Blood pressure variability and cardiovascular risk in treated hypertensive patients

BACKGROUND: The independent prognostic value of blood pressure (BP) variability in treated hypertension is not yet clear. We investigated the relationship between BP variability, evaluated by noninvasive monitoring, and cardiovascular outcome in treated hypertensive patients. METHODS: The occurrence of fatal and nonfatal cardiovascular events was evaluated in 1472 treated patients. Subjects with the standard deviation of daytime or night-time systolic BP below or above the median of the population were classified as having low or high BP variability. Specifically, 738 and 734 patients had low and high daytime BP variability, respectively, and 739 and 733 subjects had low and high night-time BP variability, respectively. RESULTS: During follow-up (4.88 +/- 2.9 years, range 0.2-11.6 years) there were 119 events. The event rates per 100 patient-years in subjects with low and high BP variability according to daytime BP were 1.18 and 2.01, respectively, and in those with low and high BP variability according to night-time BP were 1.2 and 2.05, respectively. Event-free survival was significantly different between the low and high BP variability groups (P = .006 for both daytime and night-time BP). However, after adjustment for other covariates in a Cox multivariate analysis, the adverse prognostic relevance of high BP variability was no longer detectable, whereas age, smoking habit, LDL cholesterol, diabetes, previous events, LV hypertrophy, and daytime or night-time systolic BP resulted independent predictors of risk. CONCLUSIONS: Increased BP variability is associated with higher incidence of cardiovascular events, but also with other relevant prognostic factors. Indeed, in multivariate analysis the possible adverse prognostic impact of BP variability is no longer evident. Thus, in treated hypertension, BP variability evaluated by noninvasive monitoring is not an independent predictor of outcome.     

Reduction in estimated stroke risk associated with practice-based stroke-risk assessment and awareness in a large, representative population of hypertensive patients: results from the ForLife study in Italy

OBJECTIVE: A previous analysis of the ForLife study demonstrated a high estimated risk of stroke, poor blood pressure control and higher cardiovascular risk. Data from a subsequent visit within 6 months, to evaluate the impact of systematic stroke risk assessment, are reported. METHODS: Between February and July 2003, 1800 general practitioners (GPs) recruited a total of 12,792 (7512 untreated and 5280 treated) patients with hypertension. Blood pressure values were assessed in the whole study population, and for different demographic and clinical features in two visits within 6 months. The data were recorded into a Framingham-based stroke risk score and computed using a risk calculator. RESULTS: Between the two visits the percentage of patients with controlled blood pressure (< 140/90 mmHg) increased substantially in all subgroups, being greater in patients who were not treated at baseline. Among initially treated patients, the greater control of blood pressure involved both diastolic and systolic values. The percentage of patients with diabetes whose blood pressure levels were less than 130/80 mmHg also increased at the second visit. Between the two visits the estimated stroke risk score showed a reduction, with a significant shift of patients from high to intermediate and low-risk categories. This reduction involved all subgroups, including patients with diabetes and left ventricular hypertrophy. CONCLUSION: The present large-scale observational study demonstrates that the assessment of stroke risk and increased awareness of stroke risk factors by GPs is associated with improved blood pressure control, reduced cardiovascular risk profile and a prompt reduction in the 10-year estimated risk of stroke.     

Blood pressure levels in treated hypertensive patients in general practice in Norway

The aim of this study was to examine the blood pressure (BP) levels in patients treated for essential hypertension in 1816 patients in general practice in Norway. The study was based on an optical readable questionnaire filled out by the physician including information about systolic (S) and diastolic (D) BP, gender, age, body weight, smoking habits and all pharmaceutical treatment given. Sixty-four per cent of the patients were treated with one antihypertensive drug. Only 22.3% of the women and 30.7% of the men (p < 0.05) had BP < or = 140/90 mmHg. When BP < 160/95 was used as criterion for BP control, the fraction of patients was 50%. The fraction of patients with DBP < or = 80 mmHg was 26% in the whole group of patients. DBP < or = 90 mmHg was achieved in 74% and SBP < or = 140 mmHg in 30% of the patients. The BP control was less in women and in patients above 60 years of age. Patients on combination therapy were no better controlled than those on monotherapy. Based on our results, the proportion of hypertensive patients on drug treatment with insufficient BP control is too high. Efforts should be made to improve the medical treatment of hypertension in general practice in Norway.     

