Cardiovascular risk management and its impact on hypertension control in primary care in low-resource settings: a cluster-randomized trial

Objective

To evaluate a simple cardiovascular risk management package for assessing and managing cardiovascular risk using hypertension as an entry point in primary care facilities in low-resource settings.

Methods

Two geographically distant regions in two countries (China and Nigeria) were selected and 10 pairs of primary care facilities in each region were randomly selected and matched. Regions were then randomly assigned to a control group, which received usual care, or to an intervention group, which applied the cardiovascular risk management package. Each facility enrolled 60 consecutive patients with hypertension. Intervention sites educated patients about risk factors at baseline and initiated treatment with hydrochlorothiazide at 4 months in patients at medium risk of a cardiovascular event, according to a standardized treatment algorithm. Systolic blood pressure change from baseline to 12 months was the primary outcome measure.

Findings

The study included 2397 patients with baseline hypertension: 1191 in 20 intervention facilities and 1206 in 20 control facilities. Systolic and diastolic blood pressure decreased more in intervention patients than in controls. However, at 12 months more than half of patients still had uncontrolled hypertension (systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg). Behavioural risk factors had improved among intervention patients in Nigeria but not in China. Only about 2% of hypertensive patients required referral to the next level of care.

Conclusion

Even in low-resource settings, hypertensive patients can be effectively assessed and managed in primary care facilities.     

The relationship of dietary sodium,potassium, fruits,and vegetables intake with blood pressure among Korean adults aged 40 and older

BACKGROUND/OBJECTIVES

The inverse relationships of combined fruits and vegetables intake with blood pressure have been reported. However, whether there are such relationships with salty vegetables has rarely been investigated in epidemiologic studies. We evaluated the relation of combined and separate intake of fruits, vegetable intakes, and salty vegetables, as well as sodium and potassium, with blood pressure among the middle-aged and elderly populations.

SUBJECTS/METHODS

The present cross-sectional analysis of a prospective cohort baseline survey was performed with 6,283 subjects (2,443 men and 3,840 women) and free of hypertension, diabetes, cardiovascular diseases, and cancer. Dietary data were collected by trained interviewers using food frequency questionnaire.

RESULTS

The significantly inverse linear trend of diastolic blood pressure (DBP) was found in fruits and non-pickled vegetables (81.2 mmHg in the lowest quintile vs 79.0 mmHg in the highest quintile, P for trend = 0.0040) and fruits only (80.9 mmHg in the lowest quintile vs 79.4 mmHg in the highest quintile, P for trend = 0.0430) among men. In contrast, sodium and sodium to potassium ratio were positively related with blood pressure among men (DBP, 78.8 mmHg in the lowest quintile vs 80.6 mmHg in the highest quintile, P for trend = 0.0079 for sodium; DBP, 79.0 mmHg in the lowest quintile vs 80.7 mmHg in the highest quintile, P for trend = 0.0199 and SBP, 123.8 mmHg in the lowest quintile vs 125.9 mmHg in the highest quintile for sodium/potassium). Kimchies consumption was positively related to DBP for men (78.2 mmHg in the lowest quintile vs 80.9 mmHg in the highest quintile for DBP, P for trend = 0.0003). Among women, these relations were not found.

CONCLUSION

Fruits and/or non-pickled vegetables may be inversely, but sodium, sodium to potassium, and Kimchies may be positively related to blood pressure among men.     

Frequency and related factors of masked hypertension at a worksite in Korea

Objectives

Masked hypertension is associated with metabolic risks and increased risk of cardiovascular disease. The purpose of this study was to identify the frequency of and risk factors of masked hypertension in Korean workers.

Methods

The study was conducted among 121 employees at a hotel in Gyeongju, Korea, from December 2008 to February 2009. We measured blood pressure (BP) both in the clinic and using 24-hour ambulatory BP monitors for all subjects. Hypertension was defined independently by both methods, and subjects were classified into four groups: true normotension, masked hypertension, white coat hypertension, and sustained hypertension.

