoma group. Finally, they underline the relative insensitivity of nodular hyperplasia cells to ACTH.

[Detection, diagnosis and localization of pheochromocytoma. 77 cases in a population of 21,420 hypertensive patients]

Phaeochromocytoma was diagnosed in 77 (0.36%) of 21,420 hypertensive patients examined in the hypertension units of the Broussais and Saint-Joseph hospitals, Paris, between 1976 and 1986. Our diagnostic strategy is to reserve biochemical examinations to cases with suspected phaeochromocytoma and to explore only those patients who have positive laboratory results. Patients suspected of harbouring a phaeochromocytoma are those who complain of headaches, palpitations and sweating (these 3 symptoms together having a 90.9% sensitivity and a 99.9% exclusion value), those who have a family history of phaeochromocytoma or who present with medullary thyroid carcinoma or phakomatosis, or those who do not respond to anti-hypertensive treatments. Altogether, these patients account for less than 10% of all cases of hypertension. The most sensitive test in this group is measurement of urinary metanephrines. Among 30 patients with phaeochromocytoma in whom urinary metanephrines and plasma noradrenaline were measured on the same day, none had urinary metanephrine values lower than 3.69 mumol/24 h (0.7 mg/24 h) while 6, who had normal blood pressure at the time of sampling, had noradrenaline levels below 3.53 nmol/l (600 pg/ml). Prior to surgery, the tumour was correctly located by urography (69% of 58 n = tumours), ultrasounds (74%, n = 38), arteriography (83%, n = 23), radioisotope scanning (91%, n = 32), computed tomography (95%, n = 40) and nuclear magnetic resonance imaging (12/12). In 28 patients who had both radioisotope scanning and computed tomography the sensitivities of these examinations were 90% and 100% respectively. A stage by stage approach to the diagnosis of phaeochromocytoma, using detection criteria followed by biochemistry then location methods, is an economical strategy with the best yield from diagnostic and imaging techniques.

[Ambulatory blood pressure in normotensive subjects. Definition of reference values as a function of age by the Spacelabs instrument]

For a finer assessment, by repeated blood pressure (BP) measurements, of the cardiovascular risk associated with BP levels, new instruments have been developed which provide multiple reading during periods of activity. However, the lack of epidemiological studies makes it necessary to determine reference ambulatory BP levels by another method. Twelve-hour recordings were taken with the Spacelabs instrument in 130 volunteers (45% males) aged from 20 to 90 years during their various activities. Mean systolic and diastolic BP values +/- SD were calculated per age-groups of 10 years each. That this sample was representative of the general population was confirmed by the fact that BP fluctuations and variations according to age and sex in these 130 subjects were identical with those observed in the population of an entire town (Framingham). The concept of hypertension, as defined by ambulatory BP recordings, is discussed. This study provides, for the first time, reference ambulatory BP values according to age and sex, measured in normotensive subjects with the Spacelabs instrument. These values constitute a preliminary step indispensable to evaluate this technique in hypertensive patients.

Isolated clinical syndrome of primary aldosteronism in four patients with adrenocortical carcinoma

Adrenocortical carcinoma is a rare disorder that can be revealed by an isolated syndrome of mineralocorticoid excess. In a retrospective study of 137 patients referred to our hypertension clinic in the past 10 years for primary aldosteronism, four cases of adrenocortical carcinoma were identified. The clinical presentation of these patients was similar to that of patients with Conn's adenoma, but preoperatively, malignant tumoral primary aldosteronism was suspected because of profound hypokalemia, marked elevation in plasma aldosterone levels, and enlarged size and weight of an heterogenous adrenal tumor with internal calcifications. Malignancy was confirmed by the histologic features. No prognostic criteria could be established and two patients died despite specific surgery, which was performed in all cases. More recent developments in the use of mitotane led to the addition of adrenocorticolytic therapy in the remaining two patients, who are still alive at the time of this report.

Evaluation of slow release nicardipine in essential hypertension by casual and ambulatory blood pressure measurements. Effects of acute versus chronic administration

We conducted a randomized placebo-controlled double-blind study in 40 hypertensive subjects to assess the antihypertensive effect of a new galenic form of nicardipine administered at a dosage of 50 mg twice daily for 3 weeks. Regardless of whether blood pressure was measured by standard mercury sphygmomanometer, non-ambulatory automatic oscillometry or a Remler ambulatory blood pressure recorder, it dropped by a significantly larger amount in the nicardipine group than in the placebo group. In the control group, a placebo effect was observed with the ambulatory diastolic blood pressure recording, whereas it was not observed with hospital blood pressure measurements, especially when using the serial measurements performed for 30 min by an automatic recorder. The fall in blood pressure measured with the Remler recorder was correlated with the fall measured 10-20 min during one acute intravenous nicardipine perfusion before the trial, although the correlation coefficients do not suggest clinically relevant predictability of nicardipine efficacy at the individual level. The present findings support the need for controlled double-blind trials with careful office blood pressure measurements.