Blood pressure control and cardiovascular risk profile in hypertensive patients under specialist care in Argentina: Results from the CHARTER study

Worldwide, hypertension control rate is far from ideal. Some studies suggest that patients treated by specialists have a greater chance to achieve control. The authors aimed to determine the BP control rate among treated hypertensive patients under specialist care in Argentina, to characterize patients regarding their cardiovascular risk profile and antihypertensive drug use, and to assess the variables independently associated with adequate BP control. The authors included adult hypertensive patients under stable treatment, managed in 10 specialist centers across Argentina. Office BP was measured thrice with a validated oscillometric device. Adequate BP control was defined as an average of the three readings <140/90 mm Hg (and <150/90 in patients older than 80 years). The authors estimated the proportion of adequate BP control and the variables independently associated with it through a multiple conditional logistic regression model. Among the 1146 included patients, 48.2% were men with a mean age of 63.5 (±13.1) years old. Mean office BP was 135.3 (±14.8)/80.8 (±10) mm Hg, with a 64.8% (95% CI: 62%‐67.6%) of adequate control. The mean number of antihypertensive drugs was 2.1 per participant, the commonest being angiotensin receptor blockers and calcium channel blockers. In multivariable analysis, only female sex was a predictor of adequate BP control (OR 1.33 [95% CI 1.02‐1.72], P = .04). In conclusion, almost 65% of hypertensive patients treated in specialist centers in Argentina have adequate BP control. The challenge for future research is to define strategies in order to translate this control rate to the primary care level, where most patients are managed.     

Blood pressure control with cilnidipine treatment in Japanese post-stroke hypertensive patients: The CA-ATTEND study

Blood pressure control is important in post-stroke hypertensive patients and antihypertensive treatment is recommended for such patients. Ca-channel blockers are recommended as the medications of choice for the treatment of post-stroke patients. Here, we report the results of a large-scale prospective post-marketing surveillance study of post-stroke hypertensive patients (n = 2667, male 60.4%, 69.0 ± 10.9 years) treated with cilnidipine, with regard to blood pressure control and adverse reactions. Cilnidipine treatment caused a decrease in both clinic and home blood pressures 2 months after the beginning of treatment, and the decreased blood pressure was maintained until the end of 12 months’ observation. The proportion of patients in whom clinic blood pressure was well controlled (<140/90 mmHg) increased from 21.5% to 65.3% in cilnidipine treatment, with no differences in effectiveness among the various clinical subtypes of stroke. In total, 346 adverse events occurred, with an overall incidence of 8.9% (238 of 2667 patients). In the elderly group, specifically, a fall and a hip fracture each occurred in 1 (0.1%) patient. These results indicate that cilnidipine was effective in treating uncontrolled blood pressure and was well tolerated in Japanese post-stroke hypertensive patients in a real-world clinical setting.     

Assessment of blood pressure control in hypertensive stroke survivors: an ambulatory blood pressure monitoring study