Results

The frequency of masked hypertension in our study group was 25.6%. Compared with true normotension, the factors related to masked hypertension were male gender (odds ratio [OR], 10.7; 95% confidence interval [CI], 1.41 to 81.09), aging one year (OR, 0.88; 95% CI, 0.78 to 0.99), clinic BP 120-129/80-84 mmHg (OR, 8.42; 95% CI, 1.51 to 46.82), clinic BP 130-139 / 85-89 mmHg (OR, 12.14; 95% CI, 1.80 to 81.85), smoking (OR, 5.51; 95% CI, 1.15 to 26.54), and increase of total cholesterol 1 mg / dL (OR, 1.05; 95% CI, 1.02 to 1.08). In males only, these factors were clinic BP 120-129 / 80-84 mmHg (OR, 15.07; 95% CI, 1.55 to 146.19), clinic BP 130-139 / 85-89 mmHg (OR, 17.16; 95% CI, 1.56 to 189.45), smoking (OR, 11.61; 95% CI, 1.52 to 88.62), and increase of total cholesterol 1 mg/dL (OR, 1.05; 95% CI, 1.01 to 1.09).

Conclusions

The frequency of masked hypertension was high in our study sample. Detection and management of masked hypertension, a known strong predictor of cardiovascular risk, could improve prognosis for at-risk populations.     

Intraocular pressure and its determinants in subjects with type 2 diabetes mellitus in India

Objectives

This study was conducted to show the intraocular pressure (IOP) distribution and the factors affecting IOP in subjects with type 2 diabetes mellitus (DM) in India.

Methods

We measured the anthropometric and biochemical parameters for confirmed type 2 DM patients. A comprehensive ocular examination was performed for 1377 subjects aged > 40 years and residing in Chennai.

Results

A significant difference in IOP (mean ± standard deviation) was found between men and women (14.6±2.9 and 15.0±2.8 mmHg, p = 0.005). A significantly elevated IOP was observed among smokers, subjects with systemic hypertension and women with clinically significant macular edema (CSME). After a univariate analysis, factors associated significantly with higher IOP were elevated systolic blood pressure, elevated resting pulse rate and thicker central corneal thickness (CCT). In women, elevated glycosylated hemoglobin was associated with a higher IOP. After adjusting for all variables, the elevated resting pulse rate and CCT were found to be associated with a higher IOP.

Conclusions

Systemic hypertension, smoking, pulse rate and CCT were associated with elevated intraocular pressure in type 2 DM. Women with type 2 DM, especially those with CSME, were more prone to have an elevated IOP.     

The applicability of home blood pressure measurement in clinical practice: a review of literature

Purpose

To review the literature on home blood pressure measurement (HBPM), to examine its validity and applicability for clinical practice and to provide recommendations regarding HBPM assessment.

Findings

HBPM can eliminate the white coat effect and offers the possibility to obtain multiple measurements under standardized conditions, which increases knowledge of overall blood pressure value. Although it is not entirely capable of replacing ambulatory blood pressure measurement (ABPM), HBPM correlates better with target organ damage and cardiovascular mortality than office blood pressure measurement (OBPM), it enables prediction of sustained hypertension in patients with borderline hypertension, and proves to be an appropriate tool for assessing drug efficacy. Additional advantages of HBPM are that it may increase drug compliance and patient’s awareness of hypertension. Overall, OBPM yield higher blood pressure values than HBPM. Differences between OBPM and HBPM tend to increase with age and are generally higher in patients without antihypertensive treatment than in patients with antihypertensive treatment.

Recommendations

Measurements should be performed according to accepted guidelines and recordings should be performed with a memory equipped automatic validated device. From the data reviewed here, we recommend that HBPM be assessed monthly by taking two measurements in the morning within 1 hour after awakening and two in the evening for three consecutive days, the data from the first day should be dismissed. A subject should be labeled hypertensive if his/her HBPM value is equal to or greater than 137 mmHg systolic and/or 84 mmHg diastolic.     

Risk Charts Illustrating the 10-year Risk of Stroke among Residents of Japanese Rural Communities: The JMS Cohort Study

Background

Risk charts are used to estimate the risk of cardiovascular diseases; however, most have been developed in Western countries. In Japan, currently available risk charts are based on mortality data. Using data on cardiovascular disease incidence from the JMS Cohort Study, we developed charts that illustrated the risk of stroke.

