Preventing increases in early-morning blood pressure,heart rate,and the rate-pressure product with controlled onset extended release verapamil at bedtime versus enalapril,losartan, and placebo on arising

Background Therapeutic agents for the treatment of hypertension may differ in their efficacy during the early-morning period, a time when both morbid and mortal cardiovascular events are increased compared with other times of the day. Methods We studied the effects of a chronotherapeutic delivery system of verapamil (controlled-onset extended release [COER]-24 system) dosed at bedtime versus conventional morning administration of both enalapril and losartan on the blood pressure (BP), heart rate, and the heart rate systolic BP product during the first 4 hours after awakening in a placebo-controlled, forced-titration trial. There were 357 men and women enrolled in the trial with an untreated sitting diastolic BP of 95 to 114 mm Hg and ambulatory daytime diastolic BP ≥85 mm Hg. Patients were randomized to either COER-verapamil hydrochloride each evening (240 mg titrated to 360 mg), enalapril each morning (10 mg titrated to 20 mg), losartan each morning (50 mg titrated to 100 mg), or placebo. Early morning assessments of BP, heart rate, and the heart rate systolic BP product were performed by use of 24-hour ambulatory recordings after 4 weeks (low dose) and 8 weeks (high dose) of therapy. Results Results were similar at weeks 4 and 8 for all treatment groups except that the magnitude of change was greater at week 8. After 8 weeks of treatment, reductions in early morning BP by COER-verapamil were significantly greater (−15/−10 mm Hg) than enalapril (−9/−7 mm Hg, P < .01) and losartan (−8/−5 mm Hg, P < .001). COER-verapamil also led to greater reductions in morning heart rate, the rate-pressure product, and the rate-of-rise of BP compared with the other 2 active treatment groups. Reductions in mean 24-hour BP were greater in patients treated with COER-verapamil compared with placebo and losartan, and similar to reductions in patients treated with enalapril. Conclusions Bedtime administration of an agent designed to parallel the circadian rhythm of BP and heart rate led to significantly greater early morning hemodynamic effects compared with other conventional once-daily antihypertensive agents dosed in the morning. (Am Heart J 2002;144:657-65.)     

Blood pressure levels and hypertension status among ethnic groups in England

The prevalence of cardiovascular disease and hypertension show wide variability among different ethnic groups in the UK. We combined data collected annually between 1991-1996 in the Health Surveys for England--nationwide surveys that provide information on the health status in a representative sample of the population living in England, to compare blood pressure (BP) levels, hypertension rates (systolic BP > or = 160 mm Hg or diastolic BP > or = 95 mm Hg, or those on antihypertensive medication), hypertension treatment and control rates in people of white, black (combining black-Caribbean, black-African and black-other), and South Asian origin (combining Indians, Pakistanis and Bangladeshis). Analyses were stratified into two age groups, 16-39 (younger) and > or = 40 years (older), but were focused on older adults (30,619 whites, 295 blacks and 529 South Asians). Age-adjusted mean BP levels and hypertension rates of older adults were highest among blacks, while South Asian men showed BP levels and hypertension rates similar to black men and South Asian women had mean BP levels and hypertension rates similar to white women. After controlling for age, BMI, smoking, alcohol consumption, and social class the odds ratio (OR) of being hypertensive among older adults was higher in black men (OR 2.0; 95% CI 1.4, 2.9; P < 0.001); black women (OR 1.7; 95% CI 1.2, 2.5; P < 0.01); and South Asian men (1.9; CI 1.4, 2.4; P < 0.001), than in their white counterparts. Among those studied with hypertension, treatment rates were highest among black men and women. Among those on antihypertensive medication, the odds of having BP controlled (SBP < 160 mm Hg and DBP < 95 mm Hg) did not differ among the three groups of older men but was reduced in older South Asian women, compared with white women.     

Exercise capacity and 24-h blood pressure in prehypertensive men and women

BACKGROUND: Prehypertensive individuals are at increased risk for developing hypertension and cardiovascular disease compared to those with normal blood pressure (BP). Physically active, normotensive individuals are also at lower risk for developing hypertension than sedentary individuals. We assessed the relationship between fitness and 24-h ambulatory BP in prehypertensive men and women. METHODS: We assessed exercise capacity and 24-h BP in 407 men (age 51 +/- 11 years) and 243 women (age 54 +/-10 years) with resting systolic BP 120 to 139 mm Hg and diastolic BP of 80 to 89 mm Hg, defined as prehypertension. Fitness categories (low, moderate, and high) were established according to exercise time and age. RESULTS: Multiple regression analysis revealed that fitness status was inversely associated with ambulatory BP in both genders (P < .001). After adjusting for various confounders, individuals in the lowest fitness category had significantly higher 24-h, daytime, and night-time BP than those in the moderate and high fitness categories. For men, differences between low and moderate fitness categories were 6/4 mm Hg, 8/4 mm Hg, and 7/3 mm Hg for 24-h, daytime, and night-time BP, respectively (P < .05). For women, the differences were 8/5 mm Hg, 9/5 mm Hg, and 8/7 mm Hg for 24-h, daytime, and night-time BP, respectively. Similar differences were evident in both genders between low and high fitness category (P < .05). CONCLUSIONS: Moderate physical activity promotes lower BP during a 24-h period in prehypertensive men and women. The risk for developing hypertension is likely to be lowered if moderate intensity physical activity in this vulnerable population is encouraged.     