BACKGROUND: We compared the sensitivity of office blood pressure and ambulatory blood pressure monitoring recordings in evaluating the effectiveness of antihypertensive treatment and identified factors related to inadequate blood pressure control among hypertensive stroke survivors. METHODS: Office blood pressure and ambulatory blood pressure monitoring measurements were performed at 120+/-30 days after ictus in 187 first-ever consecutive hypertensive stroke survivors who were receiving blood pressure-lowering medications according to international guidelines. Handicap was assessed by the modified Rankin Scale. Blood pressure was regarded as controlled if office and daytime ambulatory systolic and diastolic blood pressure values were <140/90 and <135/85 mmHg, respectively. Patients were subclassified according to the degree of their nocturnal systolic blood pressure fall [(mean daytime values-mean night-time values)100/mean daytime values] as dippers (>or=10%), nondippers (>or=0% and <10%) and reverse dippers (<0%). RESULTS: Effective blood pressure control was documented in significantly (P<0.001) fewer patients using ambulatory blood pressure monitoring (32.1%) than those using office recordings (43.3%), whereas in 16% of the study population a masked lack of per-treatment blood pressure control (elevated ambulatory blood pressure in the presence of normal office blood pressure levels) was identified. The distribution of dipping patterns differed significantly (P=0.01) between controlled hypertensive individuals (normal office and ambulatory measurements) and patients with isolated ambulatory hypertension (dippers: 31.3 vs. 10.0%; nondippers:56.9 vs. 53.3%; reverse dippers: 11.8 vs. 36.7%). Logistic regression analysis revealed diabetes mellitus and functional independency (modified Rankin Scale score<2) as independent predictors of inadequate blood pressure control. CONCLUSION: Ambulatory blood pressure monitoring detects a substantial number of treated hypertensive stroke survivors with a masked lack of per-treatment blood pressure control, who present a higher prevalence of abnormal circadian blood pressure patterns (reverse dipping). Diabetes mellitus and poststroke functional independency are the main factors contributing to inadequate blood pressure control.     

A cross-sectional study of blood pressure control in hypertensive patients in general practice (the I-TARGET study)

Introduction

Despite the availability of multiple effective antihypertensive drugs, hypertension control rates remain poor. The reasons for this are complex, but increasingly, physician inertia has been identified as a crucial factor. In this study we attempted to define the level of blood pressure (BP) control and reasons for not achieving control in a survey of selected general practices within South Africa.

Methods

This was a multi-centre, cross-sectional disease study involving 15 selected general practices throughout South Africa. Treated hypertensive patients over 18 years old were eligible for inclusion. The study was approved by Pharma Ethics, and after informed consent, consecutive hypertensive patients at the participating general practice centres were included, with each centre enrolling 30 patients.

Results

A total of 451 patients, from 15 sites in South Africa, were entered in the study. The mean age of the patients was 60.7 years, 56.3% were female and 15.7% were current smokers. The BP was reduced by 26.4/17.6 mmHg (p < 0.001) in 220 patients with a documented initial BP. Co-morbidities were present in 322 (71.4%) patients and overall, 37.9% had more than one co-morbidity. Lifestyle modification was not uniformly applied, with only 46.1, 59.6 and 56.8% receiving advice about weight loss, exercise and diet, respectively. Less than a third (30.7%) of patients were on monotherapy, 42.8% were on two drugs (25.9% on fixed-drug combination and 16.9% on free combination) and 26.5% were on more than two agents. Most (86.9%) practitioners used either international or local guidelines to determine target BP. Overall, 61.2% of patients were at goal (BP < 140/90 mmHg). If a stricter target BP (BP ≤ 130/80 mmHg) is applied to patients with co-morbidities, as recommended by the guidelines, 60.6% of patients did not reach goal. Of the 175 patients not at target BP, there was no action plan in 22.9%, while 39.4% were advised to undertake lifestyle changes only.

Conclusions

Control rates were quite good in comparison with other surveys within and outside South Africa. However we were able to define several important deficiencies: there was evidence of physician inertia and also practitioners need to be more cognisant of local and international guidelines to optimise treatment.     

Blood pressure control in hypertensive patients with stable coronary heart disease

