Blood pressure control in Japanese hypertensives with or without type 2 diabetes mellitus.

Patients with type 2 diabetes mellitus and hypertension are thought to be at high risk for cardiovascular diseases. Recent guidelines for treatment of hypertension such as the JNC VI and WHO/ISH guidelines, recommend that antihypertensive agents be strated at as low as at 130/85 mmHg and that blood pressure be lowered to less than 130/85 mmHg. Our study was designed to clarify how well and to what extent blood pressure (BP) was controlled in Japanese hypertensive patients with or without type 2 diabetes mellitus. We interviewed two hundred physicians, randomly sellected from among the members of the Japanese Society of Hypertension (JSH) (n=98) and the Japanese Diabetes Society (JDS) (n=102) and obtained information regarding five most recent cases of hypertension with (n=954 in total) and their 2 most recent cases of hypertension without diabetes (n=371 in total). The achieved BP was below 140/90 mmHg in 40.5% of non-diabetic and 38.3% of diabetic hypertensives. The percentage of patients whose BP was less than 130/85 mmHg was 10.8% in nondiabetics and 11.4% in diabetics. The average number of hypotensive agents used was 1.46 in nondiabetics and 1.52 in diabetics. Physicians prescribed more ACE inhibitors and alpha-blockers in diabetics than in nondiabetics, although Ca-antagonists were administered in more than 70% of patients irrespective of whether or not they had diabetes. In contrast, fewer beta-blockers and diuretics were administered to diabetics. These results suggest that although Japanese physicians are considering the effects of hypotensive agents on metabolism and renal function when they treat diabetic hypertensives, the achieved blood pressure in both hypertensives with and those without diabetes is insufficient, with only one of ten patients having a blood pressure less than 130/85 mmHg even among diabetics. Improved blood pressure control will therefore be needed to treat high risk groups such as patients with diabetes mellitus.     

Aterial hypertension and cardiovascular risk factors associated with diabetes. Report of the PHARE survey in general practice

OBJECTIVE: To evaluate the characteristics of diabetic hypertensive patients (Pts), in term of associated cardiovascular risk factors and blood pressure control in a representative population issued from a survey "PHARE" conducted in general practice in France in 1999. DESIGN AND METHODS: PHARE survey was conducted in a sample of 225 GPs representative of the French medical population included in a gallup poll. GPs had to include all patients > 18 years old over a period of one week. Pts were considered as hypertensives (HP) if the mean of two recorded BP measurements was = 140/90 mmHg and/or < 140/90 mmHg if they were under antihypertensive treatment. Patients were considered as diabetics if they were previously known and/or if they received a medication for diabetes. Hypertensives were considered as controlled if their BP levels were overall < 140/90 mmHg or at the recommended threshold < 130/85 mmHg under treatment. RESULTS: 877 diabetic Pts (7%) among 12.342 Pts and 5.190 HP were included in the study. When compared to normotensives, diabetic HP had more frequently associated risk factors with hypertension and diabetes: overweight 71% vs 45%, dyslipidemia 61% vs 34%, sendentarily 73% vs 63%, tobacco consumption 27% vs 20%. The BP control at 140/90 mmHg threshold among treated diabetic HP was 21%, and only 8% at 130/85 mmHg. Regarding WHO classification, 79% of these diabetics had a high or very high cardiovascular risk. The were no difference in antihypertensive drugs used in HP diabetics and non diabetics and 50% of them received ACEI. CONCLUSIONS: 8 from 10 diabetics taken in charge in general practice are hypertensives and 8 from 10 have a very high cardiovascular risk due to a poor BP control and associated cardiovascular risk factors.     

Pharmacotherapy and blood pressure control in elderly hypertensives in a primary care setting in Bahrain