Comparison of valsartan and amlodipine on ambulatory and morning blood pressure in hypertensive patients

BACKGROUND: Cardiovascular events occur most frequently in the morning. We aimed to study the effects of monotherapy with the long-acting angiotensin II receptor blocker valsartan compared with the long-acting calcium antagonist amlodipine on ambulatory and morning blood pressure (BP). METHODS: We performed ambulatory BP monitoring before and after once-daily dose of valsartan (valsartan group, n = 38) and amlodipine (amlodipine group, n = 38) therapy in 76 hypertensive patients. To achieve the target BP of < or =140/90 mm Hg, valsartan was titrated from 40 mg/day to 160 mg/day (mean dose 124 mg/day) and amlodipine was titrated from 2.5 mg/day to 10 mg/day (mean dose 6.4 mg/day). RESULTS: Both drugs significantly reduced clinic and 24-h systolic BP (SBP) and diastolic BP (DBP) (P <.002). However, the antihypertensive effect of amlodipine was superior to that of valsartan in clinical SBP (-26 mm Hg v -13 mm Hg, P =.001) and 24-h SBP (-14 mm Hg v -7 mm Hg, P =.008). In addition, morning SBP was significantly reduced by amlodipine from 156 to 142 mm Hg (P <.001) but not by valsartan. Both agents reduced lowest night SBP to a similar extent (amlodipine 121 to 112 mm Hg, P <.001; valsartan 123 to 114 mm Hg, P <.002). Reduction in morning SBP surge (morning SBP minus lowest night SBP) was significantly greater in patients treated with amlodipine compared with those treated with valsartan (-6.1 mm Hg v +4.5 mm Hg, P <.02). CONCLUSIONS: Amlodipine monotherapy was more effective than valsartan monotherapy in controlling 24-h ambulatory BP and morning BP in hypertensive patients.     

Effect of body weight changes on 24-hour blood pressure and left ventricular mass in hypertension: a 4-year follow-up

BACKGROUND: Few data are available on the long-term effects of weight loss on 24-h blood pressure (BP) and left ventricular mass in overweight hypertensive patients. METHODS: A total of 181 never-treated overweight hypertensive subjects (body mass index, 25 to 39 kg/m(2), office BP 145/94 +/- 12/7 mm Hg) had 24-h BP monitoring and echocardiography twice, at baseline and after 3.8 +/- 2 years (minimum 1 year). None of the subjects received antihypertensive drugs during the follow-up. Main outcome measures were changes in 24-h BP and in left ventricular mass. RESULTS: Percent change in body weight had a direct relationship with 24-h BP changes (r = 0.35 and 0.31 for systolic and diastolic BP, respectively; both P <.001). The associations with office BP changes (r = 0.13, P =.10 for systolic BP; r = 0.15, P =.06 for diastolic BP) were significantly weaker (both P <.01, z test). The patients who lost weight during follow-up (n = 106) had a significantly lower increase in 24-h BP (+0.6 +/- 9/ +0.2 +/- 6 v +4.9 +/- 9/ +2.7 +/- 7 mm Hg for systolic/diastolic BP, both P <.01) and in left ventricular mass (-3 +/- 30 g v +9 +/- 32 g, P <.02) than the remaining subjects. In a multiple linear regression, a 10% weight loss independently predicted a 4.3/3.8 mm Hg decrease in 24-h systolic/diastolic BP. CONCLUSIONS: Long-term weight loss determines a sustained BP reduction during the 24 h and a decrease in left ventricular mass in overweight hypertensive subjects. The relation of weight loss with ambulatory BP changes is closer than that with office BP.     

