J Hypertens. 2010 Jul;28(7):1527-33. Scheltens T, de Beus MF, Hoes AW, Rutten FH, Numans ME, Mosterd A, Kors JA, Grobbee DE, Bots ML. aJulius Center for Health Sciences and Primary Care, The Netherlands bDepartment of Cardiology, Heart Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands cDepartment of Cardiology, Meander Medical Center, Amersfoort, The Netherlands dDepartment of Medical informatics, Erasmus University Medical Center, Rotterdam, The Netherlands.

OBJECTIVE: Several guidelines for hypertension and cardiovascular risk management recommend an ECG in hypertensive patients to improve risk prediction. We estimated the prevalence of clinically relevant ECG abnormalities and the number needed to screen (NNS) with a routine ECG to prevent the occurrence of one death in the next 10 years conditional on adequate treatment and follow-up.

METHODS: The study population consisted of 866 hypertensive participants recruited from the Utrecht Health Project (UHP), a dynamic population study in Utrecht. Baseline measurements included an ECG and the risk factors that enable a Systematic COronary Risk Evaluation (SCORE) risk estimation for each participant. ECGs were interpreted using Modular ECG Analysis System for computerized recognition of ECG abnormalities. NNS to prevent one death was computed by the reciprocal of the prevalence of the ECG abnormalities multiplied by number needed to treat to prevent one death when the ECG abnormality is managed according to the prevailing clinical guidelines.

RESULTS: The population consisted of 54.2% men with a mean age of 53.2 years (SD 11.5). The prevalence of ECG abnormalities was 17.6 [n = 95% confidence interval (CI) 15.0-20.1]. Prevalence of atrial fibrillation or prior myocardial infarction was 2.1% (95%CI 1.1-3.0) and of other ECG abnormalities related to increased cardiovascular disease risk 15.4% (95%CI 13.1-17.9). NNS to prevent one death from cardiovascular disease within 10 years was estimated at 260 (95%CI 220-308).

CONCLUSION: Our findings support the existing recommendations to routinely record an ECG in unselected hypertensive patients as the prevalence of relevant abnormalities is considerable and NNS to prevent one death is lower than that in other widely accepted tests.

Blood pressure control in diabetes: temporal progress yet persistent racial disparities: national results from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.

Diabetes Care. 2010 Apr;33(4):798-803 Cummings DM, Doherty L, Howard G, Howard VJ, Safford MM, Prince V, Kissela B, Lackland DT. Department of Family Medicine, Pediatrics, and Public Health, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA.

OBJECTIVE: Despite widespread dissemination of target values, achieving a blood pressure of <130/80 mmHg is challenging for many individuals with diabetes. The purpose of the present study was to examine temporal trends in blood pressure control in hypertensive individuals with diabetes as well as the potential for race, sex, and geographic disparities.

RESEARCH DESIGN AND METHODS: We analyzed baseline data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based, longitudinal cohort study of 30,228 adults (58% European American and 42% African American), examining the causes of excess stroke mortality in the southeastern U.S. We calculated mean blood pressure and blood pressure control rates (proportion with blood pressure <130/80 mmHg) for 5,217 hypertensive diabetic participants by year of enrollment (2003-2007) using multivariable logistic regression models.

RESULTS: Only 43 and 30% of European American and African American diabetic hypertensive participants, respectively, demonstrated a target blood pressure of <130/80 mmHg (P < 0.001). However, a temporal trend of improved control was evident; the odds of having a blood pressure <130/80 mmHg among diabetic hypertensive participants of both races enrolled in 2007 (as compared with those enrolled in 2003) were approximately 50% greater (P < 0.001) in multivariate models.

CONCLUSIONS: These data suggest temporal improvements in blood pressure control in diabetes that may reflect broad dissemination of tighter blood pressure control targets and improving medication access. However, control rates remain low, and significant racial disparities persist among African Americans that may contribute to an increased risk for premature cardiovascular disease.

Community based lifestyle intervention for blood pressure reduction in children and young adults in developing country: cluster randomised controlled trial.

BMJ. 2010 Jun 7;340:c2641. doi: 10.1136/bmj.c2641. Jafar TH, Islam M, Hatcher J, Hashmi S, Bux R, Khan A, Poulter N, Badruddin S, Chaturvedi N; Hypertension Research Group. Department of Medicine, Aga Khan University, Karachi, Pakistan.

OBJECTIVE: To assess the effectiveness of a community based lifestyle intervention on blood pressure in children and young adults in a developing country setting.

DESIGN: Cluster randomised controlled trial.

SETTING: 12 randomly selected geographical census based clusters in Karachi, Pakistan.

PARTICIPANTS: 4023 people aged 5-39 years.

INTERVENTION: Three monthly family based home health education delivered by lay health workers.

MAIN OUTCOME MEASURE: Change in blood pressure from randomisation to end of follow-up at 2 years.

RESULTS: Analysed using the intention to treat principle, the change in systolic blood pressure (adjusted for age, sex, and baseline blood pressure) was significant; it increased by 1.5 (95% confidence interval 1.1 to 1.9) mm Hg in the control group and by 0.1 (-0.3 to 0.5) mm Hg in the home health education group (P for difference between groups=0.02). Findings for diastolic blood pressure were similar; the change was 1.5 mm Hg greater in the control group than in the intervention group (P=0.002).

CONCLUSIONS: Simple, family based home health education delivered by trained lay health workers significantly ameliorated the usual increase in blood pressure with age in children and young adults in the general population of Pakistan, a low income developing country. This strategy is potentially feasible for up-scaling within the existing healthcare systems of Indo-Asia

Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home study.

Hypertension. 2010 Jun;55(6):1346-51. Niiranen TJ, Hänninen MR, Johansson J, Reunanen A, Jula AM. Population Studies Unit, National Institute for Health and Welfare, Turku, Finland.

Previous studies with some limitations have provided equivocal results for the prognostic significance of home-measured blood pressure (BP). We investigated whether home-measured BP is more strongly associated with cardiovascular events and total mortality than is office BP. A prospective nationwide study was initiated in 2000 to 2001 on 2081 randomly selected subjects aged 45 to 74 years. Home and office BP were determined at baseline along with other cardiovascular risk factors. The primary end point was incidence of a cardiovascular event (cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, percutaneous coronary intervention, or coronary artery bypass graft surgery). The secondary end point was total mortality. After a mean follow-up of 6.8 years, 162 subjects had experienced a cardiovascular event, and 118 subjects had died. In Cox proportional hazard models adjusted for other cardiovascular risk factors, office BP (systolic/diastolic hazard ratio [HR] per 10/5 mm Hg increase in BP, 1.13/1.13; systolic/diastolic 95% confidence interval [CI], 1.05 to 1.22/1.05 to 1.22) and home BP (HR, 1.23/1.18; 95% CI, 1.13 to 1.34/1.10 to 1.27) were predictive of cardiovascular events. However, when both BPs were simultaneously included in the models, only home BP (HR, 1.22/1.15; 95% CI, 1.09 to 1.37/1.05 to 1.26), not office BP (HR, 1.01/1.06; 95% CI, 0.92 to 1.12/0.97 to 1.16), was predictive of cardiovascular events. Systolic home BP was the sole predictor of total mortality (HR, 1.11; 95% CI, 1.01/1.23).

Our findings suggest that home-measured BP is prognostically superior to office BP. On the basis of the results of this and previous studies, it can be concluded that home BP measurement offers specific advantages more than conventional office measurement.

From blood pressure to physical disability: the role of cognition.

Hypertension. 2010 Jun;55(6):1360-5. Elias MF, Dore GA, Davey A, Robbins MA, Elias PK. Department of Psychology, University of Maine, Orono, ME 04469-5742, USA.

We examined the hypothesis that lowered cognitive performance plays a role in the relation between elevated blood pressure and physical disability in performing basic physical tasks. A community-based sample (N=1025) free from stroke and dementia (mean age: 61.1 years; SD: 13.0 years; 59.8% women) was used. Using path analysis, systolic and diastolic blood pressures (predictor variable) measured over multiple longitudinal examinations were averaged and related to multiple measures of cognition (intermediate variable) and physical ability (PA; outcome variable) measured at wave 6 of the Maine-Syracuse Study. PA was indexed by time required to execute standing, walking, and turning tests. A best-fit path model including blood pressure and multiple demographic and cardiovascular disease covariates was used. Paths from systolic blood pressure to global performance, verbal memory, and abstract reasoning (Similarities test) were significant (P<0.05), as were paths from diastolic blood pressure to global performance, executive functioning, visual spatial organization/memory, verbal memory, working memory, and abstract reasoning. Regardless of the blood pressure predictor, lower cognitive performance (intermediate variable) was related to lower PA (outcome) in the path from blood pressure to PA. The direct path from blood pressure to PA was significant only for systolic blood pressure. Cognitive performance mediates between blood pressure and PA. As compared with systolic blood pressure, more domains of cognitive functioning intervene between diastolic blood pressure and PA.

Progression of Normotensive Adolescents to Hypertensive Adults. A Study of 26 980 Teenagers.

Hypertension. 2010 Jun 14. Tirosh A, Afek A, Rudich A, Percik R, Gordon B, Ayalon N, Derazne E, Tzur D, Gershnabel D, Grossman E, Karasik A, Shamiss A, Shai I. Division of Endocrinology, Diabetes, and Hypertension.

Although prehypertension at adolescence is accepted to indicate increased future risk of hypertension, large-scale/long follow-up studies are required to better understand how adolescent blood pressure (BP) tracks into young adulthood. We studied 23 191 male and 3789 female adolescents from the Metabolic Lifestyle and Nutrition Assessment in Young Adults cohort (mean age: 17.4 years) with BP <140/90 mm Hg at enrollment or categorized by current criteria for pediatric BP and body mass index (BMI) values. Participants were prospectively followed up with repeated BP measurements between ages 25 and 42 years and retrospectively between ages 17 and 25 years for the incidence of hypertension. We identified 3810 new cases of hypertension between ages 17 and 42 years. In survival analyses, the cumulative risk of hypertension between ages 17 and 42 years was 3 to 4 times higher in men than in women. Using Cox regression models adjusted for age, BMI, and stratified by baseline BP, the hazard ratio of hypertension increased gradually across BP groups within the normotensive range at age 17 years, without a discernible threshold effect, reaching a hazard ratio of 2.50 (95% CI: 1.75 to 3.57) for boys and 2.31 (95% CI: 0.71 to 7.60) for girls in the group with BP at 130 to 139/85 to 89 mm Hg. BMI at age 17 years was strongly associated with future risk of hypertension even when adjusted to BP at age 17 years, particularly in boys. Yet, BMI at age 30 years attenuated this association, more evidently in girls.

In conclusion, BP at adolescence, even in the low-normotensive range, linearly predicts progression to hypertension in young adulthood. This progression and the apparent interaction between BP at age 17 years and BMI at adolescence and at adulthood are sex dependent.

Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling.

Am J Hypertens. 2010 Apr;23(4):358-67 Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, Baynard T, Fernhall B. Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.

BACKGROUND: The acute effect of high-intensity interval exercise (HI) on blood pressure (BP) is unknown although this type of exercise has similar or greater cardiovascular benefits compared to steady-state aerobic exercise (SS). This study examined postexercise hypotension (PEH) and potential mechanisms of this response in endurance-trained subjects following acute SS and HI. Sex differences were also evaluated.

METHODS: A total of 25 endurance-trained men (n = 15) and women (n = 10) performed a bout of HI and a bout of SS cycling in randomized order on separate days. Before exercise, 30 min postexercise, and 60 min postexercise, we measured brachial and aortic BP. Cardiac output (CO), stroke volume (SV), end diastolic volume (EDV), end systolic volume (ESV), and left ventricular wall-velocities were measured using ultrasonography with tissue Doppler capabilities. Ejection fraction and fractional shortening (FS), total peripheral resistance (TPR), and calf vascular resistance were calculated from the above variables and measures of leg blood flow.

RESULTS: BP, ejection fraction, and FS decreased by a similar magnitude following both bouts but changes in CO, heart rate (HR), TPR, and calf vascular resistance were greater in magnitude following HI than following SS. Men and women responded similarly to HI. Although men and women exhibited a similar PEH following SS, they showed differential changes in SV, EDV, and TPR.

CONCLUSIONS: HI acutely reduces BP similarly to SS. The mechanistic response to HI appears to differ from that of SS, and endurance-trained men and women may exhibit differential mechanisms for PEH following SS but not HI.

All-cause and cardiovascular mortality in relation to changing heart rate during treatment of hypertensive patients with electrocardiographic left ventricular hypertrophy.

Eur Heart J. 2010 Jul 2. Okin PM, Kjeldsen SE, Julius S, Hille DA, Dahlöf B, Edelman JM, Devereux RB. Division of Cardiology, Weill Cornell Medical College of Cornell University, 525 East 68th Street, New York, NY 10065, USA.

Background: Although higher heart rate (HR) at baseline has been associated with an increased risk of cardiovascular (CV) and all-cause mortality, the relationship of in-treatment HR over time to mortality in hypertensive patients with ECG left ventricular hypertrophy (LVH) has not been examined.

Methods and results: Heart rate was evaluated over time in 9190 hypertensive patients treated with losartan- or atenolol-based regimens and followed with annual ECGs. During a mean follow-up of 4.8 +/- 0.9 years, 814 patients (8.9%) died, 438 (4.8%) from CV causes. In univariate Cox analyses, every 10 bpm higher HR on in-treatment ECGs was associated with a 25% increased risk of CV death [95% confidence interval (CI): 14-32%] and a 27% greater risk of all-cause mortality (95% CI: 21-34%). In an alternative analysis, persistence or development of a HR >/=84 bpm (upper quintile of baseline HR) was associated with an 89% greater risk of CV death (95% CI: 49-141%) and a 97% increased risk of all-cause mortality (95% CI: 65-135%). After adjusting for treatment with losartan vs. atenolol, baseline risk factors for death, baseline HR, baseline and in-treatment systolic and diastolic pressure, incident myocardial infarction, and the known predictive value of baseline and in-treatment QRS duration and ECG LVH, higher in-treatment HR in time-varying multivariable Cox models remained strongly predictive of mortality: every 10 bpm higher HR was associated with a 16% increased adjusted risk of CV mortality (95% CI: 6-27%) and a 25% greater risk of all-cause mortality (95% CI: 17-33%), with persistence or development of a HR >/=84 associated with a 55% greater risk of CV death (95% CI: 16-105%) and a 79% greater adjusted risk of all-cause mortality (95% CI: 46-121%).

Conclusion: Higher in-treatment HR on serial ECGs predicts greater likelihood of subsequent CV or all-cause mortality, independent of treatment modality, blood pressure lowering, regression of ECG LVH and changing QRS duration in hypertensive patients with ECG LVH. These findings support the value of serial assessment of HR for improved risk stratification in hypertensive patients.

Beyond insurance coverage: usual source of care in the treatment of hypertension and hypercholesterolemia. Data from the 2003-2006 National Health and Nutrition Examination Survey.

Am Heart J. 2010 Jul;160(1):115-21. Spatz ES, Ross JS, Desai MM, Canavan ME, Krumholz HM. Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, CT 06520-8088, USA.

BACKGROUND: Expanding insurance coverage, while necessary, may not be sufficient to ensure high-quality care for adults with cardiovascular disease. We sought to examine the association between having a usual source of care (USOC) and receiving medication treatment of hypertension and hypercholesterolemia.

METHODS: Using the 2003-2006 National Health and Nutrition Examination Survey, we categorized USOC (a place to go when sick or need medical advice) and insurance status in adults >or=35 years old with an indication for medication treatment of hypertension (n = 3,142) and hypercholesterolemia (n = 1,134), determined using the Joint National Committee 7 and Adult Treatment Panel III recommendations, respectively. Multivariable logistic regression modeling was used to determine the independent effect of USOC on receiving treatment of hypertension and hypercholesterolemia, controlling for age, sex, race/ethnicity, insurance status, and comorbidities. Separate multivariable models were examined stratified by insurance status.