BACKGROUND AND AIMS: Antihypertensive treatment in the elderly has important beneficial effects in terms of reduced cardiovascular morbidity and mortality. The aim of this study was to determine, in elderly hypertensives, the adherence of primary care physicians to World Health Organization/International Society of Hypertension (WHO/ISH) guidelines for the drug management of hypertension and extent of blood pressure (BP) control. METHODS: A multicentric therapeutic audit of medical records of elderly hypertensives was performed in nine primary care health centers in the Kingdom of Bahrain. RESULTS: In elderly hypertensives (> or =60 years), the WHO/ISH-1999 recommended BP targets of <140/<90 mmHg and BP<130/85 mmHg were achieved in 11.1% of elderly hypertensives and 4.1% of elderly diabetic hypertensives, respectively. Antihypertensive combination therapy was used in approximately half of the elderly. No significant difference in BP was found in elderly hypertensives treated either with monotherapy or combination therapy. As regards mono- and overall drug utilization, beta-blockers were the most frequently prescribed drugs in hypertensives, and angiotensin-converting enzyme (ACE) inhibitors in diabetic hypertensives. Diuretics and calcium channel blockers, the preferred antihypertensives for the elderly, were less often prescribed, particularly in patients with isolated systolic hypertension. CONCLUSIONS: Approximately one out of 9 elderly hypertensives and one out of 24 diabetic hypertensives achieved optimal BP control. Although preference for antihypertensives was markedly influenced by comorbidity with diabetes, tailoring of drug therapy was suboptimal and did not adhere to the recommended guidelines in elderly hypertensives. Efforts to improve the drug management of hypertension at primary care level, particularly in the elderly, are required.     

Treatment and blood pressure control in isolated systolic hypertension vs diastolic hypertension in primary care

Cross-sectional surveys on prevalence, treatment and control of hypertension could not satisfactorily distinguish between diastolic hypertension and isolated systolic hypertension because the definition of hypertension included patients under pharmacological treatment. We assessed the situation in the two types of hypertension in general practice in Belgium, based on current blood pressure (BP) measurements and on BP prior to the initiation of drug therapy. Participating physicians enrolled the first 15 at least 55-year-old men visiting the surgery, measured their BP and recorded data on medical history including pretreatment BP, drug utilization, cardiovascular risk factors and target organ damage. Diastolic hypertension was defined as diastolic BP> or =90 mmHg, irrespective of systolic BP, and isolated systolic hypertension as systolic BP > or =140 mmHg and diastolic BP < 90 mmHg. Among 3761 evaluable patients, 74% were hypertensive. Among the 1533 hypertensive patients in whom blood pressure was known prior to treatment (n=965) or who were untreated at the study visit (n=568), 1164 had diastolic hypertension and 369 isolated systolic hypertension. The prevalence of antihypertensive treatment was, respectively, 75 and 25% (P<0.001) in these two types of hypertension. The odds of being treated were independently determined by type of hypertension, severity of hypertension and level of risk (P<0.001). BP was controlled in 25% of all patients with diastolic hypertension and in 13% of all patients with isolated systolic hypertension (P<0.001). About half of the treated patients with systolic hypertension were on a diuretic and/or a calcium-channel blocker. In conclusion, isolated systolic hypertension is less frequently treated than diastolic hypertension, overall BP control is poor and actual drug therapy diverges from recommendations based on placebo-controlled intervention trials.     

Lack of control of high blood pressure and treatment recommendations in Canada

BACKGROUND: Hypertension is a major risk factor for death that affects many Canadians, but only 16% of hypertensive Canadians are treated and have their hypertension controlled. While the control rate is very low, the 2001 Canadian Hypertension Recommendations do not recommend that low risk hypertensive patients be started on pharmacotherapy, and pharmacotherapy is not recommended for people for whom there is no demonstrable benefit from randomized, controlled trails. OBJECTIVES: To determine the proportion of hypertensive patients who are appropriately managed according to the 2001 Canadian Hypertension Recommendations. METHODS: Data from the Canadian Heart Health Survey, which surveyed a cross-sectional population (n=23,129) between 1986 and 1992, were used to determine the proportion of nondiabetic hypertensive patients who are managed according to the 2001 Canadian Hypertension Recommendations. Hypertensive patients not recommended to receive pharmacotherapy include those without risk factors and target organ damage, with a diastolic blood pressure of 90 to 99 mmHg and a systolic blood pressure of less than 160 mmHg. People with diastolic blood pressures of less than 90 mmHg who have systolic blood pressures of 140 to 159 mmHg are also not recommended to have pharmacotherapy. Patients prescribed antihypertensive therapy who had blood pressure controlled to less than 140/90 mmHg were assessed as having their hypertension managed appropriately, as were those who were not treated and were not recommended to be prescribed treatment. RESULTS: There were 58,813 (1.7%) hypertensive patients who did not have target organ damage or additional risk factors, and had a systolic blood pressure of less than 160 mmHg and a diastolic blood pressure between 90 and 99 mmHg. Twenty four per cent of hypertensive persons (831,787) had a systolic blood pressure of 140 to 160 mmHg and a diastolic blood pressure of less than 90 mmHg. About 25% (23.6%+1.7%) of hypertensive Canadians in the Canadian Heart Health Survey are not recommended to be prescribed antihypertensive therapy according to the 2001 Canadian Hypertension Recommendations. Sixteen per cent of hypertensive patients were treated and had their blood pressures controlled (blood pressure less than 140/90 mmHg). Therefore, about 41% (ie, 16%+25%) of hypertensive patients are appropriately managed according to the 2001 Canadian Hypertension Recommendations. CONCLUSIONS: The results of the Canadian Heart Health survey indicate that there are a striking number of Canadians with untreated high blood pressure (59%) who probably do not have their hypertension managed according to the 2001 Canadian Hypertension Recommendations. Greater efforts are required to identify people with hypertension, and to ensure that they are managed according to the best available evidence.     