[Double-blind evaluation of slow-release nicardipine using different methods of blood pressure measurement. Predictive value of the acute response to intravenous nicardipine]

Forty hypertensive patients (diastolic greater than 95 mmHg) were included after 15 days of a single blind placebo period in a randomized placebo controlled double-blind study to assess the antihypertensive effect of a new galenic form of nicardipine (N) administered 50 mg b.i.d. for 3 weeks. They comprised 27 men and 13 women aged from 27 to 72 years (mean: 53 +/- 10). Blood pressure (BP) was measured in hospital before morning drug intake by an automatic recorder (Sentron) in supine position for 30 minutes (min) and by a mercury sphygmomanometer. Ambulatory BP was assessed by a portable patient activated recorder (Remler 2000). Mercury sphygmomanometer supine BP under N fell from 160 +/- 21/104 +/- 6 mmHg to 151 +/- 14/98 +/- 8 mmHg (n = 20; p less than 0.01/p less than 0.01) whereas BP under placebo (P) was respectively 158 +/- 14/103 +/- 6 mmHg and 156 +/- 20/102 +/- 9 mmHg (NS). Sentron BP under N fell from 158 +/- 17/96 +/- 8 mmHg to 148 +/- 13/90 +/- 7 mmHg (p less than 0.001/p less than 0.01) with no BP change under P (152 +/- 12/93 +/- 7 mmHg to 151 +/- 14/93 +/- 8 mmHg NS). BP recorder every 30 min for 12 hours revealed a decrease under N (160 +/- 18/105 +/- 10 mmHg to 142 +/- 16/94 +/- 10 mmHg; p less than 0.001/p less than 0.001) with a placebo effect in the control group on the diastolic BP (160 +/- 15/103 +/- 7 mmHg to 156 +/- 16/100 +/- 8 mmHg/NS/p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[The decision to treat moderate hypertension: repetition of office visits or ambulatory monitoring of arterial pressure?]

World Health Organization (WHO) recommends antihypertensive therapy for mild to moderate hypertensive patients after 3 or more visits. We tested the hypothesis that an ambulatory blood pressure recording could also help to decide which patient need therapy. Blood pressure was measured in 89 essential, uncomplicated, hypertensive patients (diastolic (DBP): 90-110 mmHg, mean age: 41 +/- 13 years), with a mercury sphygmomanometer at 3 visits and with an ambulatory blood pressure recorder (Spacelabs) during 12 hours. According to WHO recommendations, patients were classified "WHO+" if they need a treatment (n = 44) and "WHO-" if they did not. The mean ambulatory DBP of each subject was compared to the arbitrary limit defined as the mean +2 standard deviations of the ambulatory DBP of a population of normotensive subjects in the same decade and same sex: patients with ambulatory DBP above this limit were defined "AMB+" (n = 27), the others were "AMB-". Ten patients were "WHO- AMB+" and 24 were "WHO+ AMB-". These discordances were independent of age, body weight, duration of hypertension, variability of ambulatory systolic and diastolic blood pressure defined by the standard deviation. By contrast, the difference between the measurements of the simultaneous blood pressure measurements performed with the two methods (mercury sphyngmomanometer and Spacelabs) 2 times by each patient could explain in part these discrepancies. The Spacelabs underestimates DBP measured with the mercury sphyngmomanometer in patients "AMB-" but not in patient "AMB+".(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of the surgical treatment of Conn's adenomas]

During the last 10 years we operated on 69 Conn's adenomas of which 59 were followed up for a mean period of 16 months (range: 3-96 months). Surgery cured the hypertension (blood pressure less than 140/90) in 47 p. 100 of the patients. Improved blood pressure (systolic: mean = 46 mmHg; range 0-135 mmHg and diastolic: mean = 25 mmHg; range 0-66 mmHg) was noted in another 47 p. 100 of patients whereas no blood pressure change was noted in 3 patients. Biological primary aldosteronism was found post-operatively in 2 of these 3 patients and also in one whose hypertension was improved. In this last patient plus the three unimproved by surgery, small tumours (less than 10 mm) were found and co-existnt multifocal hyperplasia was found in the 2 patients who had had an adrenalectomy. Fifty-one patients were treated pre-operatively by spironolactone (SP) alone (3.2 +/- 1.3 mg/kg) for a mean period of 6.8 weeks (range: 3 to 20 weeks). Only 2 of the 24 patients controlled by SP were not cured by surgery and one of them had persistnt primary aldosteronism. Conversely, 3 of the 27 uncontrolled by SP were cured post-operatively, and these exceptions could be due to the weak dose of SP (n = 2) and an observance problem (n = 1). Patients cured by surgery had shorter duration of hypertension (4.3 +/- 3.0 years vs 10.1 +/- 8.1; p less than 0.01) and lower diastolic pressure (111 +/- 14 mmHg vs 121 +/- 12; p less than 0.01) than uncured patients. No significant difference between these two groups was observed with respect to systolic pressure, age, sex, plasma potassium, plasma renin activity and plasma aldosterone levels.(ABSTRACT TRUNCATED AT 250 WORDS)