RESULTS: Among subjects with an indication for treatment of hypertension and hypercholesterolemia, 32.4% and 42.0% were untreated, respectively. When compared with adults with a USOC, adults without a USOC were more likely to be untreated for hypertension (adjusted prevalence ratio [aPR] 2.43, 95% CI 1.88-2.85) and hypercholesterolemia (aPR 1.79, 95% CI 1.31-2.13). In stratified analyses among subjects with insurance, no USOC remained associated with being untreated (hypertension, aPR 2.58, 95% CI 1.88-3.08; hypercholesterolemia, aPR 1.65, 95% CI 0.97-2.18).

CONCLUSIONS: Absence of a USOC was associated with being untreated for hypertension and hypercholesterolemia, even among individuals with insurance, suggesting that efforts to improve chronic disease management should also facilitate access to a regular source of care.

European Society of Hypertension Practice Guidelines for home blood pressure monitoring.

J Hum Hypertens. 2010 Jun 3. [Epub ahead of print] Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, Kario K, Lurbe E, Manolis A, Mengden T, O'Brien E, Ohkubo T, Padfield P, Palatini P, Pickering TG, Redon J, Revera M, Ruilope LM, Shennan A, Staessen JA, Tisler A, Waeber B, Zanchetti A, Mancia G. Department of Clinical Medicine and Prevention, University of Milano-Bicocca; Centro Interuniversitario di Fisiologia Clinica e Ipertensione & Department Cardiology, S Luca Hospital, Istituto Auxologico Italiano, Milan, Italy.

Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

Prevalence of chronic kidney disease in persons with undiagnosed or prehypertension in the United States.

Hypertension. 2010 May;55(5):1102-9 Crews DC, Plantinga LC, Miller ER 3rd, Saran R, Hedgeman E, Saydah SH, Williams DE, Powe NR; Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team. Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA.

Hypertension is both a cause and a consequence of chronic kidney disease, but the prevalence of chronic kidney disease throughout the diagnostic spectrum of blood pressure has not been established. We determined the prevalence of chronic kidney disease within blood pressure categories in 17 794 adults surveyed by the National Health and Nutrition Examination Survey during 1999-2006. Diagnosed hypertension was defined as self-reported provider diagnosis (n=5832); undiagnosed hypertension was defined as systolic blood pressure > or = 140 mm Hg or diastolic blood pressure > or = 90 mm Hg, without report of provider diagnosis (n=3046); prehypertension was defined as systolic blood pressure > or = 120 and <140 mm Hg or diastolic blood pressure > or = 80 and <90 mm Hg (n=3719); and normal was defined as systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg (n=5197). Chronic kidney disease was defined as estimated glomerular filtration rate <60 mL/min per 1.73 m(2) or urinary albumin:creatinine ratio >30 mg/g. Prevalences of chronic kidney disease among those with prehypertension and undiagnosed hypertension were 17.3% and 22.0%, respectively, compared with 27.5% with diagnosed hypertension and 13.4% with normal blood pressure, after adjustment for age, sex, and race in multivariable logistic regression. This pattern persisted with varying definitions of kidney disease; macroalbuminuria (urinary albumin:creatinine ratio >300 mg/g) had the strongest association with increasing blood pressure category (odds ratio: 2.37 [95% CI: 2.00 to 2.81]).

Chronic kidney disease is prevalent in undiagnosed and prehypertension. Earlier identification and treatment of both these conditions may prevent or delay morbidity and mortality from chronic kidney disease.

Masked Hypertension: Evaluation, Prognosis, and Treatment.

Am J Hypertens. 2010 May 27. Angeli F, Reboldi G, Verdecchia P. Department of Cardiology, Clinical Research Unit-Preventive Cardiology, Hospital 'S. Maria della Misericordia', Perugia, Italy.

Blood pressure (BP) may be high during usual daily life in one out of 7-8 individuals with normal BP in the clinic or doctor's office. This condition is usually defined as masked hypertension (MH). Prevalence of MH varied across different studies depending on patient characteristics, populations studied, and different definitions of MH. Self-measured BP and ambulatory BP (ABP) have been widely used to identify subjects with MH. Various factors have been identified as possible determinants of MH. Cigarette smoking, alcohol, physical activity, job, and psychological stress may increase BP out of the clinical environment in otherwise normotensive individuals, leading to MH. In most studies, target organ damage was comparable in subjects with MH and those with sustained hypertension, and greater than in those with true normotension. Subjects with MH showed a 1.5- to 3-fold higher risk of major cardiovascular (CV) disease than those with normotension, and their risk was not different from that of patients with sustained hypertension. In an overview of literature, we found that the risk of major CV disease was higher in subjects with MH than in the normotensive subjects regardless of the definition of MH based on self-measured BP (hazard ratio (HR) 2.13; 95% confidence interval (CI): 1.35-3.35; P = 0.001) or 24-h ABP (HR 2.00; 95% CI: 1.54-2.60; P < 0.001). MH is an insidious and prognostically adverse condition that can be reliably diagnosed by self-measured BP and ABP. MH should be searched for in subjects who appear to be more likely to have this condition. Antihypertensive treatment is envisaged in these subjects, although the associated outcome benefits are still undetermined

Association of Serum Uric Acid Level With Aortic Stiffness and Arterial Wave Reflections in Newly Diagnosed, Never-Treated Hypertension.

Am J Hypertens. 2010 May 27 Vlachopoulos C, Xaplanteris P, Vyssoulis G, Bratsas A, Baou K, Tzamou V, Aznaouridis K, Dima I, Lazaros G, Stefanadis C. Peripheral Vessels and Hypertension Units, 1st Cardiology Department, Athens Medical School, Hippokration Hospital, Athens, Greece.

Background: Serum uric acid (UA) plays a key role in the development and progression of hypertension. We investigated the association of UA levels and indices of arterial function in a cohort of newly diagnosed, never-treated hypertensive subjects.

Methods: One thousand two hundred and twenty-five patients with a new diagnosis of mild to moderate arterial hypertension for which they had never received treatment were enrolled in the study (mean age 52.9 years, 728 men). Serum UA, carotid-femoral pulse-wave velocity (cfPWV), an index of aortic stiffness and augmentation index (AIx), a composite marker of wave reflections and arterial stiffness were measured.

Results: In univariable analysis, UA levels correlated with cfPWV (r = 0.23, P < 0.001) and AIx (r = -0.24, P < 0.001). In multiple linear regression analysis, an independent positive association of cfPWV with UA levels was observed after adjusting for confounders (standardized regression coefficient beta = 0.169, P < 0.001, adjusted R(2) = 0.402), indicating an increase in aortic stiffness with higher values of UA. In contrast, an independent negative association of AIx with UA levels was observed after adjusting for confounders (standardized regression coefficient beta = -0.064, P = 0.011, adjusted R(2) = 0.557), indicating a decrease in wave reflections with higher values of UA. In gender-specific analyses, UA positively correlated with cfPWV in both genders, whereas a negative correlation with AIx existed only in females.

Conclusions: Serum UA levels are independently associated with aortic stiffening and wave reflections in never-treated hypertensives. Future studies are warranted in order to explore its exact role on arterial function in the hypertensive setting.

Morning hypertension assessed by home or ambulatory monitoring: different aspects of the same phenomenon?

J Hypertens. 2010 May 21 Stergiou GS, Nasothimiou EG, Roussias LG. Hypertension Centre, Third University Department of Medicine, Sotiria Hospital, Athens, Greece.

OBJECTIVE: There is increasing interest in morning hypertension assessed using out-of-office blood pressure (BP) measurement methods. This study compared morning BP taken by home (mHBP) versus morning ambulatory BP (mABP) monitoring.

METHODS: A total of 588 hypertensives were included [mean age 53 +/- 12.4 (SD) years, 57% men, 59% untreated]. Average mHBP (6 days, duplicate morning measurements) was compared with mABP (first 1, 2 or 3 h after arising, readings at 20-min intervals). Morning 'hypertensives' were defined as individuals with mHBP or mABP at least 135/85 mmHg and morning 'reactors' as those with a difference between mHBP and average home BP or mABP and average awake ambulatory BP at the upper quartile of the respective distribution.

RESULTS: Average mABP (2 h) was the closest to mHBP with mean difference 0.4 +/- 14.0/1.2 +/- 8.6 mmHg, 95% confidence intervals -0.8, 1.5/0.5, 1.9, P NS < 0.01, for systolic/diastolic and was strongly correlated with mABP (r = 0.60/0.68, P < 0.001). There was moderate agreement between mHBP and mABP in detecting morning 'hypertensives' (agreement 72%, kappa 0.44, for systolic BP and 75%, kappa 0.51, for diastolic) and slight agreement in detecting morning 'reactors' (agreement 68%, kappa 0.15, for systolic BP and 67%, kappa 0.13, for diastolic). These findings did not change when mABP of 1 or 3 h after arising were used or when untreated and treated individuals were analyzed separately.

CONCLUSION: Despite their methodological differences, there seems to be considerable similarity between mHBP and mABP. Thus, both home and ambulatory BP monitoring appear to be interchangeable methods for the assessment of morning hypertension.

Encounter Frequency and Blood Pressure in Hypertensive Patients With Diabetes Mellitus.

Turchin A, Goldberg SI, Shubina M, Einbinder JS, Conlin PR. Division of Endocrinology, Center for Clinical Investigation, and Division of General Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Clinical Informatics Research and Development, Partners HealthCare System, Boston, Mass; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Mass; Veterans' Administration Boston Healthcare System, Boston, Mass.

The relationship between encounter frequency (average number of provider-patient encounters over a period of time) and blood pressure for hypertensive patients is unknown. We tested the hypothesis that shorter encounter intervals are associated with faster blood pressure normalization.

We performed a retrospective cohort study of 5042 hypertensive patients with diabetes mellitus treated at primary care practices affiliated with 2 academic hospitals between 2000 and 2005. Distinct periods of continuously elevated blood pressure (>/=130/85 mm Hg) were studied. We evaluated the association of the average encounter interval with time to blood pressure normalization and rate of blood pressure decrease. Blood pressure of the patients with the average interval between encounters </=1 month normalized after a median of 1.5 months at the rate of 28.7 mm Hg/month compared with 12.2 months at 2.6 mm Hg/month for the encounter interval >1 month (P<0.0001 for all). Median time to blood pressure normalization was 0.7 versus 1.9 months for the average encounter interval </=2 weeks versus between 2 weeks and 1 month, respectively (P<0.0001). In proportional hazards analysis adjusted for patient demographics, initial blood pressure, and treatment intensification rate, a 1 month increase in the average encounter interval was associated with a hazard ratio of 0.764 for blood pressure normalization (P<0.0001).

Shorter encounter intervals are associated with faster decrease in blood pressure and earlier blood pressure normalization. Greatest benefits were observed at encounter intervals (</=2 weeks) shorter than what is currently recommended.

Chronic kidney disease as an independent risk factor for new-onset atrial fibrillation in hypertensive patients.

J Hypertens. 2010 May 17. Horio T, Iwashima Y, Kamide K, Tokudome T, Yoshihara F, Nakamura S, Kawano Y Division of Hypertension and Nephrology, Department of Medicine, National Cardiovascular Center, Suita, Japan bCardiovascular Center Research Institute, Suita, Japan.

OBJECTIVE: Chronic kidney disease (CKD) has recently been recognized to be a powerful predictor of cardiovascular morbidity and mortality. Atrial fibrillation (AF), which is a common arrhythmia in hypertensives, is associated with increased risks of cardiovascular events and death. However, the association between CKD and the onset of AF has not been fully elucidated. The present study assessed the hypothesis that CKD may influence the onset of AF in hypertensives.

METHODS: A total of 1118 hypertensive patients (mean age, 63 years) without previous paroxysmal AF, heart failure, myocardial infarction, or valvular disease were enrolled. CKD was defined as decreased glomerular filtration rate (<60 ml/min per 1.73 m) and/or the presence of proteinuria (>/=1+).

RESULTS: During follow-up periods (mean, 4.5 years), 57 cases of new-onset AF were found (1.1% per year). Kaplan-Meier curves revealed that the cumulative AF event-free rate was decreased in the CKD group (log-rank test P < 0.001). By univariate Cox regression analysis, age, smoking, left atrial dimension, left ventricular mass index, and the presence of CKD were significantly associated with the occurrence of AF. Among these possible predictors, CKD (hazard ratio 2.18, P = 0.009) was an independent determinant for the onset of AF in multivariate analysis. Advanced stages of CKD (stages 4 and 5) were strongly related to the increased occurrence of AF.

CONCLUSION: The present study demonstrated that the complication of CKD, especially progressed renal dysfunction, was a powerful predictor of new-onset AF in hypertensive patients, independently of left ventricular hypertrophy and left atrial dilatation.

Physicians' degree of motivation regarding their perception of hypertension, and blood pressure control.

J Hypertens. 2010 Jun;28(6):1330-9. Consoli SM, Lemogne C, Levy A, Pouchain D, Laurent S Department of Medical Psychology and Consultation-Liaison Psychiatry, Georges Pompidou European Hospital, Assistance Publique-Hopitaux de Paris, Paris, France.

BACKGROUND: Despite clear international guidelines, the achievement of blood pressure (BP) control is still disappointing.

OBJECTIVE: To determine whether physicians' perception of hypertension, in general, is related to their patients' BP measures.

METHODS AND RESULTS: DUO-HTA is a French cross-sectional survey, which included a representative sample of 346 general practitioners, 209 cardiologists and 2014 hypertensive patients. Data were collected using two self-administered questionnaires filled out by the hypertensive patients and their physicians. A cluster analysis was performed on the responses given by the physicians, prior to the inclusion of their patients into the study, to 13 questions concerning their perception of hypertension. Physicians were divided into five groups, ranging from 'poorly motivated' to 'highly motivated' physicians, with regard to their perception of hypertension. More motivated physicians had a more confident and optimistic approach of hypertension, looked more empathetic and supportive towards patients and were characterized by higher rates of patients with controlled BP included into the study (range 32-42%, P=0.01 for trend). After adjusting for sociodemographic, clinical and psychological patient-related variables, separate analyses for the patients included into the survey by general practitioners or cardiologists found a significant decreasing gradient for SBP according to physicians' level of motivation (respectively, P=0.029 and P=0.021). Close results were observed in multivariate logistic regression analyses of uncontrolled hypertension.

CONCLUSION: These results underline the importance of physicians' perception of hypertension, in addition or concurrently to their compliance with international guidelines, for a successful management of hypertensive patients.

Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis

The Lancet, Volume 375, Issue 9731, Pages 2073 - 2081, 12 June 2010 Chronic Kidney Disease Prognosis Consortium

Background: Substantial controversy surrounds the use of estimated glomerular filtration rate (eGFR) and albuminuria to define chronic kidney disease and assign its stages. We undertook a meta-analysis to assess the independent and combined associations of eGFR and albuminuria with mortality.

Methods: In this collaborative meta-analysis of general population cohorts, we pooled standardised data for all-cause and cardiovascular mortality from studies containing at least 1000 participants and baseline information about eGFR and urine albumin concentrations. Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause and cardiovascular mortality associated with eGFR and albuminuria, adjusted for potential confounders.