Survey on treatment of hypertension and implementation of World Health Organization/International Society of Hypertension risk stratification in primary care in Belgium

OBJECTIVE : To gain insight into the prevalence, treatment and control of hypertension and into the implementation of the 1999 World Health Organization/International Society of Hypertension guidelines for the management of hypertension in general practice in Belgium. DESIGN : A prospective cross-sectional survey. SETTING : Primary care. METHODS : Participating physicians enrolled the first 15 men, at least 55 years old, who visited the surgery, measured their blood pressure with a validated automatic device and recorded data on age, medical history, drug utilization, cardiovascular risk factors and target organ damage. Patients were considered to have hypertension when systolic blood pressure was >or= 140 mmHg, diastolic blood pressure was >or= 90 mmHg or when they were under antihypertensive therapy. RESULTS : Among 3761 evaluable patients, 74% were considered to be hypertensive, 80% of whom were treated with antihypertensive drugs. Blood pressure was under control in 38% of the treated patients and in 31% of all hypertensives. Among the 1316 hypertensive patients in whom risk stratification was possible, 47, 56 and 86% of the patients in, respectively, the medium, high and very high risk groups were treated with antihypertensive drugs. Among the treated patients, 46, 37 and 31%, respectively, had reached goal pressure. Within each risk category, patients were treated more frequently when baseline blood pressure was higher. Logistic regression analysis revealed that hypertension grade and level of risk contributed independently to the odds of being treated. CONCLUSIONS : The results indicate that a large number of older hypertensive men are treated with antihypertensive drugs in primary care, but that the goal blood pressure is not reached in a substantial number of patients due to undertreatment. Furthermore, whereas patients at higher risk are treated more frequently than patients at lower risk, blood pressure itself remains an important factor for the initiation of antihypertensive drug therapy within each risk category.     

Hypertension management in patients with stable coronary disease

AIMS: To assess hypertension control in patients with stable coronary disease in France. DESIGN: A cross sectional study was conducted in a representative sample of 794 cardiologists. PARTICIPANTS: The first 6 patients with coronary disease received at practitioner's office were included. MAIN OUTCOME MEASURES: Cardiovascular risk factors, antihypertensive drugs, cardiovascular history were reported. BP was measured. Patients considered as hypertensive by his cardiologist and receiving antihypertensive drugs were considered as hypertensive. Controlled hypertension was defined as a blood pressure < 140/90 mmHg. Uncontrolled hypertension was defined as blood pressure > or = 140/90 mmHg. Among the uncontrolled hypertensives we distinguished patients with isolated systolic hypertension: diastolic blood pressure < 90 mmHg and systolic blood pressure > or = 140 mmHg. RESULTS: All variables were available in 6,349 patients who form the basis of this report. 3,161 patients were hypertensive. Of them, 1,846 (58.4%) were uncontrolled hypertensives, whom 1,280 (69.3%) were uncontrolled on the basis of systolic blood pressure alone. CONCLUSION: This study conducted in a representative sample of French cardiologists indicates that there is a considerable potential to further reduce cardiovascular morbidity in patients in secondary prevention.     