A multicenter, 14-week study of telmisartan and ramipril in patients with mild-to-moderate hypertension using ambulatory blood pressure monitoring

BACKGROUND: Blood pressure (BP) has a circadian pattern with a morning surge that is associated with an increased risk of acute coronary and cerebrovascular events. In a prospective, randomized, open-label, blinded-endpoint, parallel-group, multicenter, forced-titration study of telmisartan and ramipril, the efficacy of both drugs on mean ambulatory diastolic BP (DBP) and systolic BP (SBP) during the last 6 h of a 24-h dosing interval was evaluated. METHODS: After screening and a single-blind run-in phase, 812 adults with mild-to-moderate hypertension (defined as a mean seated DBP > or =95 mm Hg and < or =109 mm Hg and a 24-h ABPM mean DBP 7 > or = 85 mm Hg) were randomized to the open-label, 14-week, forced-titration, active-treatment phase as follows: telmisartan 40 mg/80 mg/80 mg (n = 405) or ramipril 2.5 mg/5 mg/10 mg (n = 407), once daily in the morning. The primary efficacy variable was change from baseline in the last 6-h mean DBP and SBP at 8 and 14 weeks as assessed by ambulatory BP monitoring (ABPM). Secondary efficacy variables were changes from baseline in BP control during each of the 24-h periods and in-clinic trough cuff BP. RESULTS: Telmisartan 80 mg was superior to ramipril 5 mg and 10 mg in change from baseline in the last 6-h ABPM mean DBP and SBP at both 8 and 14 weeks (both P < .0001), respectively. At 14 weeks, the adjusted mean change from baseline in DBP for telmisartan 80 mg was -8.8 mm Hg compared with that for ramipril 10 mg of -5.4 mm Hg (P < .0001). For SBP, the adjusted mean change from baseline for telmisartan 80 mg was -12.7 mm Hg compared with that for ramipril 10 mg of -7.9 mm Hg (P < .0001). At 14 weeks, telmisartan 80 mg also yielded superior reductions from baseline in trough cuff BP compared with ramipril 10 mg (DBP: -11.0 mm Hg v -7.8 mm Hg, respectively; SBP: -14.3 mm Hg v -9.1 mm Hg, respectively; both P < .0001). Measures of 24-h BP control favored telmisartan 80 mg versus ramipril 10 mg (P < .0001), as did other secondary ABPM endpoints during the daytime, night-time, and morning periods. Treatment-related adverse events were uncommon; patients treated with ramipril had a higher incidence of cough than those treated with telmisartan (10.1% v 1.5%, respectively). CONCLUSIONS: Telmisartan 80 mg was consistently more effective than ramipril 10 mg in reducing both DBP and SBP during the last 6 h of the dosing interval, a measure of the early morning period when patients are at greatest risk of life-threatening cardiovascular and cerebrovascular events. Telmisartan 80 mg was also more effective than ramipril 10 mg in reducing BP throughout the entire 24-h dosing interval. Both drugs were well tolerated.     

Type 2 diabetes is associated with left ventricular concentric remodeling in hypertensive patients

BACKGROUND: Left ventricular (LV) geometric remodeling is associated with cardiovascular prognosis in hypertensive patients. It is uncertain how LV remodeling is modulated by diabetes in hypertensive patients. In this study, we investigated the impact of diabetes and ambulatory blood pressure (BP) on LV geometric remodeling in hyptensives with/without diabetes. METHODS: Ambulatory BP monitoring and echocardiography were performed to compare 24-h BP levels and LV measurements in 400 uncomplicated hypertensives (mean age, 67 years, 152 men and 248 women) between diabetic (n = 161) and nondiabetic (n = 239) patients. RESULTS: The age (67 v 68 years), percentage of men (43% v 34%), body mass index (24.5 v 24.0 kg/m(2)), 24-h systolic BP (144/80 v 144/82 mm Hg), LV mass index (128 v 130 g/m(2)) were similar between the groups. Diabetic patients had higher relative wall thickness (0.50 v 0.44, P < .001) and higher prevalence of concentric LV hypertrophy (39.4% v 26.8%, P < .001) than nondiabetic patients. The presence of diabetes (odds ratio [OR] = 2.76; 95% confidence interval [CI] = 1.73-4.41, P < .001) and 24-h systolic BP (OR for 10 mm Hg increase = 1.17; 95% CI = 1.01-1.37, P < .05) were independently associated with the higher relative wall thickness (>/=0.45). On the other hand, 24-h systolic BP was independently associated with LV hypertrophy (OR for 10 mm Hg increase = 1.32; 95% CI = 1.14-1.52, P < .05). CONCLUSIONS: Among hypertensive patients, type 2 diabetes was associated with concentric LV geometry independent of ambulatory BP.     

Ambulatory blood pressure monitoring in a nonacademic setting. Effects of age and sex.