Findings: The analysis included 105 872 participants (730 577 person-years) from 14 studies with urine albumin-to-creatinine ratio (ACR) measurements and 1 128 310 participants (4 732 110 person-years) from seven studies with urine protein dipstick measurements. In studies with ACR measurements, risk of mortality was unrelated to eGFR between 75 mL/min/1·73 m2 and 105 mL/min/1·73 m2 and increased at lower eGFRs. Compared with eGFR 95 mL/min/1·73 m2, adjusted HRs for all-cause mortality were 1·18 (95% CI 1·05—1·32) for eGFR 60 mL/min/1·73 m2, 1·57 (1·39—1·78) for 45 mL/min/1·73 m2, and 3·14 (2·39—4·13) for 15 mL/min/1·73 m2. ACR was associated with risk of mortality linearly on the log-log scale without threshold effects. Compared with ACR 0·6 mg/mmol, adjusted HRs for all-cause mortality were 1·20 (1·15—1·26) for ACR 1·1 mg/mmol, 1·63 (1·50—1·77) for 3·4 mg/mmol, and 2·22 (1·97—2·51) for 33·9 mg/mmol. eGFR and ACR were multiplicatively associated with risk of mortality without evidence of interaction. Similar findings were recorded for cardiovascular mortality and in studies with dipstick measurements.

Interpretation: eGFR less than 60 mL/min/1·73 m2 and ACR 1·1 mg/mmol (10 mg/g) or more are independent predictors of mortality risk in the general population. This study provides quantitative data for use of both kidney measures for risk assessment and definition and staging of chronic kidney disease.

Awareness of hypertension: will it bring about a healthy lifestyle?

J Hum Hypertens. 2010 Apr 15. Scheltens T et al. Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.

Guidelines for cardiovascular disease prevention recommend a non-pharmacological approach to reduce cardiovascular risk in those with elevated blood pressure. We assessed guideline adherence in hypertensives. This study was performed in the European Investigation into Cancer and Nutrition-NL cohort, consisting of 40 011 subjects. From 1993 to 1997, participants completed questionnaires (disease history, lifestyle and diet), a physical examination was performed and blood samples were drawn. Differences in proportions of guideline targets met between aware and unaware hypertensives were studied. Of 8779 hypertensive subjects, 90% was aware of their hypertension. They more often adhered to guidelines than unaware hypertensive subjects with respect to intake of polyunsaturated fat:saturated fat (38.6% vs 33.2%), fibres (40.6% vs 34.2%), body mass index <27 kg m(-2) (53.8% vs 46.5%) and alcohol (79.7% vs 72.6%). Despite statistical significance, the magnitude of these differences was small.

Our study suggests that prevalence of a healthy lifestyle according to the recommendations in guidelines is slightly better in subjects aware of hypertension. There seems to be ample room for improvement in implementing the guidelines. Probably, patient tailored interventions and a multisiciplinary and multimodality approach can support this improvement.

Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: a meta-analysis of prospective evidence

Hypertension. 2010 Apr;55(4):1026-32. Chida Y, Steptoe A Department of Epidemiology and Public Health, University College London, London, United Kingdom

An increasing number of studies has tested whether greater cardiovascular responses to acute mental stress predict future cardiovascular disease, but results have been variable. This review aimed quantitatively to evaluate the association between cardiovascular responses to laboratory mental stress and subsequent cardiovascular risk status in prospective cohort studies. We searched general bibliographic databases, PsycINFO, Web of Science, and PubMed, up to December 2009. Two reviewers independently extracted data on study characteristics, quality, and estimates of associations. There were 169 associations (36 articles) of stress reactivity and 30 associations (5 articles) of poststress recovery in relation to future cardiovascular risk status, including elevated blood pressure, hypertension, left ventricular mass, subclinical atherosclerosis, and clinical cardiac events. The overall meta-analyses showed that greater reactivity to and poor recovery from stress were associated longitudinally with poor cardiovascular status (r=0.091 [95% CI: 0.050 to 0.132], P<0.001, and r=0.096 [95% CI: 0.058 to 0.134], P<0.001, respectively). These findings were supported by more conservative analyses of aggregate effects and by subgroup analyses of the methodologically strong associations. Notably, incident hypertension and increased carotid intima-media thickness were more consistently predicted by greater stress reactivity and poor stress recovery, respectively, whereas both factors were associated with higher future systolic and diastolic blood pressures.

In conclusion, the current meta-analysis suggests that greater responsivity to acute mental stress has an adverse effect on future cardiovascular risk status, supporting the use of methods of managing stress responsivity in the prevention and treatment of cardiovascular disease.

Definition of ambulatory blood pressure targets for diagnosis and treatment of hypertension in relation to clinic blood pressure: prospective cohort study.

BMJ. Head GA et al. Ambulatory Blood Pressure Working Group of the High Blood Pressure Research Council of Australia Baker IDI Heart and Diabetes Institute, Melbourne, Victoria 8008, Australia.

BACKGROUND: Twenty-four hour ambulatory blood pressure thresholds have been defined for the diagnosis of mild hypertension but not for its treatment or for other blood pressure thresholds used in the diagnosis of moderate to severe hypertension. We aimed to derive age and sex related ambulatory blood pressure equivalents to clinic blood pressure thresholds for diagnosis and treatment of hypertension.

METHODS: We collated 24 hour ambulatory blood pressure data, recorded with validated devices, from 11 centres across six Australian states (n=8575). We used least product regression to assess the relation between these measurements and clinic blood pressure measured by trained staff and in a smaller cohort by doctors (n=1693).

RESULTS: Mean age of participants was 56 years (SD 15) with mean body mass index 28.9 (5.5) and mean clinic systolic/diastolic blood pressure 142/82 mm Hg (19/12); 4626 (54%) were women. Average clinic measurements by trained staff were 6/3 mm Hg higher than daytime ambulatory blood pressure and 10/5 mm Hg higher than 24 hour blood pressure, but 9/7 mm Hg lower than clinic values measured by doctors. Daytime ambulatory equivalents derived from trained staff clinic measurements were 4/3 mm Hg less than the 140/90 mm Hg clinic threshold (lower limit of grade 1 hypertension), 2/2 mm Hg less than the 130/80 mm Hg threshold (target upper limit for patients with associated conditions), and 1/1 mm Hg less than the 125/75 mm Hg threshold. Equivalents were 1/2 mm Hg lower for women and 3/1 mm Hg lower in older people compared with the combined group.

CONCLUSIONS: Our study provides daytime ambulatory blood pressure thresholds that are slightly lower than equivalent clinic values. Clinic blood pressure measurements taken by doctors were considerably higher than those taken by trained staff and therefore gave inappropriate estimates of ambulatory thresholds. These results provide a framework for the diagnosis and management of hypertension using ambulatory blood pressure values.

Characteristics and predictors of obstructive sleep apnea in patients with systemic hypertension

Am J Cardiol. 2010 Apr 15;105(8):1135-9. Drager LF, Genta PR, Pedrosa RP, Nerbass FB, Gonzaga CC, Krieger EM, Lorenzi-Filho G Hypertension Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, São Paulo, Brazil.

Obstructive sleep apnea (OSA) is a secondary cause of hypertension and independently associated with target-organ damage in hypertensive patients. However, OSA remains largely underdiagnosed and undertreated. The aim of the present study was to evaluate the characteristics and clinical predictors of OSA in a consecutive series of patients followed up in a hypertension unit. A total of 99 patients (age 46 + or - 11 years, body mass index 28.8 kg/m(2), range 25.1 to 32.9) underwent polysomnography. The clinical parameters included age, gender, obesity, daytime sleepiness, snoring, Berlin Questionnaire, resistant hypertension, and metabolic syndrome. Of the 99 patients, 55 (56%) had OSA (apnea-hypopnea index >5 events/hour). Patients with OSA were older and more obese, had greater levels of blood pressure, and presented with more diabetes, dyslipidemia, resistant hypertension, and metabolic syndrome than the patients without OSA. Of the patients with OSA, 51% had no excessive daytime sleepiness. The Berlin Questionnaire and patient age revealed a high sensitivity (0.93 and 0.91, respectively) but low specificity (0.59 and 0.48, respectively), and obesity and resistant hypertension revealed a low sensitivity (0.58 and 0.44, respectively) but high specificity (0.75 and 0.91, respectively) for OSA. Metabolic syndrome was associated with high sensitivity and specificity for OSA (0.86 and 0.85, respectively). Multiple regression analysis showed that age of 40 to 70 years (odds ratio 1.09, 95% confidence interval 1.03 to 1.16), a high risk of OSA on the Berlin Questionnaire (odds ratio 8.36, 95% confidence interval 1.67 to 41.85), and metabolic syndrome (odds ratio 19.04, 95% confidence interval 5.25 to 69.03) were independent variables associated with OSA.

In conclusion, more important than the typical clinical features that characterize OSA, including snoring and excessive daytime sleepiness, the presence of the metabolic syndrome is as an important marker of OSA among patients with hypertension.

Blood pressure and pulse wave velocity values in the institutionalized elderly aged 80 and over: baseline of the PARTAGE study.

J Hypertens. 2010 Jan;28(1):41-50. Benetos A, Buatois S, Salvi P, Marino F, Toulza O, Dubail D, Manckoundia P, Valbusa F, Rolland Y, Hanon O, Gautier S, Miljkovic D, Guillemin F, Zamboni M, Labat C, Perret-Guillaume C. Department of Geriatrics, University Hospital of Nancy, Nancy, France.

OBJECTIVE: The aim of the longitudinal study PARTAGE (predictive values of blood pressure and arterial stiffness in institutionalized very aged population) was to determine the predictive value of blood pressure (BP) and arterial stiffness for overall mortality, major cardiovascular events and cognitive decline in a large population of institutionalized patients aged 80 and over. In the study herein, we present the baseline data values of this study.

METHODS: A total of 1130 patients were recruited (878 women), living in French and Italian nursing homes. Clinical and 3-day self-measurements of BP were conducted. Aortic and upper limb pulse wave velocity were obtained using a PulsePen tonometer.

RESULTS: Of this population, 76% of women and 60% of men had a known hypertension and over 91% of the patients were under antihypertensive treatment; 51% of the treated hypertensive patients were well controlled (systolic BP <140 mmHg). No significant differences were found between clinical and self-measured BP. With age, there was an increase in pulse pressure (P < 0.001) due to a decrease in diastolic BP (P < 0.001), without any increase in systolic BP. Aortic but not peripheral pulse wave velocity significantly increased with age (P < 0.005).

CONCLUSION: Baseline values obtained herein demonstrate that elderly patients living in nursing homes present hemodynamic characteristics which are different to those described in community-living elderly populations, and indicate the interest of assessing, in longitudinal studies, the role of BP and arterial stiffness in morbidity and mortality in this population.

Reproducibility of ambulatory blood pressure in treated and untreated hypertensive patients.

J Hypertens. 2010 Mar 3. Eguchi K, Hoshide S, Hoshide Y, Ishikawa S, Shimada K, Kario K. aDivision of Cardiovascular Medicine, Japan bDivision of Community and Family Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.

OBJECTIVE: We tested the reproducibility of ambulatory blood pressure (ABP), BP variability, and BP reduction in hypertensive patients.

METHODS: Forty-two hypertensive patients were enrolled, and ABP monitoring (ABPM) was performed four times in each patient: twice before and twice after the treatment. Morning BP was defined as the average of 2 h after waking, and morning BP surge (MBPS) was defined by four ways: sleep-trough, preawake, morning-evening and morning-after-bed surge. The BP variability was evaluated by standard deviation, weighted standard deviation, coefficient of variation and average real variability. The reproducibility was compared using the repeatability coefficient and the Bland-Altman's method.

RESULTS: The awake, sleep, 24-h and morning BP were well corresponded in the first and the second ABPM values in each period. The four measures of BP variability also corresponded well between the first and the second ABPM values in each period. MBPS did not correspond well in each period when it was defined by diaries, but the extent of correlation was improved when it was defined by actigraphy. The reproducibility of BP-lowering effect was fair when it was defined by a single parameter, but not very good when it was defined by two parameters (e.g. MBPS).

CONCLUSION: The reproducibility of ABP levels and BP variability was fairly good and that of MBPS was moderate when defined by actigraphy. The good reproducibility of BP reduction means that each single ABPM, before and after the treatment, is acceptable for the assessment of drug efficacy.

Implications of Recently Published Trials of Blood Pressure-Lowering Drugs in Hypertensive or High-Risk Patients.

Hypertension. 2010 Mar 8. Staessen JA, Richart T, Wang Z, Thijs L. Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium; Department of Epidemiology, Maastricht University, Maastricht, The Netherlands; Fu Wai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.

We reviewed 6 recent outcome trials of blood pressure (BP)-lowering drugs in 74 524 randomized hypertensive or high-risk patients. Over interpretation of nonsignificant or marginal probability values in large trials with overlapping end points, exclusion of patients not tolerating or not adhering to experimental treatments, labeling nonsignificant treatment effects as modest, and insufficient information on the quality of the BP measurements or on the BP changes early after randomization raise concern. From a clinical viewpoint, results should not be extrapolated to patients with characteristics dissimilar from those randomized. The benefit beyond BP lowering in cardiovascular prevention is tiny. Dual inhibition of the renin system should only be used in patients at high risk, in whom all drug combinations have been tried and who cannot be controlled by a single renin system inhibitor. Current evidence does not support BP lowering in normotensive patients or the use of renin system inhibitors for prevention of stroke recurrence. Because angiotensin-receptor blockers might offer less protection against myocardial infarction than angiotensin-converting enzyme inhibitors, the latter should remain the preferred renin system inhibitor for cardiovascular prevention in angiotensin-converting enzyme inhibitor-tolerant patients. In 2 trials, in which new-onset diabetes was a predefined end point, 1000 patients had to be treated for 1 year with an angiotensin-receptor blocker instead of placebo to prevent just 2 cases.

From a design viewpoint, the time has come to revise the concept of large simple trials and to pursue research questions that serve patient interests more than showing noninferiority or highlight the ancillary qualities of marketable antihypertensive drugs.

Epidemiology of hypertension and chronic kidney disease in China.

Curr Opin Nephrol Hypertens. 2010 Mar 3 Chen J. Department of Medicine and Tulane Hypertension and Renal Center of Excellence, Tulane University School of Medicine, New Orleans, Louisiana, USA.

PURPOSE OF REVIEW: Hypertension and chronic kidney disease have become major public health challenges in China.

RECENT FINDINGS: It is estimated that approximately 153 million Chinese adults had hypertension in 2002. It is also estimated that 2.33 million total cardiovascular deaths and 1.27 million premature cardiovascular deaths were attributable to increased blood pressure in 2005 in China. Approximately 39% of Chinese adult populations are highly sensitive to dietary sodium intake, a risk factor for hypertension and cardiovascular disease. The prevalence of chronic kidney disease varied greatly among studies due to differences in study populations and definitions of chronic kidney disease. A large prospective cohort study estimates that incidence and mortality of end-stage renal disease was 30.7 and 20.9 per 100 000 person-years among Chinese adults aged 40 years and older. Hypertension and the metabolic syndrome have been documented as risk factors for chronic kidney disease. In addition, a J-shaped association between body weight and incidence of end-stage renal disease and an inverse association between alcohol consumption and risk of end-stage renal disease were documented.

SUMMARY: These results underscore the urgent need to develop national strategies for the prevention, detection, and treatment of hypertension and chronic kidney disease.

Does a colour-coded blood pressure diary improve blood pressure control for patients in general practice: The CoCo trial.

Trials. 2010 Apr 14;11(1):38 Steurer-Stey C, Zoller M, Chmiel-Moshinsky C, Senn O, Rosemann T.

BACKGROUND: Insufficient blood pressure control is a frequent problem despite the existence of effective treatment. Insufficient adherence to self-monitoring as well as to therapy is a common reason. Blood pressure self-measurement at home (Home Blood Pressure Measurement, HBPM) has positive effects on treatment adherence and is helpful in achieving the target blood pressure. Only a few studies have investigated whether adherence to HBPM can be improved through simple measures resulting also in better blood pressure control.