Methods and Results

The JMS Cohort Study is a community-based cohort study of cardiovascular disease. Baseline data were obtained between 1992 and 1995. In the present analysis, the participants were 12 276 subjects without a history of stroke; the follow-up period was 10.7 years. Color-coded risk charts were created by using Cox’s proportional hazards models to calculate 10-year absolute risks associated with sex, age, smoking status, diabetes status, and systolic blood pressure. The risks of stroke and cerebral infarction rose as age and systolic blood pressure increased. Although the risk of cerebral hemorrhage were generally lower than that of cerebral infarction, the patterns of association with risk factors were similar.

Conclusion

These risk charts should prove useful for clinicians and other health professionals who are required to estimate an individual’s risk for stroke.Key words: stroke, blood pressure, smoking, diabetes mellitus, cohort study     

Low-level lead exposure and elevations in blood pressure during pregnancy

Background

Lead exposure is associated with elevated blood pressure during pregnancy; however, the magnitude of this relationship at low exposure levels is unclear.

Objectives

Our goal was to determine the association between low-level lead exposure and blood pressure during late pregnancy.

Methods

We collected admission and maximum (based on systolic) blood pressures during labor and delivery among 285 women in Baltimore, Maryland. We measured umbilical cord blood lead using inductively coupled plasma mass spectrometry. Multivariable models were adjusted for age, race, median household income, parity, smoking during pregnancy, prepregnancy body mass index, and anemia. These models were used to calculate benchmark dose values.

Results

Geometric mean cord blood lead was 0.66 μg/dL (95% confidence interval, 0.61–0.70). Comparing blood pressure measurements between those in the highest and those in the lowest quartile of lead exposure, we observed a 6.87-mmHg (1.51–12.21 mmHg) increase in admission systolic blood pressure and a 4.40-mmHg (0.21–8.59 mmHg) increase in admission diastolic blood pressure after adjustment for confounders. Corresponding values for maximum blood pressure increase were 7.72 (1.83–13.60) and 8.33 (1.14–15.53) mmHg. Benchmark dose lower limit values for a 1-SD increase in blood pressure were < 2 μg/dL blood lead for all blood pressure end points.

Conclusions

A significant association between low-level lead exposures and elevations in maternal blood pressure during labor and delivery can be observed at umbilical blood lead levels < 2 μg/dL.     

Control of hypertension with medication: a comparative analysis of national surveys in 20 countries

Objective

To examine hypertension management across countries and over time using consistent and comparable methods.

Methods

A systematic search identified nationally representative health examination surveys from 20 countries containing data from 1980 to 2011 on blood pressure measurements, the diagnosis and treatment of hypertension and its control with antihypertensive drugs. For each country, the prevalence of hypertension (i.e. systolic blood pressure ≥ 140 mmHg or antihypertensive use) and the proportion of hypertensive individuals whose condition was diagnosed, treated or controlled with medications (i.e. systolic pressure < 140 mmHg) were estimated.

Findings

The age-standardized prevalence of hypertension varied between countries: for individuals aged 35 to 49 years, it ranged from around 12% in Bangladesh, Egypt and Thailand to around 30% in Armenia, Lesotho and Ukraine; for those aged 35 to 84 years, it ranged from 20% in Bangladesh to more than 40% in Germany, the Russian Federation and Turkey. The age-standardized percentage of hypertensive individuals whose condition was diagnosed, treated or controlled was highest in the United States of America: for those aged 35 to 49 years, it was 84%, 77% and 56%, respectively. Percentages were especially low in Albania, Armenia, the Islamic Republic of Iran and Turkey. Although recent trends in prevalence differed in England, Japan and the United States, treatment coverage and hypertension control improved over time, particularly in England.

Conclusion

Globally the proportion of hypertensive individuals whose condition is treated or controlled with medication remains low. Greater efforts are needed to improve hypertension control, which would reduce the burden of noncommunicable diseases.     

Correlation of microalbumin and sialic acid with anthropometric variables in type 2 diabetic patients with and without nephropathy

Aim

The objective of this study is to correlate microalbumin and sialic acid levels with anthropometric variables in type 2 diabetic patients with and without nephropathy.

Methods

This study was a case control study and included 108 Trinidadian subjects (aged 15–60 years) of which 30 were healthy individuals, 38 had type 2 diabetes, and 40 were of type 2 diabetic patients with nephropathy. Blood pressure and waist to hip ratio were recorded. Fasting venous blood samples and urine samples were collected from all the subjects. Blood samples were analysed for the glucose, C-reactive protein, and sialic acid. Urine sample was analysed for microalbumin and sialic acid.