Twenty-four-hour ambulatory blood pressure measurements (ABPM) are likely to eliminate the stress of visits and observer bias in office blood pressure (BP) recordings, allow consideration of the circadian variability in BP, and correlate well with target organ damage. To define the prevalence of "white coat" hypertension in a rural community to a nonacademic setting, and to assess age and sex related differences, we studied 131 patients who had more than two prior office diastolic BP measurements greater than 90 mm Hg and less than 115 mm Hg. Blood pressure was measured every 10 to 60 min for 24 h using the SpaceLabs 90207 device. Office BP readings were higher than ABPM in the group as a whole, in individual age groups, and in both sexes. The differences were more pronounced at night. Average differences between office and ambulatory BP ranged between 14.4 +/- 1.7/2.9 +/- 2.0 (ABPM at 10:00), and 33.8 +/- 2.3/22.8 +/- 1.5 mm Hg (systolic/diastolic +/- SE) (ABPM at 01:00). The nighttime drop in systolic BP was not apparent in subjects more than 65 years old. Women had a proportionately higher mean office BP than men (115.0 +/- 0.9 office v 110.2 +/- 1.3 mm Hg ABPM in women and 112.3 +/- 0.9 v 104.3 +/- 1.1 mm Hg in men) (P = .013), and the elderly did not display the relationship between ambulatory and office mean BP seen in younger subjects (r = 0.15, P = .30 v r = 0.36, P = .0004, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)     

Differences in blood pressure values by simultaneous auscultation of Korotkoff sounds inside the cuff and in the antecubital fossa.

To elucidate whether auscultation of the Korotkoff sounds inside the cuff and in the antecubital fossa leads to different blood pressure (BP) values we measured BP at both sites simultaneously with identical flat stethoscopes in a same-arm test design (part A) in 64 normotensive (N: 32 men, 32 women; mean age: 38.7 +/- 15.1 years) and 67 hypertensive subjects (H: 36 men, 31 women; mean age: 44.6 +/- 12.9 years), and additionally in a same- and opposite-arm test design (part B) in 20 normotensive young women. While in part A systolic BP measured inside the cuff was only slightly higher (N: +1. 6 +/- 3.2 mm Hg; H: +1.0 +/- 1.4 mm Hg), diastolic BP was considerably lower (N: -10.6 +/- 5.6 mm Hg; H: -8.4 +/- 4.9 mm Hg). This result was corroborated by part B with differences in systolic/diastolic BP of +0.8 +/- 1.0/-8.5 +/- 2.2 mm Hg in the same-arm test and +0.4 +/- 4.8/-10.6 +/- 5.2 mm Hg in the opposite-arm test. Subject's age was the main variable determining differences in diastolic BP with significantly higher differences in younger than in older subjects, indicating that the elastic properties of arteries may be responsible for these differences. Our results demonstrate that a modification in the auscultatory technique of BP measurement produces significantly different diastolic BP values, the magnitude of which is important for our conceptions of threshold and target values in diagnosing and treating hypertension.     

Effects of 24-h shift work in the emergency room on ambulatory blood pressure monitoring values of medical residents

BACKGROUND: Medical residency is marked by long work hours and shift work. The acute effects of these factors on the blood pressure (BP) of medical residents have not been adequately evaluated. METHODS: A total of 61 medical residents underwent to ambulatory blood pressure monitoring (ABPM) during a 24-h shift work in the emergency room (ER) and during a common working day. RESULTS: Both mean 24-h systolic and diastolic BP (DBP) and mean diastolic BP readings during sleep were higher during the 24-h shift work in the ER than during common working day (117 v 113 mm Hg, P < .05; 73 v 69 mm Hg, P < .05; and 61 v 58 mm Hg, P < .05, respectively). Abnormally high mean BP readings were more frequent during the 24-h shift work in the ER than in common working day (19 v 8, P < .05). Pressure load, nocturnal BP fall and pulse pressure values were similar in these two different working situations. CONCLUSION: Working in the ER on a 24-h shift leads to abnormal BP behavior in medical residents, thus suggesting that this type of work may be a risk factor for cardiovascular disease.     

Strength training normalizes resting blood pressure in 65- to 73-year-old men and women with high normal blood pressure.