OBJECTIVE: Improvement of self-monitoring and improved blood pressure control by using a new colour-coded blood pressure diary. Outcome Primary outcome: Change in systolic and/or diastolic blood pressure 6 months after using the new colour-coded blood pressure diary. Secondary outcome: Adherence to blood pressure self-measurement (number of measurements / entries)

METHODS: Randomised controlled study. Population: 138 adult patients in primary care with uncontrolled hypertension despite therapy. The control group uses a conventional blood pressure diary; the intervention group uses the new colour-coded blood pressure diary (green, yellow, red according a traffic light system). Expected results/ conclusion The visual separation and entries in three colour-coded areas reflecting risk (green: blood pressure in the target range [less than or equal to]140/ [less than or equal to]90 mmHg, yellow: blood pressure >140/ >90mmHg, red: blood pressure in danger zone > 180mmHg/>110 mmHg) lead to better self-monitoring compared with the conventional (non-colour-coded) blood pressure booklet.

The colour-coded, visualised information supports improved perception (awareness and interpretation) of blood pressure and triggers correct behaviour, in the means of improved adherence to the recommended treatment as well as better communication between patients and doctors resulting in improved blood pressure control.

Periodontal bacteria and hypertension: the oral infections and vascular disease epidemiology study (INVEST)

J Hypertens. 2010 May 5 Desvarieux M, Demmer RT et al.

OBJECTIVE: Chronic infections, including periodontal infections, may predispose to cardiovascular disease. We investigated the relationship between periodontal microbiota and hypertension.

METHODS AND RESULTS: Six hundred and fifty-three dentate men and women with no history of stroke or myocardial infarction were enrolled in INVEST. We collected 4533 subgingival plaque samples (average of seven samples per participant). These were quantitatively assessed for 11 periodontal bacteria using DNA-DNA checkerboard hybridization. Cardiovascular risk factor measurements were obtained. Blood pressure and hypertension (SBP >/=140 mmHg, DBP >/=90 mmHg or taking antihypertensive medication, or self-reported history) were each regressed on the level of bacteria: considered causative of periodontal disease (etiologic bacterial burden); associated with periodontal disease (putative bacterial burden); and associated with periodontal health (health-associated bacterial burden). All analyses were adjusted for age, race/ethnicity, sex, education, BMI, smoking, diabetes, low-density lipoprotein and high-density lipoprotein cholesterol. Etiologic bacterial burden was positively associated with both blood pressure and prevalent hypertension. Comparing the highest and lowest tertiles of etiologic bacterial burden, SBP was 9 mmHg higher, DBP was 5 mmHg higher (P for linear trend was less than 0.001 in each case), and the odds ratio for prevalent hypertension was 3.05 (95% confidence interval 1.60-5.82) after multivariable adjustment.

CONCLUSION: Our data provide evidence of a direct relationship between the levels of subgingival periodontal bacteria and both SBP and DBP as well as hypertension prevalence.

Prognostic impact of the ambulatory arterial stiffness index in resistant hypertension.

J Hypertens. 2010 May 12. Muxfeldt ES, Cardoso CR, Dias VB, Nascimento AC, Salles GF. University Hospital Clementino Fraga Filho, Medical School, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil.

OBJECTIVE: The ambulatory arterial stiffness index (AASI), derived from ambulatory blood pressure (BP) monitoring recordings, is an indirect marker of arterial stiffness and a potential predictor of cardiovascular risk. Resistant hypertension is defined as uncontrolled office BP despite the use of at least three antihypertensive drugs. The aim of this prospective study was to investigate the AASI prognostic value in patients with resistant hypertension.

METHODS: At baseline, 547 patients underwent clinical-laboratory, and 24-h ambulatory BP monitoring examinations. AASI was defined as 1 minus the regression slope of DBP on SBP, and was calculated by standard and symmetric regression. Primary endpoints were a composite of fatal and nonfatal cardiovascular events and all-cause and cardiovascular mortalities. Multiple Cox regression was used to assess associations between AASI and subsequent endpoints.

RESULTS: After median follow-up of 4.8 years, 101 patients (18.4%) reached the primary endpoint, and 65 all-cause deaths (11.9%) occurred (45 from cardiovascular causes). 24-h AASI was the best independent predictor of composite endpoint (hazard ratio 1.46, 95% confidence interval 1.12-1.92, for increments of 1-SD = 0.14), whereas cardiovascular mortality was best predicted by night-time AASI (hazard ratio 1.73, 95% confidence interval 1.13-2.65), after adjustments for cardiovascular risk factors, including mean ambulatory BPs and nocturnal BP reduction. Symmetric AASI was not superior to standard AASI. In sensitivity analysis, 24-h AASI was a better predictor of cardiovascular outcomes in women, in younger individuals, and in nondiabetic individuals.

CONCLUSION: AASI is a predictor of cardiovascular morbidity and mortality in resistant hypertension, over and beyond traditional risk factors and other ambulatory BP monitoring parameters.

Acute Kidney Injury and Cardiovascular Outcomes in Acute Severe Hypertension.

Circulation. 2010 May 10. Szczech LA, Granger CB, Dasta JF, Amin A, Peacock WF, McCullough PA, Devlin JW, Weir MR, Katz JN, Anderson FA Jr, Wyman A, Varon J; for the Studying the Treatment of Acute Hypertension Investigators. Department of Medicine, Division of Nephrology, Duke University Medical Center, Durham, NC.

BACKGROUND: Little is known about the association of kidney dysfunction and outcome in acute severe hypertension. This study aimed to measure the association between baseline chronic kidney disease (estimated glomerular filtration rate), acute kidney injury (AKI, decrease in estimated glomerular filtration rate >/=25% from baseline) and outcome in patients hospitalized with acute severe hypertension.

Methods and Results: The Studying the Treatment of Acute Hypertension (STAT) registry enrolled patients with acute severe hypertension, defined as >/=1 blood pressure measurement >180 mm Hg systolic and/or >110 mm Hg diastolic and treated with intravenous antihypertensive therapy. Data were compared across groups categorized by admission estimated glomerular filtration rate and AKI during admission. On admission, 79% of the cohort (n=1566) had at least mild chronic kidney disease (estimated glomerular filtration rate <60 mL/min in 46%, <30 mL/min in 22%). Chronic kidney disease patients were more likely to develop heart failure (P<0.0001), non-ST-elevation myocardial infarction (P=0.003), and AKI (P<0.007). AKI patients were at greater risk of heart failure and cardiac arrest (P</=0.0001 for both). Subjects with AKI experienced higher mortality at 90 days (P=0.003). Any acute loss of estimated glomerular filtration rate during hospitalization was independently associated with an increased risk of death (odds ratio, 1.05; P=0.03 per 10-mL/min decline). Other independent predictors of mortality included increasing age (P<0.0001), male gender (P=0.016), white versus black race (P=0.003), and worse baseline kidney function (P=0.003).

Conclusions: Chronic kidney disease is a common comorbidity among patients admitted with acute severe hypertension, and AKI is a frequent form of acute target organ dysfunction, particularly in those with baseline chronic kidney disease. Any degree of AKI is associated with a greater risk of morbidity and mortality.

Obesity and the Prevalence and Management of Hypertension in Ontario, Canada.

Am J Hypertens. 2010 May 6. Leenen FH, McInnis NH, Fodor G Hypertension Unit, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Background: We evaluated the association of body weight with the prevalence of hypertension by age and sex, as well as the treatment and control rates in obese and nonobese hypertensives among adults in the province of Ontario, Canada.

Methods: Cross-sectional, population-based survey of 2,510 adults, 20-79 years of age representative of the Ontario population of 7,996,653. Height, weight, arm and waist circumference, and blood pressure (BP) were directly measured by a trained nurse.

Results: Prevalence of obesity (body mass index (BMI) >/=30) increased from 16% in the 20-39 years age-group to 33% in the 60-79 years age group, similarly in men and women. Prevalence of hypertension increased as BMI and age increased: in the older age group (60+) from 36% in the lean to 51% for the overweight, 59% in the obese stage I, and 68% in the obese stage II/III. Prevalence of self-reported Obesity followed a similar pattern. Presence of other risk factors (Obesity and dyslipidemia) was independently associated with higher hypertension rates. Treatment and control rates of hypertension varied by BMI and gender. Lean hypertensive males had the lowest control rates (42%) and the highest systolic BPs compared to overweight (79%) and obese (64%) males. This difference was not apparent in females.

Conclusions: Obesity is associated with markedly higher prevalence of hypertension and Obesity with age. If obesity per se is indeed a contributing factor, public health strategies to reduce the obesity epidemic would also markedly reduce the burden of hypertension and Obesity

Prehypertension: is it relevant for nephrologists?

Kidney Int. 2010 Feb;77(3):194-200. Kalaitzidis RG, Bakris GL. Hypertensive Diseases Unit, Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, The University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA.

Blood pressure (BP) in the prehypertensive range is associated with an increased risk for cardiovascular (CV) disease. Patients with co-morbidities are at greater risk for chronic kidney disease (CKD) development in the presence of prehypertension. Lifestyle changes can alter the natural history of prehypertension; however, long-term adherence is rare and thus, their impact on outcomes is limited. Pharmacological therapy in patients with prehypertension and demonstrable target organ damage with blockers of the renin-angiotensin system has demonstrated benefits on markers of CKD outcomes such as microalbuminuria. There are no data, however, on 'hard end points' such as doubling of creatinine or need for renal replacement therapy. In patients with diabetes, monitoring changes in albuminuria, along with assessment of BP in the prehypertensive range, is important to optimize early management and impact the attenuation of CKD progression. Data from natural history studies in patients with type 1 diabetes indicate that increases within the microalbuminuria range antedate increases in BP within the prehypertensive range. Even within the microalbuminuria range, however, systolic BP increases above 125 mm Hg are predictive of nephropathy.

Thus, nephrologists need to ensure that their colleagues appreciate the importance of not only early BP intervention but also of monitoring albuminuria changes in order to have maximal impact on CKD prevention.

High fruit intake is associated with a lower risk of future hypertension determined by home blood pressure measurement: the OHASAMA study.

J Hum Hypertens. 2010 May 6 Tsubota-Utsugi M, Ohkubo T, Kikuya M, Metoki H, Kurimoto A, Suzuki K, Hara A, Asayama K, Tsubono Y, Imai Y. Nutritional Epidemiology Program, National Institute of Health and Nutrition, Tokyo, Japan.

We investigate associations of fruit and vegetable intake with the risk of future hypertension using home blood pressure in a general population from Ohasama, Japan. We obtained data from 745 residents aged >/=35 years without home hypertension at baseline. Dietary intake was measured using a validated 141-item food frequency questionnaire, and subjects were then divided into quartiles according to the fruit and vegetable intake. Home hypertension was defined as home systolic/diastolic blood pressure of >/=135/85 mm Hg and/or the use of antihypertensive medication. During a 4-year follow-up period, we identified 222 incident cases of home hypertension. After adjustment for all putative confounding factors, the highest quartile of fruit intake was associated with a significantly lower risk of future home hypertension (odds ratio 0.40, 95% confidence interval 0.22-0.74, P=0.004).

In conclusion, this study, based on home blood pressure measurement, suggests that higher intake of fruit is associated with a lower risk of future home hypertension

Comparing Physical Activity Patterns of Hypertensive and Nonhypertensive US Adults.

Am J Hypertens. 2010 Apr 29. Churilla JR , Ford ES. Department of Clinical and Applied Movement Sciences, Brooks College of Health, University of North Florida, Jacksonville, Florida, USA.

Background: Nonpharmacologic management of hypertension is an important strategy in treating people with hypertension, but little is known about patterns of physical activity among such people. We compared patterns of physical activity of adults with and without hypertension in the United States using the most recent guidelines for physical activity.

Methods: We used data from 391,017 adults aged >/=18 years from the 2007 Behavioral Risk Factor Surveillance System (BRFSS) and physical activity categories based on 2008 Department of Health and Human Services (DHHS) guidelines. All information was self-reported.

Results: The age-adjusted prevalence of hypertension was 27.2%, whereas the age-adjusted prevalence of meeting DHHS recommendations was 60.2% among participants with hypertension and 66.9% among participants without hypertension. After adjusting for age, gender, race or ethnicity, education, body mass index (BMI), smoking status, and histories of diabetes and cardiovascular disease (CVD), the odds ratio (OR) for meeting DHHS recommendations among participants with hypertension was 0.85 (95% confidence interval (CI) 0.82, 0.88) compared with those who did not have hypertension.

Conclusions: Although the majority of adults with hypertension are currently meeting national guidelines for physical activity, they are less active overall than adults who do not have hypertension.

The optimal home blood pressure monitoring schedule based on the Didima outcome study.

J Hum Hypertens. 2010 Mar;24(3):158-64. Stergiou GS, Nasothimiou EG, Kalogeropoulos PG, Pantazis N, Baibas NM. Hypertension Center, Third Department of Medicine, University of Athens, Sotiria Hospital, Athens, Greece.

This study investigated the optimal schedule for home blood pressure (HBP) monitoring that has the greatest prognostic ability and provides the most reliable assessment of HBP. The Didima study assessed the value of HBP (duplicate morning and evening measurements, 3 days) in predicting cardiovascular events in the general population (662 adults, 8.2+/-0.2 years follow-up). Criteria for the optimal monitoring schedule were stabilization of mean HBP, its variability (standard deviation (s.d.)) and hazard ratios (HRs) of cardiovascular events per 1 mm Hg HBP increase. By averaging more readings (1-12), there was a progressive decline in average HBP and its s.d. and increase in HR, with most of these benefits achieved on the second day (8 readings) and little additional benefit obtained on the third day (12 readings). The first day gave higher and more unstable HBP values (higher s.d.) with less prognostic ability (lower HR). The first HBP readings per occasion gave higher values but with similar prognostic ability as the second readings taken 1 min later. There was little difference in average HBP between morning and evening readings with no prognostic superiority of morning readings. In conclusion, by averaging more readings the average HBP and its variability are reduced and the prognostic ability improved. Any aspect of HBP monitoring (first or second readings, morning or evening) has similar prognostic ability. The first day gives higher and unstable values with lower prognostic ability and should be better discarded.

These data validate the HBP monitoring schedule proposed by the European Society of Hypertension.

How to simplify the diagnostic criteria of hypertension in adolescents.

J Hum Hypertens. 2010 Apr 29. Lu Q, Ma CM, Yin FZ, Liu BW, Lou DH, Liu XL. Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, China.

Diagnosis of hypertension in adolescents is complicated because blood pressure values vary with age, gender and height. How can we simplify the diagnostic criteria for hypertension in adolescents? In 2006, anthropometric measurements were assessed in a cross-sectional population-based study of 3136 Han adolescents aged 13-17 years. Hypertension was defined according to the 2004 National High Blood Pressure Education Program Working Group definition. The following equations for blood pressure-to-height ratio (BPHR) were used: systolic BPHR (SBPHR)=SBP (mm Hg)/height (cm) and diastolic BPHR (DBPHR)=DBP (mm Hg)/height (cm). Receiver-operating characteristic curve analyses were performed to assess the accuracy of SBPHR and DBPHR as diagnostic tests for elevated systolic blood pressure (SBP) and diastolic blood pressure (DBP), respectively. After the cutoff points were determined, hypertension was defined by SBPHR/DBPHR, and the sensitivity and specificity were calculated. The accuracy of SBPHR and DBPHR (assessed by area under the curve) for identifying elevated SBP and DBP was >0.85 (0.989-1.000).

The optimal thresholds of SBPHR/DBPHR for defining hypertension (stages 1 and 2) were 0.75/0.48 for boys and 0.78/0.51 for girls, and for defining hypertension (stage 2) were 0.81/0.57 for boys and 0.84/0.63 for girls. In identifying hypertension, the sensitivity and specificity were both >90% (91.0-99.1%). In identifying stage 2 hypertension, when the sensitivity was 100%, the specificity was 98.6% for boys and 99.1% for girls. BPHR is a simple, accurate and non-age-dependent index for screening hypertension in Han adolescents, especially for stage 2 hypertension

Pulse pressure amplification a mechanical biomarker of cardiovascular risk.