Results

Urinary microalbumin was higher among diabetic subjects (28.9 ± 30.3 mg/L) compared with controls (8.4 ± 10.2 mg/L) and was significantly higher in diabetic patients with nephropathy (792.3 ± 803.9 mg/L). Serum sialic acid was higher in subjects with diabetic nephropathy (71.5 ± 23.3 mg/dL) compared to diabetics (66.0 ± 11.7 mg/dL) and controls (55.2 ± 8.3 mg/dL). Increased microalbumin and sialic acid were correlated with other cardiovascular risk factors such as hypertension and waist to hip ratios (p < 0.05).

Conclusions

From these results it can be concluded that the increased microalbumin and sialic acid were strongly correlated with hypertension and waist to hip ratios in Trinidadian type-2 diabetic patients. Measurement of sialic acid, microalbumin, and waist to hip ratio along with the blood pressure is recommended for all type 2 diabetic patients to reduce the cardiovascular risk.     

Epidemiology of hypertension in Serbia: results of a National Survey

Background

We evaluated the prevalence of high blood pressure and the level of awareness, treatment, and control of hypertension in a Serbian population.

Methods

A cross-sectional study of an adult population was carried out across Serbia in 2006. The study involved 14 204 adults aged 20 years or older. Interviews and measurements of blood pressure were performed at participants’ homes.

Results

Overall, 47% of the Serbian adult population had hypertension: 25.3% had stage 1 hypertension and 18.1% had stage 2 hypertension. Only 58.0% of the hypertensive population were aware that they had the disease, and 60.4% were receiving medical treatment. Among those receiving medical treatment, only 20.9% had a blood pressure within the normal range. One in 10 participants with hypertension were not treated because, among other reasons, they thought treatment was unnecessary (55.3%) or they lacked money for medication (19.3%).

Conclusions

The prevalence of undiagnosed and untreated hypertension is high in the adult population of Serbia. Further action is required to hasten detection and treatment of high blood pressure. Attention should be directed toward educational programs that improve knowledge, attitudes, and awareness of hypertension among adults.Key words: hypertension, adult population, Serbia     

Peer Reviewed: Lifestyle Interventions for Hypertension and Dyslipidemia Among Women of Reproductive Age

Introduction

Hypertension and dyslipidemia often precede cardiovascular disease. Lifestyle modifications help prevent these conditions, and referrals for women may be possible during reproductive health care visits. However, screening recommendations vary, which may affect screening rates. The objectives of this systematic review were to 1) assess the available literature on the effectiveness of lifestyle interventions, 2) review hypertension and dyslipidemia screening recommendations for consistency, and 3) report prevalence data for hypertension and dyslipidemia screening among women of reproductive age.

Methods

We conducted a systematic literature search (January 1990-November 2010) for 1) randomized controlled trials on the impact of lifestyle interventions on cardiovascular disease risk factors in women of reproductive age, 2) evidence-based guidelines on hypertension and dyslipidemia screening, and 3) population-based prevalence studies on hypertension or dyslipidemia screening or both.

Results

Twenty-one of 555 retrieved studies (4%) met our inclusion criteria. Lifestyle interventions improved lipid levels in 10 of 18 studies and blood pressure in 4 of 9 studies. Most guidelines recommended hypertension screening at least every 2 years and dyslipidemia screening every 5 years, but recommendations for who should receive dyslipidemia screening varied. One study indicated that 82% of women of reproductive age received hypertension screening during the preceding year. In another study, only 49% of women aged 20 to 45 years received recommended dyslipidemia screening.

Conclusions

Lifestyle interventions may offer modest benefits for reducing blood pressure and lipids in this population. Inconsistency among recommendations for dyslipidemia screening may contribute to low screening rates. Future studies should clarify predictors of and barriers to cholesterol screening in this population.     

Gender Differences in Hypertension Control Among Older Korean Adults: Korean Social Life,Health, and Aging Project

Objectives:

Controlling blood pressure is a key step in reducing cardiovascular mortality in older adults. Gender differences in patients’ attitudes after disease diagnosis and their management of the disease have been identified. However, it is unclear whether gender differences exist in hypertension management among older adults. We hypothesized that gender differences would exist among factors associated with hypertension diagnosis and control among community-dwelling, older adults.