OBJECTIVE: To determine the effects of heavy resistance strength training (ST) on resting blood pressure (BP) in older men and women. DESIGN: Prospective intervention study. SETTING: University of Maryland Exercise Science Laboratory. PARTICIPANTS: Twenty-one sedentary, healthy older men (69 +/- 1 year, n = 11) and women (68 +/- 1 year, n = 10) served as subjects for the study. INTERVENTION: Six months of progressive whole body ST performed 3 days per week using Keiser K-300 air-powered resistance machines. MEASUREMENTS: One-repetition maximum (1 RM) strength was measured for seven different exercises before and after the ST program. Resting BP was measured on six separate occasions before and after ST for each subject. RESULTS: Substantial increases in 1 RM strength were observed for upper body (UB) and lower body (LB) muscle groups for men (UB: 215 vs 265 kg; LB: 694 vs 838 kg; P < .001) and women (UB: 128 vs 154 kg; LB: 441 vs 563 kg; P < .001). The ST program led to reductions in both systolic (131 +/- 2 vs 126 +/- 2 mm Hg, P < .010) and diastolic (79 +/- 2 vs 75 +/- 1 mm Hg, P < .010) BP. Systolic BP was reduced significantly in men (134 +/- 3 vs 127 +/- 2 mm Hg, P < .01) but not in women (128 +/- 3 vs 125 +/- 3 mm Hg, P < .01), whereas diastolic BP was reduced following training in both men (81 +/- 3 vs 77 +/- 1, mm Hg, P = .054) and women (78 +/- 2 vs 74 +/- 2 mm Hg, P = .055). CONCLUSIONS: Six months of heavy resistance ST may reduce resting BP in older persons. According to the latest guidelines from the Joint National Committee for the Detection, Evaluation, and Treatment of Hypertension, the changes in resting BP noted in the present study represent a shift from the high normal to the normal category.     

Pulse pressure lowering effect of dual blockade with candesartan and lisinopril vs. high-dose ACE inhibition in hypertensive type 2 diabetic subjects: a CALM II study post-hoc analysis

BACKGROUND: Elevated pulse pressure (PP) is strongly associated with micro- and macrovascular complications in type 2 diabetic patients. We examined the effect of 12 months of dual blockade with candesartan and lisinopril vs. high-dose lisinopril monotherapy on ambulatory PP in hypertensive type 2 diabetic patients from the CALM (Candesartan and Lisinopril Microalbuminuria Trial) II study. METHODS: The CALM II study was a 12-month prospective, randomized, parallel-group, double-masked study that included 75 type 1 and type 2 diabetic subjects with hypertension. Participants were randomized for treatment with either high-dose lisinopril (40 mg once daily (o.d.)) or for dual blockade treatment with candesartan (16 mg o.d.) and lisinopril (20 mg o.d.). In this article, we present data from the post-hoc subgroup of 51 type 2 diabetic subjects who completed the full 12-month study period with successful ambulatory blood pressure (BP) measurements at both baseline and follow-up visits. RESULTS: Baseline 24-h BP values were similar in the two groups (24-h systolic BP (SBP) 130 +/- 12 vs. 127 +/- 9, 24-h diastolic BP (DBP) 77 +/- 8 vs. 74 +/- 7, and 24-h PP 53 +/- 8 vs. 53 +/- 7 mm Hg, for the lisinopril and dual blockade groups, respectively, P > 0.2 for all). Compared with lisinopril monotherapy, dual blockade treatment caused a highly significant reduction in 24-h PP levels (-5 +/- 5 mm Hg, P = 0.003), albeit the difference in the BP lowering effect between the treatment groups did not differ significantly for 24-h systolic (P = 0.21) or diastolic (P = 0.49) BP. Dual blockade treatment significantly lowered 24-h SBP (-5 +/- 11 mm Hg, P = 0.03), but not 24-h DBP (-2 +/- 7 mm Hg, P = 0.29), whereas in the lisinopril group, the opposite effect was observed (24-h SBP -1 +/- 9 mm Hg, P = 0.45, 24-h SBP -3 +/- 7 mm Hg, P = 0.03). CONCLUSIONS: Twelve months of dual blockade with candesartan and lisinopril significantly reduced PP when compared with high-dose monotherapy with lisinopril. Larger studies are needed to confirm this observation, and to evaluate whether this effect translates into a greater degree of end-organ protection from dual blockade treatment than from conventional angiotensin-converting enzyme (ACE) inhibition.     

Additive effect of drospirenone/17-beta-estradiol in hypertensive postmenopausal women receiving enalapril