J Am Coll Cardiol. 2010 Mar 9;55(10):1032-7. Benetos A, Thomas F, Joly L, Blacher J, Pannier B, Labat C, Salvi P, Smulyan H, Safar ME Department of Geriatrics CHU de Nancy, and INSERM U691, University of Nancy, Nancy, France.

OBJECTIVES: The aim of this study was to determine whether the carotid/brachial (C/B) ratio is an independent predictor of cardiovascular (CV) risk.

BACKGROUND: Brachial and carotid pulse pressure (PP) are independent predictors of CV risk, mainly in elderly patients. Because PP is physiologically lower at the brachial than at the carotid arterial site, PP amplification is represented by the C/B ratio and could independently predict CV risk.

METHODS: In a Paris population (n = 834), brachial and carotid PP were measured from sphygmomanometry and pulse wave analysis. With stepwise multiple regression, carotid PP was calculated from a nomogram including age, sex, body height, brachial PP, and plasma glucose. This model was applied to 125,151 subjects, followed for 12 years, during which 3,997 deaths occurred (735 of CV origin). With Cox regression analysis, multi-adjusted hazard ratios (HRs) were calculated for 1 SD increase of brachial PP, calculated carotid PP, and C/B ratio.

RESULTS: Brachial PP was significantly associated with both CV and all-cause mortality (HR: 1.16, 95% confidence interval [CI]: 1.13 to 1.19, and HR: 1.13, 95% CI: 1.10 to 1.17, respectively). Calculated carotid PP predicted a similar risk (HR: 1.21, 95% CI: 1.15 to 1.28, and HR: 1.18, 95% CI: 1.12 to 1.25, respectively). Finally, the C/B ratio was a strong risk predictor (HR: 1.22, 95% CI: 1.12 to 1.32, and HR: 1.41, 95% CI: 1.14 to 1.73, respectively). Addition of drug treatment and other confounding variables did not statistically modify the results.

CONCLUSIONS: Brachial PP, calculated carotid PP, and C/B PP amplification all predict CV mortality. In contrast to brachial and carotid PP, the C/B ratio is less dependent on blood pressure calibration and thus can be directly applicable to large population studies.

Cost-Effectiveness of Electrocardiography vs. Electrocardiography Plus Limited Echocardiography to Diagnose LVH in Young, Newly Identified, Hypertensives.

Am J Hypertens. 2010 Mar 25 Leese PJ, Viera AJ, Hinderliter AL, Stearns SC. Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Background: In the United States, screening for left ventricular hypertrophy (LVH) in a newly diagnosed hypertensive patient is typically performed using electrocardiography (ECG). Echocardiography (echo) is a more accurate but also more expensive procedure. However, the introduction of limited echo within the past decade has made sonographic imaging of the heart less expensive and more available for routine screening.

Methods: The cost per additional correct diagnosis of LVH for ECG vs. ECG plus limited echo (with limited echo utilized in patients without ECG evidence of LVH) was analyzed using decision analytic modeling. A structured literature search was used to parameterize model probabilities, and costs are based on the 2008 Medicare Physician Fee Schedule. The study population consisted of black and white cohorts ~50 years of age with new diagnosis of hypertension. Outcomes included short-term results of LVH screening and diagnosis, and the study perspective was health system.

Results: Base-case results indicate each additional correct LVH diagnosis by ECG plus limited echocardiography instead of ECG cost $655 in the black cohort and $829 in the white cohort. Results in both cohorts were most sensitive to the cost of echocardiography. Simulation-generated cost-effectiveness acceptability curves demonstrated costs per additional correct diagnosis have a 90% likelihood of being below $993 and $1,420 in the black and white cohorts, respectively.

Conclusions: LVH detection by ECG plus limited echocardiography may be an economically feasible alternative to ECG due to increased accuracy. However, final recommendations require analysis of long-term effects on morbidity, mortality, quality of life, and subsequent treatment costs between the diagnostic approaches

Childhood obesity, other cardiovascular risk factors, and premature death.

N Engl J Med. 2010 Feb 11;362(6):485-93. Franks PW, Hanson RL, Knowler WC, Sievers ML, Bennett PH, Looker HC. Diabetes Epidemiology and Clinical Research Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, USA.

BACKGROUND: The effect of childhood risk factors for cardiovascular disease on adult mortality is poorly understood.

METHODS: In a cohort of 4857 American Indian children without diabetes (mean age, 11.3 years; 12,659 examinations) who were born between 1945 and 1984, we assessed whether body-mass index (BMI), glucose tolerance, and blood pressure and cholesterol levels predicted premature death. Risk factors were standardized according to sex and age. Proportional-hazards models were used to assess whether each risk factor was associated with time to death occurring before 55 years of age. Models were adjusted for baseline age, sex, birth cohort, and Pima or Tohono O'odham Indian heritage.

RESULTS: There were 166 deaths from endogenous causes (3.4% of the cohort) during a median follow-up period of 23.9 years. Rates of death from endogenous causes among children in the highest quartile of BMI were more than double those among children in the lowest BMI quartile (incidence-rate ratio, 2.30; 95% confidence interval [CI], 1.46 to 3.62). Rates of death from endogenous causes among children in the highest quartile of glucose intolerance were 73% higher than those among children in the lowest quartile (incidence-rate ratio, 1.73; 95% CI, 1.09 to 2.74). No significant associations were seen between rates of death from endogenous or external causes and childhood cholesterol levels or systolic or diastolic blood-pressure levels on a continuous scale, although childhood hypertension was significantly associated with premature death from endogenous causes (incidence-rate ratio, 1.57; 95% CI, 1.10 to 2.24).

CONCLUSIONS: Obesity, glucose intolerance, and hypertension in childhood were strongly associated with increased rates of premature death from endogenous causes in this population. In contrast, childhood hypercholesterolemia was not a major predictor of premature death from endogenous causes.

Exercise training normalizes skeletal muscle vascular endothelial growth factor levels in patients with essential hypertension.

J Hypertens. 2010 Feb 22. Hansen AH, Nielsen JJ, Saltin B, Hellsten Y. Copenhagen Muscle Research Centre, Institute for Exercise and Sport Sciences, University of Copenhagen, Denmark bRigshospitalet, Copenhagen, Denmark.

METHODS: Vascular endothelial growth factor (VEGF) protein and capillarization were determined in muscle vastus lateralis biopsy samples in individuals with essential hypertension (n = 10) and normotensive controls (n = 10). The hypertensive individuals performed exercise training for 16 weeks. Muscle samples as well as muscle microdialysis fluid samples were obtained at rest, during and after an acute exercise bout, performed prior to and after the training period, for the determination of muscle VEGF levels, VEGF release, endothelial cell proliferative effect and capillarization.

RESULTS: Prior to training, the hypertensive individuals had 36% lower levels of VEGF protein and 22% lower capillary density in the muscle compared to controls. Training in the hypertensive group reduced (P < 0.01) mean arterial blood pressure by 7.1 +/- 0.8 mmHg, enhanced (P < 0.01) the capillary-to-fiber ratio by 17% and elevated (P < 0.05) muscle VEGF protein by 67%. Before training, acute exercise did not induce an increase in muscle interstitial VEGF levels above resting levels, but a five-fold increase (P < 0.05) was observed after the training period. Acute exercise induced an elevated (P < 0.05) endothelial cell proliferative effect of muscle dialysate after, but not before, training.

CONCLUSION: In summary, exercise training markedly elevates VEGF protein levels in muscle tissue, increases exercise-induced VEGF release from muscle and the cell proliferative effect of muscle dialysate. These alterations are paralleled by a lowering of blood pressure and an increased capillary-per-fiber ratio, but unaltered capillary density

Controlling Evening BP As Well As Morning BP Is Important in Hypertensive Patients With Prediabetes/Diabetes: The JMS-1 Study.

Am J Hypertens. 2010 Feb 18. [Epub ahead of print] Eguchi K, Matsui Y, Shibasaki S, Hoshide S, Kabutoya T, Ishikawa J, Ishikawa S, Shimada K, Kario K; ; on behalf of the Japan Morning Surge-1 (JMS-1) Study Group. Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.

Background: The significance of home blood pressure (BP) measurement in type 2 diabetes (T2DM) has not been well investigated. We aimed to test the hypotheses that home BP is more closely associated with target-organ damage than clinic BP, and that the presence of prediabetes/T2DM enhances the impact of home BP measurement.

Methods: We studied 551 hypertensives (99 diabetics and 452 nondiabetics) whose self-measured systolic BP (SBP) was >135 mm Hg while on medication. The subjects were followed for 6 months after allocation to either a control group or an active treatment group. The changes in clinic BP and home BP were analyzed in relation to the changes in the spot urine albumin-creatinine ratio (UAR).

Results: The extent of clinic and home BP reduction was similar between the diabetic and nondiabetic groups. The change in UAR in nondiabetics was significantly associated with the extent of SBP reduction in the clinic (r = 0.19), morning (r = 0.33), and evening (r = 0.22, all P < 0.01). In contrast, in the diabetic group, the change in UAR was significantly associated with the changes in morning SBP (r = 0.23, P = 0.02) and evening SBP (r = 0.39, P < 0.001), but not with clinic BP. The correlation with evening SBP in the diabetic group tended to be stronger than the nondiabetic group.

Conclusions: In hypertensives with prediabetes/T2DM, changes in home BP were better than changes in clinic BP to predict changes in UAR. In particular, this suggests the hypothesis that aggressive control of evening home BP might be equally or more important to morning BP in hypertensives with prediabetes/ T2DM,

Optimal schedule for home blood pressure monitoring based on a clinical approach.

J Hypertens. 2010 Feb;28(2):259-64. Johansson JK, Niiranen TJ, Puukka PJ, Jula AM. Population Studies Unit, Department of Chronic Disease Prevention, National Institute for Health and Welfare, Peltolantie, Turku, Finland.

OBJECTIVE: The aim of this study was to determine the optimal schedule for home blood pressure (HBP) measurement based on a clinical approach.

METHODS: Four hundred and sixty-four participants underwent HBP measurement for 7 days (duplicate measurements in the morning and in the evening), ambulatory blood pressure (ABP) monitoring, and measurement of target organ damage (echocardiography and microalbuminuria). To evaluate the optimal schedule for HBP measurement, correlations of HBP with ABP and HBP with indicators of target organ damage were calculated.

RESULTS: HBP decreased slightly (day 1, 129.9/85.3 mmHg; day 7, 128.6/84.8 mmHg), whereas the association between HBP and ABP or target organ damage increased with the cumulative number of measurements. The highest correlations were obtained by using the mean of all 28 measurements, although no major increase occurred after day 4. There was no change in the correlations when the measurements performed during the first day were discarded. Morning and evening HBP correlated equally well with ABP and microalbuminuria. The mean of the first measurements on each measurement occasion was 2.3/1.2 mmHg higher (P < 0.001 for both) than the mean of the second measurements, but discarding the first measurements did not result in greater correlations. The results were similar in both hypertensive and normotensive populations.

CONCLUSION: Duplicate measurements on at least 4 days in the evening and in the morning are needed to reliably estimate an individual's BP level and the risk for target organ damage. Measurements performed during the first day should not be discarded, as suggested by the current European guidelines.

Parental longevity and offspring's home blood pressure: the Ohasama study.

J Hypertens. 2010 Feb;28(2):272-7. Watanabe Y, Metoki H, Ohkubo T, Hirose T, Kikuya M, Asayama K, Inoue R, Hara A, Obara T, Hoshi H, Totsune K, Imai Y. Department of Clinical Pharmacology and Therapeutics, Japan.

OBJECTIVE: Longevity is clustered in particular families. Some studies using conventional blood pressure (BP) reported an association between parental longevity and offspring's BP. No study has used self-measurement of BP at home (home BP). We examined the association between parental longevity and home BP values of adult Japanese offspring.

METHOD: Home and conventional BPs were measured in 1961 residents aged 40 years and over in the general population of Ohasama, Japan. Information about the ages of offspring's parents (age at death or current age) was obtained from a standardized questionnaire.

RESULTS: The mean +/- SD values of systolic/diastolic home BP in offspring whose mothers died at less than 69 years of age, at 69-84 years of age, and in offspring whose mothers were alive at age 84 years were 127.4 +/- 13.2/76.2 +/- 9.1, 124.8 +/- 15.0/74.4 +/- 10.0, and 123.4 +/- 15.2/74.4 +/- 10.3 mmHg (P = 0.0002/0.009), respectively. Corresponding values in offspring whose fathers died at less than 66 years of age, at 66-80 years of age, and in offspring whose fathers were alive at age 80 years were 125.7 +/- 15.2/75.6 +/- 10.6, 124.7 +/- 14.1/75.0 +/- 9.2 and 122.4 +/- 14.6/73.6 +/- 9.5 mmHg (P = 0.001/0.003), respectively. Multivariate analysis demonstrated associations that were only weakly observed for conventional BP values (conventional BP: P = 0.3/0.4 for maternal and P = 0.3/0.3 for paternal longevity; home BP: P = 0.05/0.2 for maternal and P = 0.0004/0.007 for paternal longevity).

CONCLUSION: Parental premature death was significantly associated with higher home BP levels in adult offspring, suggesting that parental longevity might be a useful additional marker for screening adult offspring at higher risk of hypertension.

Relations of central and brachial blood pressure to left ventricular hypertrophy and geometry: the Strong Heart Study.

J Hypertens. 2010 Feb;28(2):384-8. Roman MJ, Okin PM, Kizer JR, Lee ET, Howard BV, Devereux RB. Division of Cardiology, Weill Cornell Medical College, New York 10021, USA.

OBJECTIVE: We previously demonstrated stronger relations of central vs. brachial blood pressure, particularly pulse pressure, to carotid artery hypertrophy and extent of atherosclerosis. Data regarding the relative impacts of central and brachial pressures on left ventricular hypertrophy and geometry are limited.

METHODS: Echocardiography and radial applanation tonometry were performed in American Indian participants in the 4th Strong Heart Study examination. Left ventricular mass was calculated using an anatomically validated formula and adjusted for height. Brachial blood pressure was measured according to a standardized protocol. Central pressures were derived using a generalized transfer function.

RESULTS: Of 2585 participants in the analysis, 60% were women, 21% had diabetes and 33% were hypertensive; the mean age was 40 +/- 17 years. All blood pressure variables were significantly related to left ventricular absolute and relative wall thicknesses and left ventricular mass index (all P < 0.001), with considerable variation in correlation coefficients (r = 0.135-0.432). Central and brachial systolic pressures were uniformly more strongly related to left ventricular wall thicknesses, diastolic diameter and mass index than their respective pulse pressures (all P < 0.005 by z statistics). Left ventricular relative wall thickness and mass index were more strongly related to central than brachial pressures.

CONCLUSION: Left ventricular hypertrophy is more strongly related to systolic pressure than to pulse pressure. Furthermore central pressures are more strongly related than brachial pressures to concentric left ventricular geometry. These data suggest that absolute (systolic) pressure is more important in stimulating left ventricular hypertrophy and remodeling, whereas pulsatile stress (pulse pressure) is more important in causing vascular hypertrophy and atherosclerosis

Effects of the Dietary Approaches to Stop Hypertension Diet, Exercise, and Caloric Restriction on Neurocognition in Overweight Adults With High Blood Pressure.

Hypertension. 2010 Mar 19. Smith PJ, Blumenthal JA, Babyak MA, Craighead L, Welsh-Bohmer KA, Browndyke JN, Strauman TA, Sherwood A. Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC; Department of Psychology, Emory University, Atlanta, Ga; Department of Psychology and Neuroscience, Duke University, Durham, NC.