Interarm differences in seated systolic and diastolic blood pressure: the Hypertension Genetic Epidemiology Network study

OBJECTIVE: To examine whether blood pressure (BP) differs between arms in hypertensive siblings and randomly selected volunteers, and whether this difference is explained by cardiovascular risk factors. METHODS: The Hypertension Genetic Epidemiology Network recruited 2395 hypertensive siblings and 854 volunteers. BP was measured six times (three measurements per arm) in seated participants using a Dinamap monitor. The average of three measurements was calculated per arm and the difference taken between arms (i.e. interarm BP differences). RESULTS: The mean age of the subjects was 56 years, and about one-half of the sample was male. More than one-half of the sample was African-American. The mean diastolic BP was equal in the two arms in the random sample (68.8 versus 68.7 mmHg) and in hypertensive siblings (73.4 versus 73.1 mmHg), as was systolic BP (random, 119.6 versus 119.3 mmHg; hypertensives, 130.8 versus 130.7 mmHg). The mean interarm diastolic and systolic BP differences were 2.96 +/- 2.51 and 4.61 +/- 4.10 mmHg, respectively, in the random sample and were 3.09 +/- 2.73 and 5.35 +/- 4.98 mmHg, respectively, in hypertensive siblings. Few (random, 1.6%; hypertensives, 2.8%) had interarm diastolic BP differences > 10 mmHg, but 9.2% of the random sample and 14.2% of hypertensive siblings had systolic BP differences > 10 mmHg. Obesity, higher heart rate, and higher systolic BP were associated with larger interarm BP differences. These results have implications for blood pressure measurement in research settings and in screening programs.     

Appraisal of the knowledge of hypertensive patients and assessment of the role of the pharmacists in the management of hypertension: results of a regional survey

The objectives of the study were to appraise the knowledge which the patients have about their hypertension, and to assess the knowledge and involvement of pharmacists in the management of the hypertensive patient. All the pharmacies in the Poitou-Charentes area were invited both to participate in a training session about arterial hypertension and asked to fill in a pharmacist's questionnaire. Furthermore, each participant was required to submit a patient's questionnaire to 20 consecutive hypertensives. A total of 104 pharmacies and 1015 hypertensive patients participated in the survey. In all, 88% of the patients (n = 893) were aware of their blood pressure (BP) figures, but 68% (349/515) considered themselves wrongly, to be normalized; 39% (n = 350) only had BP figures <140/90 mmHg. They said they had been poorly informed about recommended lifestyle changes. In all, 18% (n = 185) were equipped with an automatic device. A total of 77% (n = 779) were able to give the names of their drugs without the help of the pharmacist. Treatment-related unwanted effects were reported by 8% of the patients (n = 79). Only 18% (n = 29) of the pharmacists were able to provide a correct definition of hypertension. Most of them thought hypertension was well controlled in the general population and considered that both tolerance of and compliance with antihypertensive treatment were satisfactory. They could most often (80%, n = 135) supply a SBPM device, but 58 (36%) only were able to provide relevant advice regarding the recommended procedures. In conclusion, The BP goals and the lifestyle modifications are poorly known by the hypertensives. Pharmacists' knowledge is frequently wrong and should be improved by appropriate training programmes.     

Differences between management guidelines and global health strategies for arterial hypertension with metabolic disorders in France in 1999. Ohara study

Taking into account all the risk factors and blood pressure levels, as indicated by several American and European recommendations available since 1997, is a leading strategy to reduce mortality and morbidity of hypertensive patients. The aim of this study was to quantify how, in 1999. French practitioners applied recommendations on hypertension (HTN), diabetes and hypercholesterolemia in recently diagnosed hypertensive patients and to evaluate whether or not the recommended targets were met. 1639 French GPs and cardiologists included 5831 recently diagnosed (7.5 +/- 3.6 months) hypertensives (57 +/- 12 years of age, M/F = 55/45%). Initial BP was 173 +/- 15/99 +/- 9 mmHg. 56% had no concomitant disease, 36% had either diabetes, dyslipidemia or coronary heart disease, 8% had at least two concomitant diseases. At the time of the study corresponding to 6.3 +/- 3.8 months after initiation of diet and/or medical treatment, their BP was 148 +/- 17/86 +/- 11 mmHg (-25/-19 mmHg). At that time only 37% of patients with stage 2 HTN were encouraged to adopt lifestyle modifications without any medical treatment as recommended by the JNC VI. Among these hypertensives, measurement of plasma cholesterol was performed in only 61%, HDL-C/LDL-C in 26% and blood glucose in 51%. In the patients with dyslipidemia, LDL-C was measured in only 47%. In the 677 diabetic patients only 27% had a glycated hemoglobin measurement. The percentage of patients reaching target BP was 59% as regard DBP < 90 mmHg, 25% as regard SBP < 140 mmHg, and 23% reached both target values of BP. In addition, 30% of patients with dyslipidemia reached the target LDL-C as defined by French recommendations (ANAES 1996) and 30% of the diabetic patients reached the target value for glycemia recommended by ADA (1997). In 1999 in France, a minority of patients reaches the national or international recommended target values for blood pressure, glycemia and plasma LDL-cholesterol. In spite of that, French practitioners do not implement all the available diagnostic tools to improve the treatment of metabolic disorders in hypertensive patients. As a conclusion, to improve the prognosis of hypertensive patients, it is mandatory to raise the awareness of physicians about multiple risk factor management and help them implement the recommendations in their daily practice.     