Methods:

This cross-sectional study analyzed data from 653 Koreans aged ≥60 years who participated in the Korean Social Life, Health, and Aging Project. Multiple logistic regression was used to compare several variables between undiagnosed and diagnosed hypertension, and between uncontrolled and controlled hypertension.

Results:

Diabetes was more prevalent in men and women who had uncontrolled hypertension than those with controlled hypertension or undiagnosed hypertension. High body mass index was significantly associated with uncontrolled hypertension only in men. Multiple logistic regression analysis indicated that in women, awareness of one’s blood pressure level (odds ratio [OR], 2.86; p=0.003) and the number of blood pressure checkups over the previous year (OR, 1.06; p=0.011) might influence the likelihood of being diagnosed with hypertension. More highly educated women were more likely to have controlled hypertension than non-educated women (OR, 5.23; p=0.013).

Conclusions:

This study suggests that gender differences exist among factors associated with hypertension diagnosis and control in the study population of community-dwelling, older adults. Education-based health promotion strategies for hypertension control might be more effective in elderly women than in elderly men. Gender-specific approaches may be required to effectively control hypertension among older adults.     

Screening For Hypertension Annually Compared With Current Practice

PURPOSE

Hypertension is the most common diagnosis in ambulatory care, yet little evidence exists regarding recommended screening intervals or the sensitivity and specificity of a routine office-based blood pressure measurement, the most common screening test. Screening for hypertension is usually performed by measuring blood pressure at every outpatient visit, which often results in transiently elevated findings among adults who do not have a diagnosis of hypertension. We hypothesize that a more limited annual screening strategy may increase specificity while maintaining sensitivity.

METHODS

A retrospective case-control study of 372 adults without hypertension and 68 patients with newly diagnosed hypertension was conducted to compare the usual screening practice of checking blood pressure at every visit with a second strategy that considered only annual blood pressure measurements.

RESULTS

Specificity improved from 70.4% (95% CI, 65.5%-75.0%) for the usual practice to 82.0% (95% CI, 77.7%-85.8%) for the annual screening strategy. No statistically significant difference in sensitivity existed between the 2 methods.

CONCLUSION

A limited annual screening strategy for hypertension can improve specificity without sacrificing sensitivity when compared with routine screening at every visit in previously normotensive adults.Key words: hypertension, blood pressure, blood pressure determination, preventive health services, sensitivity and specificity, mass screening     

Dietary patterns and levels of blood pressure and serum lipids in a Japanese population

Background

Associations between dietary patterns and cardiovascular disease risk factors remain unclear. The objective of this study was to evaluate the association between dietary patterns derived from factor analysis and the levels of blood pressure and serum lipids in a Japanese population.

Methods

We conducted a cross-sectional analysis among 6886 (in the analysis on blood pressure) and 7641 (in the analysis on serum lipids) Japanese subjects aged 40-69 years. Dietary patterns were identified from a food frequency questionnaire by factor analysis. Associations between dietary patterns and blood pressure and serum lipids were examined after taking potential confounders into account.

Results

Three dietary patterns were identified: vegetable, meat, and Western. In men, the meat pattern was associated with higher total, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) cholesterol. The Western pattern was associated with higher total and LDL cholesterol. In women, the vegetable pattern was associated with lower systolic and diastolic blood pressure and pulse pressure, and higher HDL cholesterol. The meat pattern was associated with higher total and HDL cholesterol. The Western pattern was associated with higher total, HDL, and LDL cholesterol, and the least intake pattern of Western diet was associated with higher systolic and diastolic blood pressures.

Conclusions

Dietary patterns of a Japanese population were related to cardiovascular disease risk factors, especially in women.Key words: Diet, Factor Analysis, Statistical, Blood Pressure, Cholesterol, Japan     

Non-pharmacological Interventions in Hypertension: A Community-based Cross-over Randomized Controlled Trial

Background:

Hypertension is the most prevalent non-communicable disease causing significant morbidity/mortality through cardiovascular, cerebrovascular, and renal complications.