High blood pressure increases the risks of stroke, dementia, and neurocognitive dysfunction. Although aerobic exercise and dietary modifications have been shown to reduce blood pressure, no randomized trials have examined the effects of aerobic exercise combined with dietary modification on neurocognitive functioning in individuals with high blood pressure (ie, prehypertension and stage 1 hypertension). As part of a larger investigation, 124 participants with elevated blood pressure (systolic blood pressure 130 to 159 mm Hg or diastolic blood pressure 85 to 99 mm Hg) who were sedentary and overweight or obese (body mass index: 25 to 40 kg/m(2)) were randomized to the Dietary Approaches to Stop Hypertension (DASH) diet alone, DASH combined with a behavioral weight management program including exercise and caloric restriction, or a usual diet control group. Participants completed a battery of neurocognitive tests of executive function-memory-learning and psychomotor speed at baseline and again after the 4-month intervention. Participants on the DASH diet combined with a behavioral weight management program exhibited greater improvements in executive function-memory-learning (Cohen's D=0.562; P=0.008) and psychomotor speed (Cohen's D=0.480; P=0.023), and DASH diet alone participants exhibited better psychomotor speed (Cohen's D=0.440; P=0.036) compared with the usual diet control. Neurocognitive improvements appeared to be mediated by increased aerobic fitness and weight loss. Also, participants with greater intima-medial thickness and higher systolic blood pressure showed greater improvements in executive function-memory-learning in the group on the DASH diet combined with a behavioral weight management program.

In conclusion, combining aerobic exercise with the DASH diet and caloric restriction improves neurocognitive function among sedentary and overweight/obese individuals with prehypertension and hypertension.

Effect of cocoa products on blood pressure: systematic review and meta-analysis.

Am J Hypertens. 2010 Jan;23(1):97-103. Desch S, Schmidt J, Kobler D, Sonnabend M, Eitel I, Sareban M, Rahimi K, Schuler G, Thiele H. Department of Cardiology, University of Leipzig-Heart Center, Leipzig, Germany

BACKGROUND: Cocoa products such as dark chocolate and cocoa beverages may have blood pressure (BP)-lowering properties due to their high content of plant-derived flavanols.

METHODS: We performed a meta-analysis of randomized controlled trials assessing the antihypertensive effects of flavanol-rich cocoa products. The primary outcome measure was the change in systolic and diastolic BP between intervention and control groups.

RESULTS: In total, 10 randomized controlled trials comprising 297 individuals were included in the analysis. The populations studied were either healthy normotensive adults or patients with prehypertension/stage 1 hypertension. Treatment duration ranged from 2 to 18 weeks. The mean BP change in the active treatment arms across all trials was -4.5 mm Hg (95% confidence interval (CI), -5.9 to -3.2, P < 0.001) for systolic BP and -2.5 mm Hg (95% CI, -3.9 to -1.2, P < 0.001) for diastolic BP.

CONCLUSIONS: The meta-analysis confirms the BP-lowering capacity of flavanol-rich cocoa products in a larger set of trials than previously reported. However, significant statistical heterogeneity across studies could be found, and questions such as the most appropriate dose and the long-term side effect profile warrant further investigation before cocoa products can be recommended as a treatment option in hypertension.

Hypertension, Prehypertension, and Transient Elevated Blood Pressure in Children: Association With Weight Excess and Waist Circumference.

Am J Hypertens. 2010 Mar 18. Genovesi S, Antolini L, Giussani M, Brambilla P, Barbieri V, Galbiati S, Mastriani S, Sala V, Valsecchi MG, Stella A. Department of Clinical Medicine and Prevention, Nephrology Unit, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.

Background: To assess the prevalence of hypertension (H), prehypertension (PH), and transient elevated blood pressure (TH) and their relationship with weight class and waist circumference (WC) in an unselected population of Northern Italian children.

Methods: A cross-sectional study was conducted in 5,131 children (5-11 years). Weight class was defined according to the International Obesity Task Force references, H and PH according to the National High Blood Pressure Education Program. A child was classified as having PH or H when systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) at first screening were >/=90th percentile and the mean of three subsequent measures was between the 90th and 95th or >/=95th percentile, respectively. When BP values at the first screening were >/=90th percentile but the mean of three subsequent measures was <90th percentile the child was classified as having TH.

Result: sA proportion of 3.4% presented H, 2.7% PH, and 10.4% TH, 20% overweight, and 6% obesity. Weight class and WC were significantly associated to an increased risk of falling into any of the hypertensive categories. In children with TH BP z-scores of the mean of the three subsequent measurements following the first screening were significantly higher than BP z-scores observed in normotensive children (P value <0.001).

Conclusions: Weight class and WC are associated with BP. This is observed not only for H but also for PH, and for nonsustained forms of H. Prospective studies are needed to assess whether children with PH and TH will develop sustained H.

Family History of Hypertension and Cardiovascular Risk Factors in Prepubertal Children.

Am J Hypertens. 2010 Jan 14. Rodríguez-Moran M, Aradillas-García C, Simental-Mendia LE, Monreal-Escalante E, de la Cruz Mendoza E, Dávila Esqueda ME, Guerrero-Romero F. [1] Biomedical Research Unit, Mexican Social Security Institute at Durango, Durango, Mexico [2] Research Group on Diabetes and Chronic Illnesses, Durango, Mexico.

Background: To determine the relationship between family history of hypertension (FHH) and cardiovascular risk factors (CVRF) in healthy prepubertal children.

Methods and Design: Cross-sectional, population-based study. Setting: Elementary schools from San Luis Potosi and Durango, cities in middle and northern Mexico.

Participants: A total of 358 randomly enrolled, healthy boys and girls aged 6-10 years in Tanner stage 1, with and without FHH. Outcome measures: Odds ratio (OR) that estimates the relationship between FHH and CVRF.

Results: FHH was identified in 72 (20.1%) children; 212 (59.2%) children had at least one CVRF, where low high-density lipoprotein (HDL)-cholesterol (36.3%), elevated waist circumference (WC) (29.3%), and hypertriglyceridemia (28.8%) were the most frequent; high-blood pressure (HBP) and hyperglycemia were recognized in 10 (3.3%) and 1 (0.3%) children. Metabolic syndrome and hyperinsulinemia were identified in 36 (10.0%) and 48 (13.4%) children. In all subjects, hyperinsulinemia (OR 2.0; 95% confidence interval (CI) 1.2-8.4), but not other CVRF was significantly associated with FHH. Subsequent analysis stratified by WC showed that FHH was not associated with CVRF in children with elevated WC. Among children with nonelevated WC, FHH in the maternal branch, but not in the paternal branch, was associated with hyperinsulinemia (OR 1.5; 95% CI 1.1-5.5), HBP (OR 4.0; 95% CI 1.3-30.1), hypertriglyceridemia (OR 1.6; 95% CI 1.1-7.2), and low HDL-cholesterol (OR 1.3; 95% CI 1.1-3.0).

Conclusion: Results show that FHH in the maternal branch is associated with CVRF in children with nonelevated WC.

Microparticles, vascular function and hypertension.

Curr Opin Nephrol Hypertens. 2010 Jan 5. Boulanger CM. INSERM U970, Paris Cardiovascular Research Center - PARCC, France Université Paris Descartes, UMR-S970, Paris, France.

PURPOSE OF REVIEW: To summarize the potential role of microparticles in hypertension and in cardiovascular diseases. Microparticles are submicron vesicles shed from the membrane in response to cell activation or apoptosis. Microparticles of different cellular origins are found in the plasma of healthy individuals and their circulating levels augment in patients with cardiovascular diseases.

RECENT FINDINGS: Recent studies demonstrate that circulating levels of microparticles originating from endothelial cells, which represent a small fraction of the overall pool of plasma microparticles, augment with increased endothelial dysfunction in patients with cardiovascular diseases. Therefore, endothelial microparticles constitute an emerging surrogate marker of endothelial dysfunction, with potential prognostic value for major adverse events in patients with cardiovascular diseases. In addition, microparticles of endothelial and other cellular origins are also potential biological effectors in inflammation, vascular injury, angiogenesis and thrombosis.

SUMMARY: In summary, circulating endothelial microparticles may serve not only as an index of arterial damage but also as a trigger of vascular repair.

Additive Interaction of Metabolic Syndrome and Chronic Kidney Disease on Cardiac Hypertrophy, and Risk of Cardiovascular Disease in Hypertension.

Am J Hypertens. 2009 Dec 31 Iwashima Y, Horio T, Kamide K, Tokudome T, Yoshihara F, Nakamura S, Ogihara T, Rakugi H, Kawano Y. Division of Hypertension and Nephrology, Department of Medicine, National Cardiovascular Center, Osaka, Japan.

Background: recent epidemiologic analyses have demonstrated a link between the metabolic syndrome (MetS) and chronic kidney disease (CKD). We examined the association between MetS, CKD, and left ventricular hypertrophy (LVH), and prospectively investigated the predictive value of the combination of MetS and CKD for cardiovascular disease (CVD) in essential hypertension.

Methods: A total of 1,160 essential hypertensive patients (mean age 63 years, 53% male) underwent clinical evaluation, laboratory testing, and Doppler echocardiography, and were monitored for a mean follow-up of 4.8 years

Results: At baseline, total subjects were divided into four groups according to the presence/absence of MetS and/or CKD, and, compared to the group without MetS and CKD (MetS(-)/CKD(-)); those with MetS and CKD (MetS(+)/CKD(+)) had a multivariate-adjusted odds ratio of 2.40 (95% confidence interval (CI) 1.66-3.48) for LVH. During the follow-up period, 172 subjects developed CVD. Multiple Cox regression analysis including LV mass index (LVMI) showed that the presence of MetS as well as that of CKD were each independent predictors of CVD (hazard ratio 1.90 for MetS, 1.82 for CKD). We then divided the total subjects into four groups, and found that, compared to the MetS(-)/CKD(-) group, multivariate-adjusted HR for the MetS(+)/CKD(+) group was 3.58 (95% CI 2.14-5.95).

Conclusions: Our findings suggest that, in essential hypertension, the combination of MetS and CKD is a strong risk for LVH as well as a strong and independent predictor of subsequent CVD. These findings highlight the clinical importance of the concomitance of MetS and CKD in essential hypertension.

Differences between office and ambulatory control of hypertension in very elderly patients. The CARDIORISC - MAPAPRES project.

Med Clin (Barc). 2009 Nov 28;133(20):769-76. Epub 2009 Oct 12. Llisterri JL, Alonso FJ, Gorostidi M, Sierra C, de La Sierra A, Banegas JR, Segura J, Sobrino J, De La Cruz JJ, Madruga F, Aranda P, Redon J, Ruilope LM; en representación de los investigadores del Proyecto CARDIORISC-MAPAPRES. Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA). Centro de Salud Joaquín Benlloch, Valencia, España.

BACKGROUND AND OBJECTIVE: Hypertension is highly prevalent in the very elderly. We studied control rates of hypertension according to clinic blood pressure (BP) and ambulatory BP monitoring (ABPM) in treated hypertensives aged >/=80 years.

PATIENTS AND METHOD: Data came from the Spanish Society of Hypertension ABPM Registry (CARDIORISC - MAPAPRES project), which comprises a nation-wide network of more than 1,000 physicians sending standardized ABPM registries via web. Between June 2004 and April 2007 we obtained a 33.829-patient database. Control of hypertension was defined at the clinic when office BP was <140/90mmHg and at the ABPM when mean BP during the 24-h period was <130/80mmHg.

RESULTS: We identified 2,311 patients (6.8%) aged >/=80 years. Mean age (SD) was 83.1 (3.2) years and 63% were women. Control of clinic BP was observed in 21.5% of cases (95%CI: 19.1-23.9) and control of 24-h BP in ABPM was 42.1% (95%CI: 39.7-45.3). Prevalence of masked hypertension was 7.0% (95%CI: 6.0-8.0) and prevalence of office-resistant control (white coat) was 27.6% (95% CI: 25.7-29.4). Diabetes, kidney disease, and duration of hypertension were associated with lack of control in ABPM.

CONCLUSIONS: In very old hypertensives, control of clinic BP was 21.5% but ambulatory-based hypertension control was 42.1%. Physicians should be aware that the likelihood of misestimating BP control is high in these subjects. A wider use of ABPM in the elderly with hypertension should be considered

Home blood pressure monitoring in blood pressure control among haemodialysis patients: an open randomized clinical trial.

Nephrol Dial Transplant. 2009 Dec;24(12):3805-11. da Silva GV, de Barros S, Abensur H, Ortega KC, Mion D Jr; Cochrane Renal Group Prospective Trial Register: CRG060800146. Nephrology Division, Hypertension Unit, University of São Paulo School of Medicine, São Paulo, Brazil.

BACKGROUND: It is not known if the adjustment of antihypertensive therapy based on home blood pressure monitoring (HBPM) can improve blood pressure (BP) control among haemodialysis patients.

METHODS: This is an open randomized clinical trial. Hypertensive patients on haemodialysis were randomized to have the antihypertensive therapy adjusted based on predialysis BP measurements or HBPM. Before and after 6 months of follow-up, patients were submitted to ambulatory blood pressure monitoring (ABPM) for 24 h, HBPM during 1 week and echocardiogram.

RESULTS: A total of 34 and 31 patients completed the study in the HBPM and predialysis BP groups, respectively. At the end of study, the systolic (SBP) and diastolic (DBP) blood pressure during the interdialytic period measured by ABPM were significantly lower in the HBPM group in relation to the predialysis BP group (mean 24-h BP: 135 +/- 12 mmHg/76 +/- 7 mmHg versus 147 +/- 15 mmHg/79 +/- 8 mmHg; P < 0.05). In the HBPM analysis, the HBPM group showed a significant reduction only in SBP compared to the predialysis BP group (weekly mean: 144 +/- 21 mmHg versus 154 +/- 22 mmHg; P < 0.05). There were no differences between the HBPM and predialysis BP groups in relation to the left ventricular mass index at the end of the study (108 +/- 35 g/m(2) versus 110 +/- 33 g/m(2); P > 0.05).

CONCLUSIONS: Decision making based on HBPM among haemodialysis patients has led to a better BP control during the interdialytic period in comparison with predialysis BP measurements. HBPM may be a useful adjuvant instrument for blood pressure control among haemodialysis patients.

Prevalence of ambulatory hypotension in elderly patients with CKD stages 3 and 4.

Nephrol Dial Transplant. 2009 Dec;24(12):3751-5. Tomlinson LA, Holt SG, Leslie AR, Rajkumar C. Brighton and Sussex Medical School, Audrey Emerton Building, Brighton, East Sussex, BN2 5BE, UK.

BACKGROUND: Recent understanding of the incidence of chronic kidney disease (CKD) has led us to the introduction of national blood pressure (BP) targets aimed at reducing the incidence of end-stage renal failure. The target clinic BP is <140/90 mmHg and <130/80 in patients with significant proteinuria according to UK NICE guidelines. However, the relationship between clinic BP and ambulatory hypotension has not been studied.

METHODS: We prospectively collected data regarding cardiovascular risk factors, clinic and 24-h ambulatory blood pressure monitoring (24-h ABPM) in 98 treated patients with CKD stages 3 and 4.

RESULTS: The mean percentage of systolic blood pressure (SBP) recordings <100 mmHg was 21.2 +/- 16.2% and of diastolic blood pressure (DBP) recordings <60 mmHg was 19.8 +/- 16.9%. The patients were divided into two groups above and below the median age. The older group had a higher percentage of cardiovascular disease than younger patients (57.1 versus 34.7, P = 0.03) and a lower percentage of primary renal disease (18.4 versus 55.1, P < 0.01). Clinic SBP was higher in the older group (158.4 +/- 20.1 versus 147.2 +/- 17.8 mmHg, P < 0.01) but 24-h ABPM SBP was not different (117.3 +/- 14.7 versus 121.0 +/- 12.8 mmHg, P = 0.19). DBP was lower in the older group for both clinic BP (80.3 +/- 10.2 versus 85.5 +/- 12.3 mmHg, P = 0.03) and 24-h ABPM (69.1 +/- 8.2 versus 76.7 +/- 8.8 mmHg, P = <0.01). There were a higher percentage of systolic (SBP <100 mmHg) and diastolic (DBP<60 mmHg) hypotensive episodes in the older group (21.3 +/- 18.9 versus 13.2 +/- 13.6% P = 0.02 and 21.6 +/- 17.9 versus 8.1 +/- 13.3%, P < 0.01, respectively).