Overall cardiovascular risk still ignored in general practice care of hypertension

BACKGROUND: Recent guidelines for the management of arterial hypertension have emphasized the importance of total cardiovascular risk for setting the blood pressure (BP) goal to be achieved and the intensity with which it should be pursued. DESIGN: To assess the degree of BP control in hypertensives receiving long-term antihypertensive treatment according to the presence of major cardiovascular risk factors or diseases and the level of individual total cardiovascular risk, a large sample of general practitioners throughout Italy had to evaluate a random sample of their hypertensive patients. METHODS: A clinical history was collected for each patient and BP was measured three times using a reliable automatic instrument. To stratify the cardiovascular risk we used the criteria suggested by the 1999 WHO-ISH guidelines. RESULTS: Among the 1204 patients recruited (mean age 64.2 +/- 11.4 years, 663 females), only 399 patients (33.1%) had a BP lower than 140/90 mmHg. Except for male sex and previous myocardial infarction, the concomitant presence of major cardiovascular risk factors or diseases was never associated to a better control of hypertension. BP control was unrelated to individual overall cardiovascular risk: BP was < 140/90 mmHg respectively in 44.0, 37.7, 33.5 and 42.1% (P for trend = 0.54) of people aged less than 65 years with low, medium, high and very high risk and in 27.7, 25.9 and 27.1% (P for trend = 0.91) of people aged more than 65 years at medium, high and very high risk. CONCLUSIONS: BP control in Italian hypertensives is still unsatisfactory, even in patients at high and very high cardiovascular risk.     

Cardiovascular risk in white-coat and sustained hypertensive patients

We compared cardiovascular outcome between patients with white-coat and sustained hypertension who had previously participated in the Ambulatory Blood Pressure Monitoring and Treatment of Hypertension (APTH) trial. Baseline characteristics, including office and ambulatory blood pressure (BP), were measured during the 2-month run-in period of the APTH trial. During follow-up, information on the occurrence of major cardiovascular events (death, myocardial infarction, stroke and heart failure), achieved office BP and treatment status was obtained. At entry, 326 patients had sustained hypertension (daytime ambulatory BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic) and 93 had daytime ambulatory BP below these limits and were classified as white-coat hypertensives. During 2088 patientyears of follow-up (median follow-up 5.3 years), all major cardiovascular events ( n = 22) occurred in the patients with sustained hypertension (rate 12.7 per 1000 patient-years, p = 0.02 for between-group difference). Furthermore, multiple Cox regression confirmed that after adjustment for important covariables, daytime ambulatory BP - but not office BP at entry - significantly and independently predicted cardiovascular outcome. After additional adjustment for office BP, daytime ambulatory BP still predicted the occurrence of major cardiovascular events. Although white-coat hypertension was less frequently associated with antihypertensive drug treatment during follow-up, it carried a significantly better prognosis than sustained hypertension.     