OBJECTIVE: To evaluate systolic blood pressure (SBP) control in hypertensive patients with a stable coronary heart disease (CHD) in general practice in France. METHODS: A survey was conducted in a sample of 206 general practitionners (GP) representative of the French medical population, in 2003 [LHYCORNE survey]. Each GP had to include 3 hypertensive patients, >18 years old, BP > or = 140/90 mmHg and/or treated for hypertension, and with evidence of CHD documented by myocardial infarction (MI) or angina pectoris (AP) [diagnosis previously established by a cardiologist]. Three office BP measurements were performed, the last two recorded. BP levels were considered as controlled by treatement if they were < 140/90 mmHg. RESULTS: 595 patients were included, 75% men mean age 66 years, 25% women mean age 73 years. All patients had a CHD: MI 46%, AP 54%; 533 (90%) had more than 2 cardiovascular risk factors: hyperlipidemia (411; 69%), smokers (375; 63%), diabetes (158; 27%). Mean BP was 140.7 +/- 14/80.8 +/- 9.7 mmHg; 553 (93%) of these hypertensive patients were treated, and 239 (40%) were considered as having a controlled SBP at the treshold of 140 mmHg: 47% in patients with previous MI and 38% with AP (p < 0.001). Diastolic BP (DBP) was <90 mmHg in 480 (81%) and pulse pressure was >65 mmHg in 202 (34%); 313 (53%) patients received a combination of three drugs or more; 354 (60%) had a beta-blocker, 260 (44%) a calcium channel blocker, 237 (40%) an ACE inhibitor, 287 (48%) other antihypertensive drugs (246 diuretics, 41%); 502 (84%) received antiplatelet therapy, 403 (68%) statins. CONCLUSION: This survey shows that systolic BP is not at goal in 6/10 hypertensive patients with stable CHD suggesting there is a place for a more effective combination therapy according to evidence-based medicine.     

Blood pressure control after a one year follow-up in high risk subject screened in occupational medicine

OBJECTIVE: To identify factors predicting the success or the failure of intervention on blood pressure in a population estimated at high risks. METHODS: The program "Coeur 2001" has analysed the absolute cardiovascular risk (ACVR Framingham) in 107 371 voluntary French railways employees. In the company, were considered at high risk (HR), subjects for whom risk was > or = to the 95th percentile of the distribution of the observed ACVR by age range: ACVR > or = 4.5% before 35 years, 12% between 35 and 45 years and 19% beyond 45 years, i.e. a total of 4 190 subjects. These subjects were warned about their risk and advised to choose and consult a physician. A two-year follow up was planned. Identical data (risk factors, ACVR, type of management and therapies) were collected during the first consultation with the occupational physician (T0), one year later (T1) and two years later (T2). RESULTS: Our work concerned 2376 employees at HR, consulting at T1. At T1, 54% of subjects were in the hight risk group (SHR) [48% when BP at T1 was < 140/90 mmHg and 62% when the BP was > or = 140/90 mmHg]. The mean decrease of the systolic BP (SBP) was 4 mmHg in the whole sample, 7.7 mmHg in subjects with normalised ACVR, and it remained stable in the group still at HR (-0.7 mmHg). At T0, blood pressure (BP) was > or = 140/90 mmHg in 55.8% of the patients and 38.4 at T1. This high BP was associated with higher frequency of diabetes (14 vs 7%) and overweight (BMI > or =30 kg/m2; 32.8 vs 19.7%). The percentage of treated hypertensive subjects had increased from 35 to 62% but one third of uncontrolled hypertensive subjects was treated by mono therapies at T1. CONCLUSION: To keep BP under control is a difficult task in routine medicine. At T1, despite a more aggressive treatment, 38% of subjects at high risk were still hypertensive subjects.     

Arterial stiffness and orthostatic blood pressure changes in untreated and treated hypertensive subjects

Carotid-femoral pulse wave velocity (PWV), an integrated marker of segmental aortic stiffness, was recently proposed as one of the underlying mechanisms inducing orthostatic hypotension in the elderly with marked arterial rigidity. We examined the relationship between PWV (Complior; Colson, Paris, France) and orthostatic blood pressure (BP) changes, measured repeatedly, over a wide range of age and arterial stiffness. Sixty-nine hypertensive subjects (age, 37 to 76 years; 39 untreated and 30 treated) were studied. BP, in both sitting and erect position, was measured at two occasions a few weeks apart, and in between PWV was assessed by means of pulse wave analysis. In untreated hypertensive subjects, the orthostatic alterations in systolic, but not in diastolic blood pressure (DBP), were inversely related to PWV, independently from age, gender, mean BP, and diabetes mellitus. The greater the aortic stiffness the larger was the systolic blood pressure (SBP) decrease during upraises. On the contrary, no such association was found between PWV and orthostatic changes of BP in treated hypertensive subjects. These results suggest the presence of a pathophysiological association between arterial stiffening and BP postural changes. Antihypertensive drug treatment, as well as other factors that have not been evaluated in the present study, might have modulated this association. However, it might be argued that a causal association between arterial stiffness – disturbed baroreflex sensitivity – postural BP changes, even in subjects without pronounced vascular aging or orthostatic hypotension, is implied.     