CONCLUSIONS: Hypotension was common among treated CKD patients and despite similar clinic SBP, older CKD patients had lower 24-h ABPM DBP and more frequent systolic and diastolic hypotensive episodes. Further research is underway into how this relates to antihypertensive therapy and future outcomes.

Ambulatory blood pressure monitoring in stroke survivors: do we really control our patients?

Eur J Intern Med. 2009 Dec;20(8):760-3. Epub 2009 Sep 29. Castilla-Guerra L, Fernández-Moreno Mdel C, Espino-Montoro A, López-Chozas JM. Department of Internal Medicine, Hospital de la Merced, Osuna, Seville, Spain.

BACKGROUND: We aim to evaluate prospectively the long-term changes of blood pressure (BP) in stroke survivors using ambulatory BP monitoring (ABPM) and compare them with the clinic conventional measurements.

METHODS: We studied 101 patients who were admitted within 24h after stroke onset. To study the circadian rhythm of BP a continuous BP monitor (Spacelab 90207) was used. After six and twelve months follow-up a new ABPM was undertaken. Data were analyzed using the SSPS 12.0.

RESULTS: We studied 62 males and 39 females, mean age: 70.9+/-10.7 years. We included 88 ischemic strokes and 13 hemorrhagic strokes. In the acute phase mean 24 h BPs were 136+/-19/78.6+/-11.4 mm Hg. The normal diurnal variation in BP was abolished in 88 (87.1%) patients. After six months, 74 patients were assessed. Mean office readings were 137.5+/-23.8/76.4+/-11.4 mm Hg, and high systolic BPs and diastolic BPs were found in 37% and 11% of the subjects respectively. ABPM revealed a mean BP of 118.5+/-20.1/70.3+/-8.6 (p<0.0001). In 57 (76.9%), the normal BP pattern remained abolished (p<0.001). After one year, 63 patients were assessed. Mean office readings were 130.8+/-26.3/77.6+/-9.3 mm Hg, and high systolic BPs and diastolic BPs were found in 23.8% and 10% of the subjects respectively. Mean 24 h BPs were 117+/-12.5/69.7+/-7.2 (p<0.001). The normal diurnal variation in BP was now abolished in 47 (74.6%) patients (p<0.001).

CONCLUSION: Survivors of stroke, both hypertensive and non-hypertensive patients, present a chronic disruption of circadian rhythm of BP. Conventional clinical recordings are an unreliable method of controlling these patients and ABPM should be routinely performed in this population.

A primary care pragmatic cluster randomized trial of the use of home blood pressure monitoring on blood pressure levels in hypertensive patients with above target blood pressure.

Fam Pract. 2009 Dec 23. Godwin M, Lam M, Birtwhistle R, Delva D, Seguin R, Casson I, Macdonald S. Family Medicine, Memorial University of Newfoundland, St. John's.

BACKGROUND: The measurement of blood pressure (BP) at home by patients with hypertension is increasingly used to assess and monitor BP. Evidence for its effectiveness in improving BP control is mixed.

METHODS: To determine if home BP monitoring improves BP a pragmatic cluster randomized contolled trial was carried out in family practices in southeastern Ontario, Canada. Family practice patients with uncontrolled hypertension were recruited to the trail. Patients were divided into two groups: one with at least weekly measurements of BP at home, recording those measurements and showing those to the family physician during office visits for hypertension and the control group were given usual care. The primary outcome was mean awake BP on ambulatory monitoring at 6- and 12-month follow-up and the secondary outcomes were mean BP on full 24-hour ambulatory blood pressure monitoring (ABPM), mean sleep BP on ABPM and BP on the BpTRU device, all at 6- and 12-month follow-up.

RESULTS: Home BP monitoring did not improve BP compared to usual care at 12-month follow-up: mean awake systolic BP on ABPM [141.1 versus 142.8 mmHg, mean difference 1.7 mmHg; 95% confidence interval (CI) -0.6 to 4.0, P = 0.314] and mean awake diastolic BP on ABPM (78.7 versus 79.4 mmHg, mean difference 0.7 mmHg; 95% CI -7.7 to 9.1, P = 0.398). Similar negative results were obtained for men and women separately. However, outcomes using the full 24-hour ABPM and the BpTRU device showed a significantly lower diastolic BP at 12 months. When analysis was done by sex, this effect was shown to be only in men.

CONCLUSION: Home BP monitoring may improve BP control in men with hypertension.

Resting Heart Rate Pattern During Follow-Up and Mortality in Hypertensive Patients.

Hypertension. 2009 Dec 28. Paul L, Hastie CE, Li WS, Harrow C, Muir S, Connell JM, Dominiczak AF, McInnes GT, Padmanabhan S. British Heart Foundation Glasgow Cardiovascular Research Centre, Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; College of Medicine, Dentistry, and Nursing, Ninewells Hospital, University of Dundee, Dundee, United Kingdom.

There is a linear relationship between resting heart rate (HR) and mortality in normotensive and untreated hypertensive individuals. However, it is not clear whether HR is a marker of increased risk in hypertensive patients on treatment. We investigated the relationship between HR and mortality in patients with hypertension.

We analyzed baseline HR, final HR, and HR change during follow-up in patients attending the Glasgow Blood Pressure Clinic. Using a threshold of 80 bpm, we classified patients into those who had a consistently high (high-high) or low (low-low) HR or patients whose HR increased (low-high) or decreased (high-low) over time. Survival analysis was carried out using Cox proportional hazards models adjusted for age, sex, body mass index, smoking, rate-limiting therapy, systolic blood pressure, and serum cholesterol.

For each beat of HR change there was a 1% change in mortality risk. The highest risk of an all-cause event was associated with patients who had increased their HR by >/=5 bpm at the end of follow-up (1.51 [95% CI: 1.03 to 2.20]; P=0.035). Compared with low-low patients, high-high patients had a 78% increase in the risk of all-cause mortality (HR: 1.78 [95% CI: 1.31 to 2.41]; P<0.001). Cardiovascular mortality showed a similar pattern of results. Rate-limiting therapy did not have an independent effect on outcomes in this analysis.

Change in HR achieved during follow-up of hypertensive patients is a better predictor of risk than baseline or final HR. After correction for rate-limiting therapy, HR remained a significant independent risk factor.

Obstructive Sleep Apnea, Masked Hypertension, and Arterial Stiffness in Men.

Am J Hypertens. 2009 Dec 17. Drager LF, Diegues-Silva L, Diniz PM, Bortolotto LA, Pedrosa RP, Couto RB, Marcondes B, Giorgi DM, Lorenzi-Filho G, Krieger EM. Hypertension Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.

Background: Obstructive sleep apnea (OSA) is an established cause of hypertension. However, it is not clear whether the frequency of masked hypertension in patients with OSA and whether OSA have an independent role on arterial stiffness taking into account ambulatory blood pressure (BP) monitoring (ABPM)

Methods: We evaluated 61 male normotensive participants as determined by casual clinic BP level <140/90 mm Hg without clinical evidence of cardiovascular disease and on no medications (43 patients with moderate-to-severe OSA (apnea-hypopnea index (AHI) >/=15 events/hour by polysomnography) and 18 age- and body mass index-matched controls without OSA (AHI <5 events/hour)). Pulse wave velocity (PWV), an index of arterial stiffness, and 24-h ABPM were performed in a blinded fashion. Masked hypertension was defined when abnormal daytime ABPM was >/=135 or >/=85 mm Hg.

Results: The AHI and lowest oxygen saturation were 2.6 +/- 1.6 and 90 +/- 2 vs. 52.8 +/- 21.0 events/hour and 75 +/- 10% for controls and OSA patients, respectively; P < 0.001. Compared with controls, patients with OSA had higher office systolic BP (113 +/- 9 vs. 118 +/- 10 mm Hg; P = 0.05) and a higher unadjusted proportion of masked hypertension (2 controls (11.1%) vs. 13 patients (30.2%); P < 0.05). PWV was 8.7 +/- 0.7, 9.4 +/- 1.0, and 10.6 +/- 1.1 m/s in the control, OSA without and with masked hypertension groups, respectively (P < 0.01 for each comparison). Multiple regression showed that systolic daytime ABPM and the lowest oxygen saturation were independently related to PWV (adjusted R(2) = 0.34; P < 0.01).

Conclusions: Patients with OSA presented a higher unadjusted rate of masked hypertension than matched controls. Lowest oxygen saturation has an independent association with arterial stiffness

Preventing misdiagnosis of ambulatory hypertension: algorithm using office and home blood pressures.

J Hypertens. 2009 Sep;27(9):1775-83. Shimbo D, Kuruvilla S, Haas D, Pickering TG, Schwartz JE, Gerin W. Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA.

OBJECTIVES: An algorithm for making a differential diagnosis between sustained and white coat hypertension (WCH) has been proposed - patients with office hypertension undergo home blood pressure monitoring (HBPM) and those with normal HBP levels undergo ambulatory blood pressure monitoring (ABPM). We tested whether incorporating an upper office blood pressure (OBP) cut-off in the algorithm, higher than the traditional 140/90 mmHg, reduces the need for HBPM and ABPM.

METHODS: Two hundred twenty-nine normotensive and untreated mildly hypertensive participants (mean age 52.5 +/- 14.6 years, 54% female participants) underwent OBP measurements, HBPM, and 24-h ABPM. Using the algorithm, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for sustained hypertension and WCH were assessed. We then modified the algorithm utilizing a systolic and diastolic OBP cut-off at a specificity of 95% for ambulatory hypertension - those with office hypertension but OBP levels below the upper cut-off underwent HBPM and subsequent ABPM, if appropriate.

RESULTS: Using the original algorithm, sensitivity and PPV for sustained hypertension were 100% and 93.8%, respectively. Despite a specificity of 44.4%, NPV was 100%. These values correspond to specificity, NPV, sensitivity, and PPV for WCH, respectively. Using the modified algorithm, the diagnostic accuracy for sustained hypertension and WCH did not change. However, far fewer participants needed HBPM (29 vs. 84) and ABPM (8 vs. 15).

CONCLUSION: In this sample, the original and modified algorithms are excellent at diagnosing sustained hypertension and WCH. However, the latter requires far fewer participants to undergo HBPM and ABPM. These findings have important implications for the cost-effective diagnosis of sustained hypertension and WCH.

Strict blood-pressure control and progression of renal failure in children.

N Engl J Med. 2009 Oct 22;361(17):1639-50. ESCAPE Trial Group, Wühl E, Trivelli A, Picca S, Litwin M, Peco-Antic A, Zurowska A, Testa S, Jankauskiene A, Emre S, Caldas-Afonso A, Anarat A, Niaudet P, Mir S, Bakkaloglu A, Enke B, Montini G, Wingen AM, Sallay P, Jeck N, Berg U, Caliskan S, Wygoda S, Hohbach-Hohenfellner K, Dusek J, Urasinski T, Arbeiter K, Neuhaus T, Gellermann J, Drozdz D, Fischbach M, Möller K, Wigger M, Peruzzi L, Mehls O, Schaefer F., Collaborators (27)

BACKGROUND: Although inhibition of the renin-angiotensin system delays the progression of renal failure in adults with chronic kidney disease, the blood-pressure target for optimal renal protection is controversial. We assessed the long-term renoprotective effect of intensified blood-pressure control among children who were receiving a fixed high dose of an angiotensin-converting-enzyme (ACE) inhibitor.

METHODS: After a 6-month run-in period, 385 children, 3 to 18 years of age, with chronic kidney disease (glomerular filtration rate of 15 to 80 ml per minute per 1.73 m(2) of body-surface area) received ramipril at a dose of 6 mg per square meter of body-surface area per day. Patients were randomly assigned to intensified blood-pressure control (with a target 24-hour mean arterial pressure below the 50th percentile) or conventional blood-pressure control (mean arterial pressure in the 50th to 95th percentile), achieved by the addition of antihypertensive therapy that does not target the renin-angiotensin system; patients were followed for 5 years. The primary end point was the time to a decline of 50% in the glomerular filtration rate or progression to end-stage renal disease. Secondary end points included changes in blood pressure, glomerular filtration rate, and urinary protein excretion.

RESULTS: A total of 29.9% of the patients in the group that received intensified blood-pressure control reached the primary end point, as assessed by means of a Kaplan-Meier analysis, as compared with 41.7% in the group that received conventional blood-pressure control (hazard ratio, 0.65; confidence interval, 0.44 to 0.94; P=0.02). The two groups did not differ significantly with respect to the type or incidence of adverse events or the cumulative rates of withdrawal from the study (28.0% vs. 26.5%). Proteinuria gradually rebounded during ongoing ACE inhibition after an initial 50% decrease, despite persistently good blood-pressure control. Achievement of blood-pressure targets and a decrease in proteinuria were significant independent predictors of delayed progression of renal disease.

CONCLUSIONS: Intensified blood-pressure control, with target 24-hour blood-pressure levels in the low range of normal, confers a substantial benefit with respect to renal function among children with chronic kidney disease. Reappearance of proteinuria after initial successful pharmacologic blood-pressure control is common among children who are receiving long-term ACE inhibition.

Value of retinal examination in hypertensive encephalopathy.

J. Hum Hypertens. 2009 Oct 29. Amraoui F, van Montfrans GA, van den Born BJ. Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands.

The presence of grade III or IV hypertensive retinopathy (HRP) is considered to distinguish hypertensive urgencies from emergencies. However, case-reports suggest that these retinal changes may be lacking in patients with hypertensive encephalopathy. To assess the frequency of grade III and IV retinopathy in this hypertensive emergency, we conducted a retrospective cohort study. We retrieved 162 patients with malignant hypertension and 34 patients (17%) fulfilled the predefined criteria for hypertensive encephalopathy. Data on retinal examination were incomplete for 6 patients (18%), thus leaving 28 patients who were analysed for the presence or absence of grade III and IV HRP. In 9 (32%) patients with hypertensive encephalopathy, grade III or IV HRP was absent, 11 (39%) patients presented with grade III and 8 (29%) patients with grade IV retinopathy. Patients without retinal abnormalities were on average 13 years younger (P=0.05), more often black (P=0.02) and displayed lower blood pressure (BP) values (P=0.04 for systolic and diastolic BP). A substantial proportion of patients with hypertensive encephalopathy lack grade III or IV HRP.

This suggests that the decision to admit these patients should not only rely on the presence of grade III and IV retinopathy alone, but should also include a careful neurological examination.

Validation of a Case Definition to Define Hypertension Using Administrative Data.

Hypertension. 2009 Oct 26. Quan H, Khan N, Hemmelgarn BR, Tu K, Chen G, Campbell N, Hill MD, Ghali WA, McAlister FA; for the Hypertension Outcome Surveillance Team of the Canadian Hypertension Education Programs. Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.

We validated the accuracy of case definitions for hypertension derived from administrative data across time periods (year 2001 versus 2004) and geographic regions using physician charts. Physician charts were randomly selected in rural and urban areas from Alberta and British Columbia, Canada, during years 2001 and 2004. Physician charts were linked with administrative data through unique personal health number. We reviewed charts of approximately 50 randomly selected patients >35 years of age from each clinic within 48 urban and 16 rural family physician clinics to identify physician diagnoses of hypertension during the years 2001 and 2004. The validity indices were estimated for diagnosed hypertension using 3 years of administrative data for the 8 case-definition combinations. Of the 3362 patient charts reviewed, the prevalence of hypertension ranged from 18.8% to 33.3%, depending on the year and region studied. The administrative data hypertension definition of "2 claims within 2 years or 1 hospitalization" had the highest validity relative to the other definitions evaluated (sensitivity 75%, specificity 94%, positive predictive value 81%, negative predictive value 92%, and kappa 0.71). After adjustment for age, sex, and comorbid conditions, the sensitivities between regions, years, and provinces were not significantly different, but the positive predictive value varied slightly across geographic regions.