Objectives:

This community-based study tested the efficacy of non-pharmacological interventions in preventing/controlling hypertension.

Materials and Methods:

This is a cross-over randomized controlled trial (RCT) of the earlier RCT (2007) of non-pharmacological interventions in hypertension, conducted in the urban service area of our Institute. The subjects, prehypertensive and hypertensive young adults (98 subjects: 25, 23, 25, 25 in four groups) were randomly allotted into a group that he/she had not belonged to in the earlier RCT: Control (New Group I), Physical Exercise (NG II)-brisk walking for 50 to 60 minutes, three to four days/week, Salt Intake Reduction (NG III) to at least half of their previous intake, Yoga (NG IV) for 30 to 45 minutes/day, five days/week. Blood pressure was measured before and after eight weeks of intervention. Analysis was by ANOVA with a Games-Howell post hoc test.

Results:

Ninety-four participants (25, 23, 21, 25) completed the study. All three intervention groups showed significant reduction in BP (SBP/DBP mmHg: 5.3/6.0 in NG II, 2.5/2.0 in NG III, and 2.3/2.4 in NG IV, respectively), while the Control Group showed no significant difference. Persistence of significant reduction in BP in the three intervention groups after cross-over confirmed the biological plausibility of these non-pharmacological interventions. This study reconfirmed that physical exercise was more effective than Salt Reduction or Yoga. Salt Reduction, and Yoga were equally effective.

Conclusion:

Physical exercise, salt intake reduction, and yoga are effective non-pharmacological methods for reducing blood pressure in young pre-hypertensive and hypertensive adults.     

Cardiovascular Health Metrics and All-cause and Cardiovascular Disease Mortality Among Middle-aged Men in Korea: The Seoul Male Cohort Study

Objectives

This study estimated the association of cardiovascular health behaviors with the risk of all-cause and cardiovascular disease (CVD) mortality in middle-aged men in Korea.

Methods

In total, 12 538 men aged 40 to 59 years were enrolled in 1993 and followed up through 2011. Cardiovascular health metrics defined the following lifestyle behaviors proposed by the American Heart Association: smoking, physical activity, body mass index, diet habit score, total cholesterol, blood pressure, and fasting blood glucose. The cardiovascular health metrics score was calculated as a single categorical variable, by assigning 1 point to each ideal healthy behavior. A Cox proportional hazards regression model was used to estimate the hazard ratio of cardiovascular health behavior. Population attributable risks (PARs) were calculated from the significant cardiovascular health metrics.

Results

There were 1054 total and 171 CVD deaths over 230 690 person-years of follow-up. The prevalence of meeting all 7 cardiovascular health metrics was 0.67%. Current smoking, elevated blood pressure, and high fasting blood glucose were significantly associated with all-cause and CVD mortality. The adjusted PARs for the 3 significant metrics combined were 35.2% (95% confidence interval [CI], 21.7 to 47.4) and 52.8% (95% CI, 22.0 to 74.0) for all-cause and CVD mortality, respectively. The adjusted hazard ratios of the groups with a 6-7 vs. 0-2 cardiovascular health metrics score were 0.42 (95% CI, 0.31 to 0.59) for all-cause mortality and 0.10 (95% CI, 0.03 to 0.29) for CVD mortality.

Conclusions

Among cardiovascular health behaviors, not smoking, normal blood pressure, and recommended fasting blood glucose levels were associated with reduced risks of all-cause and CVD mortality. Meeting a greater number of cardiovascular health metrics was associated with a lower risk of all-cause and CVD mortality.     

Maternal Blood Lead Levels and the Risk of Pregnancy-Induced Hypertension: The EDEN Cohort Study

Background

Prior studies revealed associations of environmental lead exposure with risks of hypertension and elevated blood pressure.

Objective

We examined the effect of blood lead levels on blood pressure and the incidence of pregnancy-induced hypertension (PIH) in the second and third trimesters of pregnancy.

Methods

One thousand seventeen pregnant women were enrolled in two French municipalities between 2003 and 2005 for the EDEN (Etude des Déterminants pré et post natals du développement et de la santé de l′ Enfant) cohort study. Blood lead concentrations were measured by atomic absorption spectrometry in mothers between 24 and 28 weeks of gestation.