Blood pressure control and cardiovascular risk in hypertensive patients with type 2 diabetes: The German T2Target registry

Blood pressure control in patients with type 2 diabetes and hypertension is poor. It is unclear how effectively general practitioners assess and treat such patients. T2Target included hypertensive patients with type 2 diabetes mellitus who had undergone ambulatory blood pressure monitoring within the past 3 months. Recordings were analyzed by the general practitioner and an independent center and the conclusions were compared. Nighttime hypertension was reported less frequently by the general practitioner in comparison with central assessment (43.9% vs 77.9%, P<.001), as were masked (4.0% vs 13.1%, P<.001) and isolated office (4.4% vs 8.8%, P<.001) hypertension. A total of 13.9% of patients were deemed to have controlled blood pressure (ambulatory blood pressure monitoring). For the 784 patients with uncontrolled blood pressure, 40.7% underwent no change to their antihypertensive treatment. Cardiovascular risk was underestimated, with 11.1% deemed to be at very high risk, in contrast to the 97.0% of patients by central assessment. In conclusion, blood pressure control in hypertensive patients with type 2 diabetes mellitus is poor and not accurately assessed by office‐based general practitioners, despite the use of ambulatory blood pressure monitoring.     

伴阻塞性睡眠呼吸暂停低通气综合征高血压患者的血压控制研究

目的探讨伴阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的高血压患者,同时服用降压药和接受持续气道正压通气(CPAP)是否能有效控制血压。方法选取2014年1月至2015年6月南京医科大学第一附属医院睡眠中心就诊的伴有OSAHS高血压患者180例,根据服用降压药物后血压是否被有效控制,分为控制组(n=87)和未控制组(n=93),两组在服用降压药同时接受CPAP 6个月,比较服用不同降压药方案和CPAP治疗前后血压是否得到有效控制的关系。结果所有患者共使用13种不同的降压药方案进行治疗。控制组与未控制组患者降压药方案差异无统计学意义(P0.05),多因素logistic回归分析表明降压药方案不是影响伴OSAHS高血压患者血压控制的独立预测因子(OR=1.897,P=0.094)。使用CPAP后控制组、非控制组夜间收缩压(SBP)和舒张压(DBP)均下降,差异有统计学意义(P0.01)。结论伴OSAHS高血压病患者的降压治疗方案与血压控制无明显相关性,而CPAP治疗可使降压药有效组和无效组患者的夜间血压都降低。     

The great Hanshin-Awaji earthquake aggravates blood pressure control in treated hypertensive patients

A major earthquake (Hanshin-Awaji earthquake) struck Kobe on January 17, 1995. We had a unique opportunity to study the effect of tremendous psychological stress on blood pressure control in 221 hypertensive patients receiving antihypertensive medication. During the 4 weeks after the earthquake, on average, the mean blood pressure increased significantly for both 105 patients who were exposed (living in the area of the very severe earthquake) and 116 patients who were not exposed (living in the surrounding area) (+4.2 ± 1.0 mm Hg, P < .001, and +2.4 ± 0.7 mm Hg, P < .005, respectively). In the exposed group, the increase in mean blood pressure peaked in the first week (+6.7 ± 1.6 mm Hg, P < .001), declined thereafter, and returned to the baseline within 6 weeks after the disaster. The earthquake related blood pressure elevation was, however, significantly attenuated (P < .02) in patients receiving β-blockers compared with those receiving other drugs. The results indicate that acute psychological stress associated with a sudden natural disaster causes blood pressure elevation in treated hypertensive patients, and suggest the beneficial effect of β-blockers on such a stress-related high blood pressure.     