BACKGROUND: Aldosterone has been implicated in the pathogenesis of progressive cardiovascular disease. Drospirenone (DRSP) is a novel progestin with aldosterone receptor antagonist activity developed for hormone replacement therapy (HRT) as DRSP/17beta-estradiol (DRSP/ E2). We investigated the additive effect of DRSP/E2 versus placebo on 24-h ambulatory blood pressure (BP) in postmenopausal women with hypertension treated with enalapril maleate (ENA). METHODS: This was a double-blind, randomized, two-parallel group trial. Twenty-four nonsmoking postmenopausal women receiving 10 mg of ENA twice a day before study were randomized to DRSP/E2 + ENA (n = 12) or placebo (P) + ENA (n = 12) for 14 days. Twenty-four-hour ambulatory BP, plasma renin activity, and serum aldosterone were determined at baseline and on day 14. RESULTS: Compared to placebo, 24-h mean [SD] BP in the DRSP/E2 + ENA group decreased significantly from baseline (139/80 mm Hg), systolic (-9 [51 mm Hg, P = .014) and diastolic (-5 [4] mm Hg, P = .007). Essentially no change from baseline (139/83 mm Hg) in systolic or diastolic 24-h ambulatory BP were observed in the P + ENA group. Aldosterone (mean [SD]) increased from baseline by 2.6 [4.5] ng/dL in the DRSP/E2 + ENA group, and decreased by 0.3 [5.5] ng/dL in the P + ENA group (P = .08) consistent with an antimineralocorticoid effect. CONCLUSIONS: Our results suggest a significant additive BP-lowering effect of DRSP/E2 on both systolic and diastolic BP in hypertensive postmenopausal women receiving ENA, consistent with an antimineralocorticoid effect. DRSP/E2, a HRT with antimineralocorticoid effects, could offer a novel potential mechanism for reducing cardiovascular end points in postmenopausal women.     

The influence of physical activity on the variability of ambulatory blood pressure

The aim of this study was to assess the contribution of physical activity levels to blood pressure (BP) variability, and to assess the effect age, gender, body mass index, and use of antihypertensive medications on this relationship. We simultaneously monitored 24-h ambulatory BP by automated recorder and activity by actigraphy in 431 patients. Mean activity scores for the 5, 10, 15, and 20 min preceding each BP measurement were calculated, and BP and heart rate were related to these variables using linear mixed model regression. Various patient characteristics were added to the mixed model as covariates. Patients were heterogeneous in age (48 +/- 13 years), sex (49% men), and average 24-h BP (132/81 +/- 15/10 mm Hg). Mean daytime activity level was 44 +/- 15 U. During the daytime, systolic BP (r = 0.33), diastolic BP (r = 0.29), and heart rate (r = 0.42) correlated best with the average activity for the 15 min preceding each measurement (P < .001). Variance was very high, with activity explaining from 0% to 62% of BP variability for different individuals. Men and the obese had a greater reactivity of systolic BP to activity; older patients and those on antihypertensive therapy had a lower reactivity of heart rate. Blood pressure level is significantly associated with physical activity, but the percentage of variance of BP explained by physical activity varies greatly between individuals. Correlation is strongest between BP and average activity integrated over the previous 15 min. Much of the variance in blood pressure remains unexplained.     

Effects of celecoxib on ambulatory blood pressure in hypertensive patients on ACE inhibitors

Nonselective nonsteroidal anti-inflammatory agents have been shown to attenuate the antihypertensive efficacy of ACE inhibitors with average increases in systolic blood pressure (BP) of 5 to 10 mm Hg. Less is known about the specific cyclooxygenase-2 (COX-2) inhibitors now widely used for the treatment of arthritis. The objective of this study was to determine the effects of celecoxib compared with placebo on 24-hour BP levels in ACE inhibitor-treated patients with hypertension. This was a randomized, double-blind, placebo-controlled, parallel-group clinical trial involving 178 men and women (mean age, 53 years) with essential hypertension who were treated and controlled with lisinopril monotherapy (10 to 40 mg daily). Baseline BP values were obtained using 24-hour ambulatory recordings. Patients received either celecoxib, 200 mg twice daily (twice the recommended dose for osteoarthritis) (n=91), or placebo (n=87) for 4 weeks, and changes in the 24-hour BP, body weight, and clinical laboratory parameters were assessed. Mean changes from baseline in the 24-hour systolic and diastolic BP were 2.6/1.5+/-0.9/0.6 mm Hg on celecoxib versus 1.0/0.3+/-1/0.6 mm Hg on placebo (P=0.34 for systolic BP; P=0.45 for diastolic BP). The proportion of patients whose 24-hour BP increased by at least 5, 10, 15, or 20 mm Hg were also similar on celecoxib and placebo. No changes in body weight, serum creatinine, or potassium occurred in either group. Thus, these data demonstrate that high doses of celecoxib have no significant effect on the antihypertensive effect of the ACE inhibitor lisinopril. The placebo-subtracted changes observed in 24-hour BP (1.6/1.2 mm Hg) are less than what has been reported for nonselective nonsteroidal anti-inflammatory agents in ACE inhibitor-treated patients.     