Results

PIH was diagnosed in 106 subjects (10.9%). Age, parity, weight gain, alcohol, smoking habits, and calcium supplementation were comparable between hypertensive and nonhypertensive women. Lead levels were significantly higher in PIH cases (mean ± SD, 2.2 ± 1.4 μg/dL) than in normotensive patients (1.9 ± 1.2 μg/dL; p = 0.02). Adjustment for potential confounder effects slightly attenuated but did not eliminate the significant association between blood lead levels and the risk of PIH (adjusted odds ratio of PIH = 3.3; 95% confidence interval, 1.1–9.7). We also observed geographic differences in lead exposure and in the incidence of PIH and found significant correlations between blood lead levels and unadjusted as well as adjusted systolic and diastolic blood pressures after 24 weeks of gestation.

Conclusions

These findings confirm the relationship between blood lead levels at mid-pregnancy and blood pressure and suggest that environmental lead exposure may play an etiologic role in PIH.     

Assessing the effects of non-steroidal anti-inflammatory drugs on antihypertensive drug therapy using post-marketing surveillance database

Background

Antihypertensive and non-steroidal anti-inflammatory drugs (NSAIDs) are used to treat many common diseases. However, it has been suspected that interactions between these drugs exist. Here, we assessed the interactions between non-selective NSAIDs and several classes of antihypertensive drugs.

Methods

The study design was a cohort study using “The Antihypertensive Drug Database,” which is a collection of data accumulated from Drug Use Investigations. Subjects newly starting antihypertensive drug therapy were identified in the database. We compared the “User” group, who were co-administered NSAIDs, with the “Non-user” group, who were not. The outcome measure was the change in systolic blood pressure from the baseline after 2 months of treatment. We estimated the non-adjusted and adjusted differences in the change in systolic blood pressure between the “User” and “Non-user” groups.

Results

Data were collected for a total of 1,204 subjects, of whom 364 were prescribed beta blockers, 60 were prescribed diuretics, 628 were prescribed angiotensin-converting enzyme inhibitors, and 152 were prescribed calcium channel blockers. The adjusted difference in the change in systolic blood pressure between the User (n = 301) and Non-user (n = 903) groups was 2.88 mmHg (95% confidence interval: 0.89, 4.87); thus, systolic blood pressure in the Non-User group decreased further from the baseline than that in the User group. In subjects administered beta blockers, diuretics, angiotensin-converting enzyme inhibitors, and calcium channel blockers, the corresponding differences were 0.37 mmHg (-3.24, 3.98), 6.11 mmHg (-3.16, 15.37), 3.85 mmHg (1.16, 6.66), and 3.50 mmHg (-2.03, 9.02).

Conclusion

The effectiveness of antihypertensive drugs was attenuated by the co-administration of NSAIDs. The differences in the effects of NSAIDs varied with different classes of antihypertensive drugs.Key words: Drug Interactions, Antihypertensive Agents, NSAIDs, Database     

Blood pressure reduction due to hemoglobin glycosylation in type 2 diabetic patients

Objective:

To test the hypothesis that glycosylation of hemoglobin constitutes a risk factor for hypertension.

Methods:

A total of 129 relative uniform diabetic subjects (86 women and 42 men) were enrolled in a cross sectional study. Exclusion criteria included alcohol consumption, smoking, ischemic heart disease, stroke, neoplasia, renal, hepatic, and chronic inflammatory disease. Systolic and diastolic pressures were recorded in subsequent days and mean arterial blood pressure (MAP) was determined. Hemoglobin glycosylation was measured by determining the percentage glycosylated hemoglobin (HbA1c) by means of the automated microparticle enzyme immunoassay test.

Results:

MAP was found to be independent of the concentration of HbA1c; however, correcting MAP for the variability in hematocrit, to evidence the level of vasoconstriction (or vasodilatation) showed that MAP is negatively correlated with the concentration of HbA1c (p for trend <0.05), when patients treated for hypertension are excluded from the analysis. Patients treated for hypertension showed the opposite trend with increasing MAP as HbA1c increased (p for the difference in trends <0.05).

Conclusions:

Glycosylation per se appears to lead to blood pressure reduction in type 2 diabetic patients untreated for hypertension. Treatment for hypertension may be associated with a level of endothelial dysfunction that interferes with the antihypertensive effect of HbA1c.