Treatment of hypertension in patients with nondiabetic chronic kidney disease

Hypertension is highly prevalent in patients with chronic kidney disease (CKD). As either the cause or the consequence of CKD, hypertension is an important independent factor determining the rate of loss of renal function. Hypertension is also a significant independent risk factor for cardiovascular events in patients with CKD, the leading cause of their morbidity and mortality. Based on evidence from observational cohort studies and randomized clinical trials, the Canadian Hypertension Education Program (CHEP) recommends a target blood pressure (BP) of lower than 130/80 mmHg in hypertensive patients with nondiabetic CKD. The CHEP also endorses the use of renin-angiotensin system blockers for the BP-lowering regimen in nondiabetic patients with CKD and significant proteinuria. It is recognized that the majority of nondiabetic patients with CKD will require two or more BP-lowering drugs to attain target BP. Furthermore, extracellular fluid volume expansion is a major contributor to hypertension in patients with CKD, and diuretics should be part of the BP-lowering regimen in the majority of patients. Patients with CKD are recognized to be at high risk for cardiovascular events, and studies testing new emerging treatments of hypertension to reduce the burden of CKD on renal and cardiovascular outcomes are underway. In this regard, the CHEP will continue to review and update all its recommendations annually.     

Regional management of arterial hypertension in France. Report of a survey of general practitioners

A survey was conducted in 14 regional samples of general practitioners (GPs) included in Gallup-up poll. 2,423 GPs contributed to the study and had to include all patients > 18 years old over a period of one week. Patients were considered hypertensives if the mean of two recorded BP measurements was > or = 140/90 mmHg and/or < 140/90 mmHg if they were under antihypertensive treatment. Hypertensives were considered as controlled if there BP levels were overall < 140/90 mmHg under treatment. The risk factors associated with hypertension were collected in order to evaluate the cardiovascular risk, according to 1999 ISH-OMS recommendations. 156,470 patients recruited by 2423 GPs were included in the study representing 14 different French regions: Ile-de-France I (1), Ile-de-France II (2), Ile-de-France-Pays-de-la-Loire (3), Bretagne (4), Normandie-Picardie (5), Nord-Pas-de-Calais (6), Alsace-Lorraine (7), Bourgogne-Franche Comté (8), Rh?nes-Alpes (9), Provence-C?te d'Azur (10), Languedoc-Provence (11), Limousin-Auvergne (12), Midi-Pyrénées (13), Aquitaine (14). Among 70,073 hypertensives, 23,054 had never received antihypertensive treatment, and 32,059 (47%) had a high or a very high cardiovascular risk. 67% of hypertensives (47,019) were treated, and 32.8% of treated hypertensives (15,422) had a BP < 140/90 mmHg. The study illustrated few differences in prevalence and control of hypertension in the different French regions: BP control at the 140/90 mmHg threshold vary from 28.5 to 36.6% among treated hypertensives and % of patients at high cardiovascular risk from 42.1% (South-France) to 49.7% (East-France).     

Hypertension screening in a salami factory: a worksite hypertension study

The prevalence, awareness and control of hypertension are important epidemiological research topics worldwide. The screening of hypertension in a workplace has some special aspects. We have screened the employees in a Hungarian salami factory (Pick Salami Factory, Szeged, Hungary) for hypertensives. In a cross-sectional survey, the blood pressure (BP) was measured with an instrument meeting accepted measuring principles (BP-TRU BP) and a questionnaire was filled. In all, 1012 factory workers were screened (600 male and 412 female) and 25.7% of the workers proved to be hypertensives. Of these, 61.5% of the hypertensive employees were aware that their BP is high. Among the treated hypertensives, 21.9% were controlled. These results suggest that the efficacy of the management of hypertension in Hungary cannot be solely responsible for the high cardiovascular morbidity and mortality. The improvement of the management of hypertension should decrease the cardiovascular risk in the hypertensive population. The worksite screening and follow-up of hypertension seem to be logical health service solutions. This has been proven to be cost-effective.     

Ambulatory blood pressure monitoring in hypertensive patients with high cardiovascular risk: a cross-sectional analysis of a 20,000-patient database in Spain