Effects of the selective aldosterone blocker eplerenone versus the calcium antagonist amlodipine in systolic hypertension

Eplerenone is a highly selective aldosterone blocker, which is under development for the treatment of hypertension and heart failure. To assess its usefulness in older patients with systolic hypertension and widened pulse pressure, we compared the effects of eplerenone with amlodipine, on clinic blood pressure (BP) and pulse pressure and in a subset of the patients, ambulatory BP, vascular compliance, and urinary albumin excretion. The study involved 269 patients > or =50 years of age who were randomly assigned to either eplerenone (50 to 200 mg daily) or amlodipine (2.5 to 10 mg daily) in a double-blind titration to effect design. After 24 weeks of therapy, reductions in clinic systolic BP were similar for both treatments (eplerenone, -20.5+/-1.1 mm Hg; amlodipine, -20.1+/-1.1 mm Hg). Reductions in clinic diastolic BP were modestly larger on amlodipine (-6.9+/-0.7 mm Hg) compared with eplerenone (-4.5+/-0.7 mm Hg) (P=0.014). Pulse pressure was also reduced similarly from baseline by the 2 treatment groups (eplerenone, -15.9 mm Hg versus amlodipine, -13.4 mm Hg, P=0.07). Changes from baseline in pulse wave velocity after 24 weeks of therapy were statistically similar for eplerenone and amlodipine. In patients with microalbuminuria at baseline (>30 mg albumin/g creatinine), eplerenone reduced the urinary albumin/creatinine ratio by 52% compared with a reduction of 10% by amlodipine (P=0.04). Thus, eplerenone was as effective as amlodipine in lowering systolic BP and pulse pressure as well as pulse wave velocity in older patients with widened pulse pressure hypertension. Furthermore, eplerenone reduced microalbuminuria to a greater extent than amlodipine in this older patient group.     

Comparison of candesartan versus enalapril in essential hypertension. Italian Candesartan Study Group

BACKGROUND: The objective of this study was to compare the antihypertensive efficacy and tolerability of candesartan cilexetil (CC) with that of enalapril (E) and placebo (P) in hypertensives by clinic and ambulatory blood pressure (BP). PROCEDURES: The study was an Italian multicenter, randomized, double-blind, parallel group trial including 227 mild to moderate essential hypertensives (age range, 18 to 70 years). After 4 weeks of P, patients were randomized to 8 weeks of treatment with P or CC (4 mg) or E (10 mg) once daily, which was eventually increased to 8 mg and 20 mg once daily in nonresponders. At the end of each study phase, trough BP was measured by conventional sphygmomanometry and ambulatory BP was monitored over 24 h by a Spacelabs device. Analysis of 24-h BP profile included calculation of 24-h, daytime, nighttime, and hourly average values. RESULTS: In the 178 patients evaluable per protocol, at the end of 8 weeks of treatment, trough systolic (S) and diastolic (D) BP were similarly reduced by both active treatments (13 +/- 12 and 10 +/- 7 mm Hg for CC and 14 +/- 12 and 10 +/- 7 mm Hg for E) and significantly more by both treatments than by P (6 +/- 11 and 7 +/- 8 mm Hg, P < .01 v CC and E). In the 85 patients with valid 24-h recordings reduction in 24-h BP was again similar for the two active groups. The antihypertensive effect was still evident during h 23 and 24 after the last dose for both active treatments (8 +/- 20 v 5 +/- 18 mm Hg for SBP and 4 +/- 12 v 6 +/- 13 mm Hg for DBP, CC v E, respectively) but not for P. Heart rate was not significantly modified by either active treatment. The incidence of adverse events was greater in the E than in the CC group. CONCLUSIONS: Our study provides evidence that CC at a dose of 4 to 8 mg is as effective as E at a dose of 10 to 20 mg over 24 h, but is better tolerated than E.     

ST-segment depression in hypertensive patients is linked to elevations in blood pressure,pulse pressure and double product by 24-h Cardiotens monitoring

BACKGROUND: Various statements are made concerning peaks of heart rate (HR), blood pressure (BP) and double product (product of HR and systolic BP) as triggers for ST-segment depression. The aim of the present study was to identify determinants of ST-segment depression with a new ambulatory device for simultaneous 24-h electrocardiogram (ECG) and BP monitoring. METHODS: A total of 63 treated patients (63 +/- 9 years, 33 women and 30 men) with arterial hypertension and ischemic heart disease were studied with a new ambulatory 24-h BP measurement (ABPM) device evaluated according to the BHS protocol (Cardiotens, Meditech, Hungary). This device allows simultaneous ST-segment analysis with extra BP recordings triggered by episodes of ST-segment depression. RESULTS: ST-segment (Holter ECG) depression (> 1 mm and > 60 s) was demonstrated in 26 patients with a mean duration of 4.95 +/- 2.6 min and a peak in the early morning hours. All ST-segment depressions were silent and occurred during a significant increase of BP (15 +/- 11 mmHg systolic and 10 +/- 5 mmHg diastolic, compared with the mean ABPM values) and a significant increase of the double product from 10 921 +/- 2 395 (24-h mean) to 14 515 +/- 2329 (during ST-depression). The recorded systolic and diastolic BP (SBP, DBP) values from the pre ST-event were significant higher compared with 24-h values (153 +/- 19 versus 145 +/- 22 mmHg systolic, 83 +/- 12 versus 78 +/- 14 diastolic). The mean pulse pressure (PP) value in the group with ST-depression was significantly higher than in the group without ST changes (69 +/- 16 versus 58 +/- 10 mmHg; P < 0.005). A total of 73% of patients with ST-events compared with 35% without ST-events showed a PP >or= 60 mmHg (P = 0.025). CONCLUSION: Simultaneous ABPM and ST-segment analysis identifies episodes of silent myocardial ischemia during increases of BP and HR. Hypertensive patients with ischemic heart disease and ST events show higher mean pulse pressure values than are observed in patients without events. A PP of >or= 60 mmHg is linked to an increased risk of silent myocardial ischemias.     