White coat effect in treated versus untreated hypertensive individuals: a case-control study using ambulatory and home blood pressure monitoring

BACKGROUND: Some studies have shown a significant white coat effect (WCE) (i.e., difference between clinic blood pressure [CBP] and awake ambulatory blood pressure [ABP]) to be present not only in untreated but also in treated hypertensive individuals. This study aims to assess 1) the prevalence and the magnitude of the WCE in treated versus untreated hypertensive persons, and 2) the usefulness of home blood pressure (HBP) versus ABP in the detection of this phenomenon. METHODS: A case-control study was conducted in 138 treated hypertensive patients and same number of sex- and age-matched untreated hypertensive subjects who had measurements of CBP (at least three visits), HBP, and ABP. Subjects with a WCE of >20/10 mm Hg (systolic/diastolic) were classified as clinic reactors. RESULTS: There was a trend for a larger WCE assessed by ABP monitoring in the untreated group (mean difference in systolic WCE, 1.8 +/- 22.2 mm Hg, 95% CI -2.0 to 5.5; diastolic 1.8 +/- 11.9 mm Hg, 95% CI -0.2 to 3.8) and for more untreated clinic reactors (27% untreated v 20% treated, odds ratio 1.5, 95% CI 0.9 to 2.7). The sensitivity, specificity, and positive and negative predictive values of HBP to detect clinic reactors correctly were 56%/62% (treated/untreated), 87%/84%, 52%/59%, and 89%/86%, respectively, with moderate agreement between HBP and ABP (kappa 0.42/0.46). CONCLUSIONS: In treated hypertensive patients, WCE seems to be reduced compared with that in untreated hypertensive persons but is not eliminated. In both untreated and treated hypertensive individuals HBP monitoring appears to be useful in the detection of the WCE, but it may not be appropriate as an alternative to the ABP method.     

Blood pressure control in patients with hypertension: a community-based study

The objective of own study was to investigate the quality of hypertension management in a rural Chinese population. A prospective cross-sectional study was conducted in 922 hypertensive patients in a regional community in southern China. The average systolic (SBP) and diastolic blood pressure (DBP) was 167.8 +/- 22.5 mmHg and 94.3 +/- 14.2 mmHg respectively. A total of 823 patients (89.3%) patients had a SBP of greater than or equal to 140 mmHg, and 596 (64.6%) had a DBP of greater than or equal to 90 mmHg. Fully 568 patients (69.7%) were treated with one or two antihypertensive drugs, mostly with calcium channel blockers. In patients treated with antihypertensive drugs, the average SBP and DBP were 170.3 +/- 23.1 mmHg and 96.2 +/- 14.8 mmHg, respectively. Blood pressure was poorly controlled in these hypertensive patients. Further studies are required to identify the barriers to the effective management of uncontrolled hypertension in a rural setting.     

Probability of stroke in Korean hypertensive patients visiting community-based hospitals: using a risk profile from the Framingham study

Hypertension is the most important single modifiable risk factor of stroke. The purpose of this study was to investigate the distribution patterns of risk factors of stroke and 10-year probability of stroke in hypertensive patients visiting community-based hospitals. A total of 1088 hypertensive patients who visited 61 community-based hospitals nationwide were enrolled. Risk factors of stroke were evaluated using a series of laboratory tests and physical examinations, and the 10-year probability of stroke was determined by applying the Framingham stroke risk equation. The proportion of patients who have uncontrolled hypertension despite the use of antihypertensives was 63.3% (59.6% women, 68.7% men; P=0.006). The average 10-year probability of stroke in hypertensive patients was 16.05% (14.68% women, 17.99% men; P<0.001). The 10-year probability of stroke in patients with hypertension gradually increased in proportion to age. In patients treated with antihypertensives, 10-year probability of stroke gradually increased in proportion to blood pressure. The 10-year risk of stroke in hypertensive patients was approximately 4.6 times higher than that of stroke in the general population. In conclusion, as the 10-year risk of stroke in hypertensive patients was approximately 4.6 times higher than that of stroke in the general population, more aggressive interventions are needed to reduce blood pressure and stroke risk in hypertensive patients.