OBJECTIVE: To evaluate ambulatory blood pressure monitoring (ABPM) parameters in a broad sample of high-risk hypertensive patients. METHODS: The Spanish Society of Hypertension is developing a nationwide project in which more than 900 physicians send ABPM registries and corresponding clinical records to a central database via www.cardiorisc.com. Between June 2004 and July 2005 a 20 000-patient database was obtained; 17 219 were valid for analysis. RESULTS: We identified 6534 patients with high cardiovascular risk according to the 2003 European Society of Hypertension/European Society of Cardiology guidelines stratification score. Office blood pressure (BP) was 158.8/89.9 mmHg and 24-h BP was 135.8/77.0 mmHg. Patients with grade 3 BP in the office showed ambulatory systolic BP values less than 160 mmHg in more than 80%. A non-dipping pattern was observed in 3836 cases (58.7%), whereas this abnormality was present in 47.9% of patients with low-to-moderate risk [odds ratio (OR) 1.54; 95% confidence interval (CI) 1.45-1.64]. The prevalence of non-dippers was higher as ambulatory BP increased ( approximately 70% when 24-h systolic BP > 155 mmHg) and was similar in both groups. At the lowest levels of BP (24-h systolic BP < 135 mmHg) a non-dipping pattern was more prevalent in high-risk cases (56.6 versus 45.7%; OR 1.51; 95% CI 1.40-1.64). CONCLUSION: There was a remarkable discrepancy between office and ambulatory BP in high-risk hypertensive patients. The prevalence of a non-dipper BP pattern was almost 60%. In the lowest levels of ambulatory BP, high-risk patients showed a higher prevalence of non-dipping BP than lower-risk cases. These observations support the recommendation of a wider use of ABPM in high-risk hypertensive patients.     

Prevalence and determinants of undertreatment of hypertension in the Netherlands

The objective of this study was to determine the prevalence, treatment, and control of hypertension, and the determinants of undertreatment in the Dutch population. The study design was cross-sectional. A population-based survey on cardiovascular disease risk factors in the Netherlands from 1996 to 2002 was the setting of the study. A total of 10 820 men and women, aged 30-59 years, were included in the study. The main outcome measures of the study were: Prevalence of hypertension, treatment, and control of hypertension and determinants of undertreatment of hypertension. Hypertension was defined as: systolic blood pressure (SBP) > or =140 mmHg and/or diastolic blood pressure (DBP) > or =90 mmHg, and/or the use of antihypertensive medication. Treated and controlled hypertension was defined as SBP <140 mmHg and DBP <90 mmHg. Multivariate logistic regression was used to assess the determinants of undertreatment. The prevalence of hypertension in men was 21.4% and in women 14.9%, and 17.9% of the hypertensive men and 38.5% of the hypertensive women were receiving antihypertensive medication. Of the untreated hypertensives, 21.9% of the men and 13.6% of the women were eligible for treatment with antihypertensive medication according to Dutch guidelines. Female gender and the use of cholesterol-lowering medication were associated with an increased chance of being treated. Subjects who were physically active, on a low salt diet, and current smokers had an increased chance of being untreated. Taking cholesterol-lowering medication and no asthma or allergy were factors associated with better control of blood pressure. In conclusion, a considerable proportion of hypertensives were untreated and uncontrolled. Therefore, the detection and control of hypertension in the Netherlands needs to improve. Several groups of hypertensives were identified that need additional care and attention.     

Arterial hypertension management in general practice in France according to global risk factors

OBJECTIVE: The absolute benefit of antihypertensive medications increases with the level of cardiovascular risk. Moreover in high risk groups, it has been demonstrated that tight blood pressure (BP) control conferred a substantial reduction in the risk of cardiovascular events compared to less tight BP control. Taking into accounts these data, the WHO guidelines recommend to achieve normal BP in high risk subjects. The aim of the study was to assess BP control in a large population of hypertensives (HT) after stratification by cardiovascular risk. METHODS: 15,514 HT defined as office BP > or = 140/90 or the presence of antihypertensive treatment were recruited in France by 3,152 general practitioners. Cardiovascular risk factors and office BP were recorded. Controlled hypertension was defined as a BP < 140/90 mmHg. In patients free of cardiovascular disease, 10-year cardiovascular risks were calculated on the basis of the equations derived from the Framingham Study. RESULTS: 10-year risks were available in 13,560 HT. Those in the highest quartile had greater body mass index (BMI) and the highest concentration of diabetics and current smokers (upper quartile versus lower quartile: BMI: 28.15 vs 26.51 kg/m2; diabetics: 45% vs 3%; current smoking 32% vs 12%; p < .001). [table: see text] Increasing quartiles of risk were associated with the prevalence of uncontrolled hypertension and at a lesser extent with the use of combination therapy. Subjects in the upper quartile had more frequent calcium-blockers, ACE inhibitors and diuretics use and a less frequent betablocker use. CONCLUSION: In general practice, 85% of hypertensives at highest risk are uncontrolled whereas half of them are under monotherapy. An antihypertensive strategy based on global risk may improve BP control in high risk patients.