Distribution of blood pressure and prevalence of hypertension in Tehran adult population: Tehran Lipid and Glucose Study (TLGS), 1999-2000

The purpose of this study was to estimate the current prevalence and distribution of hypertension in an adult Tehranian population. Data were collected for 3343 men and 5148 women aged 20-69 years in the Tehran Lipid and Glucose Study (TLGS), which is a cross-sectional phase of a large epidemiologic study, first established in 1999. The study used the mean of two separate blood pressure (BP) measurements in each individual. Twenty-two percent (23% of women vs 20% of men, P = 0.01) had hypertension according to 'JNC-VI' and 'WHO-ISH' criteria. The average systolic BP (SBP), diastolic BP (DBP) and pulse pressure of hypertensive participants were 31, 16, and 15 mm Hg higher than the corresponding value for normotensives, respectively. Thirty-six percent of participants with JNCVI-based hypertension were using antihypertensive medication (23% of men and 43% of women). Of these, 40% (45% of men and 39% of women) had normal BP. Hypertension awareness was 50% in these participants (57% in men vs 37% in women, P < 0.001). Data for 3179 men and 4646 women aged 20-69 years with no antihypertensive treatment were used for analysis of BP measures. Of these, 15% (16% of men and 14% of women, P = 0.006) had high and 85% (84% of men and 86% of women) normal or high-normal BP levels according to JNC-VI. Prevalence of optimal BP was 49% (47% of men and 51% of women). Mean SBP was 117.8 +/- 16.6 and 116.4 +/- 16.4 mm Hg in men and women, respectively (P < 0.001). The equivalent values were 77.4 +/- 10.7 and 77.3 +/- 9.9 mm Hg for DBP (P = 0.5) and 40.4 +/- 12 and 39.1 +/- 11.7 mm Hg for pulse pressure (P < 0.001). A relatively high prevalence of JNC-VI/WHO-ISH defined hypertension was found in the TLGS adult population with 50% undiagnosed and 60% uncontrolled hypertension. These findings emphasise further considerations for detection and better management of hypertension in the urban population of Tehran.     

Ambulatory blood pressure characteristics in normotensive and treated hypertensive older people

The objective of this study was to determine the normal values and characteristics of 24-h ambulatory blood pressure (ABP) and to describe the ABP level of treated hypertensive subjects in an older Finnish population. ABP was measured in 502 randomly selected subjects aged 64 years or over living in a Finnish municipality (mean age 70 years, range 64-87 years). A total of 211 subjects did not have blood pressure (BP) affecting medication. ABP measurements were taken every 30 min for 24 h, and the day- and night-time periods were diary-based. The results were that in untreated subjects, the average office BP was 134/82 +/- 16/9 (s.d.) mm Hg for men and 140/81 +/- 18/8 mm Hg for women. The 24-h average BP was 120/75 +/- 14/8 mm Hg (95th percentile upper limit 145/93 mm Hg) for men and 125/75 +/- 15/7 (95th = 154/89 mm Hg) for women. The daytime averages were 127/78 +/- 12/7 mm Hg (95th = 154/99 mm Hg) and 131/78 +/- 15/7 mm Hg (95th = 158/91 mm Hg) for men and women, respectively. The ABP daytime value of 130/83 mm Hg corresponded best to the office BP value of 140/90 mm Hg. All BP values were significantly higher in the treated hypertensive group compared to the normotensive group. Night-time BP was markedly lower than daytime BP, and no difference in circadian variability was found between the normotensive and hypertensive subjects. Both office and ambulatory BPs were significantly higher in women than in men. This study provides sex-specific normal values for ABP in a 64 to 87-year-old age group. The normal values of ABP were markedly lower than the office BP values. Hypertensives, even when treated, tended to have elevated values.