These results provide evidence that administrative data can be used as a relatively valid source of data to define cases of hypertension for surveillance and research purposes.

The potency of team-based care interventions for hypertension: a meta-analysis.

Arch Intern Med. 2009 Oct 26;169(19):1748-55. Carter BL, Rogers M, Daly J, Zheng S, James PA. Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, IA 52242, USA.

BACKGROUND: Team-based care is the strategy that has had the greatest effect on improving blood pressure (BP). The purpose of this systematic review was to determine the potency of interventions for BP involving nurses or pharmacists.

METHODS: A MEDLINE search for controlled clinical trials that involved a nurse or pharmacist intervention was conducted. Mean reductions in systolic (S) and diastolic (D) BP were determined by 2 reviewers who independently abstracted data and classified the different intervention components.

RESULTS: Thirty-seven articles met the inclusion criteria. Education about BP medications was significantly associated with a reduction in mean BP (-8.75/-3.60 mm Hg). Other strategies that had large effect sizes on SBP include pharmacist treatment recommendations (-9.30 mm Hg), intervention by nurses (-4.80 mm Hg), and use of a treatment algorithm (-4.00 mm Hg). The odds ratios (95% confidence intervals) for controlled BP were: nurses, 1.69 (1.48-1.93); pharmacists within primary care clinics, 2.17 (1.75-2.68); and community pharmacists, 2.89 (1.83-4.55). Mean (SD) reductions in SBP were: nursing studies, 5.84 (8.05) mm Hg; pharmacists in clinics, 7.76 (7.81) mm Hg; and community pharmacists, 9.31 (5.00) mm Hg. There were no significant differences between the nursing and pharmacy studies (P > or = .19).

CONCLUSIONS: Team-based care was associated with improved BP control, and individual components of the intervention appeared to predict potency. Implementation of new hypertension guidelines should consider changes in health care organizational structure to include important components of team-based care.

Intradialytic Hypertension: A Less-Recognized Cardiovascular Complication of Hemodialysis.

Am J Kidney Dis. 2009 Oct 21. [Epub ahead of print] Inrig JK. University of Texas Southwestern Medical Center at Dallas, Dallas, TX.

Intradialytic hypertension, defined as an increase in blood pressure during or immediately after hemodialysis that results in postdialysis hypertension, has long been recognized to complicate the hemodialysis procedure, yet often is largely ignored. In light of recent investigations suggesting that intradialytic hypertension is associated with adverse outcomes, this review broadly covers the epidemiologic characteristics, prognostic significance, potential pathogenic mechanisms, prevention, and possible treatment of intradialytic hypertension. Intradialytic hypertension affects up to 15% of hemodialysis patients and occurs more frequently in patients who are older, have lower dry weights, are prescribed more antihypertensive medications, and have lower serum creatinine levels. Recent studies associated intradialytic hypertension independently with higher hospitalization rates and decreased survival. Although the pathophysiologic mechanisms of intradialytic hypertension are uncertain, it likely is multifactorial and includes subclinical volume overload, sympathetic overactivity, activation of the renin-angiotensin system, endothelial cell dysfunction, and specific dialytic techniques. Prevention and treatment of intradialytic hypertension may include careful attention to dry weight, avoidance of dialyzable antihypertensive medications, limiting the use of high-calcium dialysate, achieving adequate sodium solute removal during hemodialysis, and using medications that inhibit the renin-angiotensin-aldosterone system or decrease endothelin 1 levels.

In summary, although intradialytic hypertension often is underappreciated, recent studies suggest that it should not be ignored. However, further work is necessary to elucidate the pathophysiologic mechanisms of intradialytic hypertension and its appropriate management and determine whether treatment of intradialytic hypertension can improve clinical outcomes

Association of Hypertension Treatment and Control With All-Cause and Cardiovascular Disease Mortality Among US Adults With Hypertension.

Am J Hypertens. 2009 Oct 22. Gu Q, Dillon CF, Burt VL, Gillum RF. Division of Health and Nutrition Examination Survey, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA.

Background: Clinical trials have provided convincing evidence that blood pressure (BP) lowering treatment reduces the risk of cardiovascular disease (CVD) and total mortality. The objective of this study was to examine the association of hypertension treatment, control, and BP indexes with all-cause and cardiovascular mortality among US adults with hypertension.

Methods: Persons aged >/=18 years from the Third National Health and Nutrition Examination Survey (NHANES III) were identified as hypertensives based on a BP >/=140/90 mm Hg or current treatment for hypertension. Vital status in 2006 was ascertained by passive follow-up using the National Death Index. Cox regression models were used to assess correlates of survival

Results; At baseline, 52% of hypertensive adults reported currently taking prescription medicine for high BP and 38% of treated persons had BP controlled. Compared to treated controlled hypertensives, treated uncontrolled hypertensives had a 1.57-fold (95% confidence interval (CI) 1.28-1.91) and 1.74-fold (95% CI 1.36-2.22) risk of all-cause and cardiovascular mortality; untreated hypertensives had a 1.34-fold (95% CI 1.12-1.62) and 1.37-fold (95% CI 1.04-1.81) risk of all-cause and cardiovascular mortality, respectively. The association persisted after further excluding persons with pre-existing hypertension comorbidities. Mortality risk was linearly increased with systolic BP (SBP), pulse pressure (PP), and mean arterial pressure (MBP), whereas diastolic BP (DBP) was not a significant predictor of cardiovascular mortality overall. No significant associations were observed between drug classes and mortality risk

Conclusions: This study indicates that uncontrolled and untreated hypertension was associated with increased risk of total and cardiovascular mortality among the general hypertensive population.

Incidence of heart failure in relation to QRS duration during antihypertensive therapy: the LIFE study

J Hypertens. 2009 Oct 14. Okin PM, Devereux RB, Kjeldsen SE, Edelman JM, Dahlöf B. aGreenberg Division of Cardiology, Weill Cornell Medical College, New York, New York, USA bUllevål University Hospital, Oslo, Norway cUniversity of Michigan Medical Center, Ann Arbor, Michigan, USA dMerck & Co. Inc., North Wales, Pennsylvania, USA eSahlgrenska University Hospital/Ostra, Gothenburg, Sweden.

BACKGROUND: Prolonged QRS duration (QRS) has been associated with left ventricular dyssynchrony and dysfunction and with the development of heart failure. However, whether persistence or development of increased QRS over time is associated with an increased incidence of heart failure in hypertensive patients, independent of blood pressure lowering and regression of electrocardiographic left ventricular hypertrophy (LVH) has not been examined.

METHODS AND RESULTS: The relation of QRS over time to incident heart failure was examined in 8945 hypertensive patients without history of heart failure who were randomly assigned to losartan-based or atenolol-based treatment. During 4.7 +/- 1.1 years follow-up, heart failure hospitalization occurred in 282 patients (3.2%): in 157 with in-treatment QRS less than 110 ms (4.6 per 1000 patient-years) and in 125 with persistence or development of QRS 110 ms or more (13.4 per 1000 patient-years). In univariate Cox analyses in which QRS during the study was entered as a time-varying covariate, in-treatment persistence or development of a QRS 110 ms or more was associated with a 153% increased risk of developing heart failure [hazard ratio 2.53, 95% confidence interval (CI) 2.00-3.20]. After adjusting for treatment, baseline risk factors for heart failure, incident myocardial infarction and for baseline and in-treatment electrocardiographic LVH and blood pressure, persistence or development of a QRS 110 ms or more remained associated with a 102% increased risk of new-onset heart failure (hazard ratio 2.02, 95% CI 1.49-2.74).

CONCLUSION: Persistence or development of a prolonged QRS during antihypertensive therapy is associated with an increased likelihood of new-onset heart failure, independent of blood pressure lowering, treatment modality and regression of electrocardiographic LVH in patients with essential hypertension. These findings suggest that serial assessment of QRS over time can be used to track the risk of heart failure in hypertensive patients.

Nocturnal nondipping of heart rate predicts cardiovascular events in hypertensive patients.

J Hypertens. 2009 Oct 14. Eguchi K, Hoshide S, Ishikawa J, Pickering TG, Schwartz JE, Shimada K, Kario K. aDepartment of Cardiology, International University of Health and Welfare Hospital, Nasushiobara, Japan bDivision of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan cCenter for Behavioral Cardiovascular Health, Division of General Medicine, Columbia University Medical Center, New York, USA dDepartment of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, New York, USA.

OBJECTIVE: It has not been established whether nocturnal nondipping of heart rate (HR) predicts future cardiovascular disease (CVD). We performed this study to test the hypothesis that nocturnal nondipping of HR predicts the risk of incident CVD independent of nocturnal blood pressure dipping pattern.

METHODS: Ambulatory blood pressure monitoring was performed in 457 uncomplicated patients, who were being treated or evaluated for hypertension. They were followed for an average of 72 +/- 26 months. Nondipping HR was defined as a night/day HR ratio greater than 0.90. We chose two outcomes for this analysis: CVD events (defined as stroke, myocardial infarction, or sudden cardiac death) and all-cause mortality. Cox regression analyses (stepwise method) were used to estimate hazard ratios and their 95% confidence interval after adjusting for covariates.

RESULTS: In univariate analysis, increased sleep HR and nondipping of HR were associated with increased risk of CVD and all-cause mortality, but awake HR was not. In multivariable analyses, HR nondipping status significantly predicted an increased risk of CVD events (hazard ratio, 2.37; 95% confidence interval, 1.22-4.62; P = 0.01), but not for all-cause mortality. Increased 24-h HR was significantly associated with increased risk of all-cause mortality (hazard ratio, 1.67; 95% confidence interval, 1.11-2.51; P = 0.01).

CONCLUSION: The risk of future CVD was shown to be 2.4 times higher in those whose HR does not exhibit the typical nocturnal decline. The relationship was independent of nondipping of SBP and was not dependent on diabetes status or blood pressure level.

Relationship between therapeutic changes in blood pressure and outcomes in acute stroke: a metaregression

Hypertension. 2009 Oct;54(4):775-81. Geeganage CM, Bath PM. Division of Stroke Medicine, University of Nottingham, Nottingham City Campus, Nottingham, United Kingdom.

Both low and high blood pressures (BPs) during the acute phase of stroke are associated independently with a poor outcome. Several small clinical trials have involved the alteration of BP, and this study assessed the relationship between change in BP and functional outcome.

Randomized, controlled trials of interventions that would be expected, on pharmacological grounds, to alter BP in patients within 1 week of the onset of acute ischemic or hemorrhagic stroke were sought using electronic searches. Data were collected on BP and clinical outcome. The relationship between the differences in on-treatment BP and odds ratios for outcomes was assessed using meta-regression. Thirty-seven trials involving 9008 patients were included. A U- or J-shaped relationship was found among on-treatment BP difference and early death, death at the end of 90-day follow-up, and combined death or dependency at the end of follow-up. Although outcomes were not significantly reduced at any level of change in BP, the lowest odds occurred at the following times: early death (odds ratio: 0.87; 95% CI: 0.54 to 1.23), 8.1 mm Hg; death at the end of follow-up (odds-ratio: 0.96; 95% CI: 0.31 to 1.65), 14.4 mm Hg; and combined death or dependency at the end of follow-up (odds ratio: 0.95; 95% CI: 0.11 to 1.72), 14.6 mm Hg.

Although large falls or increases in BP are associated with a worse outcome, modest reductions may reduce death and combine death or dependency, although the CIs are wide and compatible with an overall benefit or hazard.

Long-term weight loss from lifestyle intervention benefits blood pressure?: a systematic review

Hypertension. 2009 Oct;54(4):756-62. Aucott L, Rothnie H, McIntyre L, Thapa M, Waweru C, Gray D. Medical Statistician, Section of Population Health, Polwarth Building, University of Aberdeen, Foresterhill, Aberdeen, UK. l.aucott@abdn.ac.uk

Weight gain may increase blood pressure. Weight loss may reduce this. Reviews have considered the long-term effects of weight loss but are related mainly to more obese participants often on obesity medication and/or undergoing obesity surgery. This systematic review, based on lifestyle interventions for adults (18 to 65 years) with mean baseline BMI of <35 kg/m(2), links weight change to blood pressure difference. A systematic review of studies reporting weight differences and blood pressure outcomes, published between 1990 and 2008 with follow-up of > or =2 years identified 8 clinical trials or controlled before and after studies (represented by 9 articles) and 8 cohort studies. Differences ranged from -11 to +4kg for weight, -7 to +2.2 mm Hg for diastolic blood pressure and -13 to +6.1 mm Hg for systolic blood pressure. For this population group, no quantifiable relationship between weight and diastolic blood pressure difference was found, possibly because of small weight losses, differing weight status responses, or because pharmacologically controlled hypertension masked weight loss influences. Systolic differences were in line with previous reviews of 1 kg:1 mm Hg relationship, but only for follow-up periods of 2 to 3 years, possibly reflecting the fact that regardless of maintained weight loss, blood pressure often reverts back to higher levels. Lifestyle interventions for weight and blood pressure are limited in this target group, and there has been no exploration of successful intervention components.

An individual patient data analysis may uncover baseline and medication effects, explore differences between weight groups, and may identify successful components. Such an analysis would enable effective development of preventative interventions for both hypertension and obesity.

Blood pressure development and hypertensive retinopathy: 20-year follow-up of middle-aged normotensive and hypertensive men.

J Hum Hypertens.. Gudmundsdottir H, Taarnhøj NC, Strand AH, Kjeldsen SE, Høieggen A, Os I. [1] Department of Nephrology, Ulleval University Hospital, Oslo, Norway [2] Department of Cardiovascular and Renal Research Center, Ulleval University Hospital, Oslo, Norway.

Screening for hypertensive organ damage is important in assessing cardiovascular risk in hypertensive individuals. In a 20-year follow-up of normotensive and hypertensive men, signs of end-organ damage were examined, focusing on hypertensive retinopathy. In all, 56 of the original 79 men were reexamined for hypertensive organ damage, including by digital fundus photography. The diameters of the central retinal artery equivalent (CRAE) and vein were estimated and the artery-to-vein diameter ratio calculated. Components of metabolic syndrome were assessed. Fifty percent of the normotensive men developed hypertension during follow-up. Significant differences appeared in CRAE between the different blood pressure groups (P=0.025) while no differences were observed for other markers of hypertensive organ damage. There were significant relationships between CRAE and blood pressure at baseline (r=-0.466, P=0.001) and at follow-up (r=-0.508, P<0.001). A linear decrease in CRAE was observed with increasing number of components of the metabolic syndrome (beta=-3.947, R(2)=0.105, P=0.023). Retinal vascular diameters were closely linked to blood pressures and risk factors of the metabolic syndrome.

The diversity in the development of hypertensive organ damage, with changes in retinal microvasculature preceding other signs of damage, should encourage more liberal use of fundus photography in assessing cardiovascular risk in hypertensive individuals.

Hospitalization Costs Associated With Hypertension as a Secondary Diagnosis Among Insured Patients Aged 18-64 Years.

Am J Hypertens. Wang G, Zhang Z, Ayala C. Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: We estimated the hospitalization costs associated with hypertension as a secondary diagnosis among insured adults aged 18-64 years by using data from 2005 MarketScan Commercial Claims and Encounters (CCAE) inpatient admissions.

Methods: We analyzed costs for four patient groups (N = 455,944): (i) all selected patients; (ii) patients with the primary diagnosis of ischemic heart disease (IHD); (iii) patients with the primary diagnosis of cerebrovascular disease; and (iv) patients with neither IHD nor cerebrovascular disease as the primary diagnosis. We conducted propensity score matching to control possible bias in cost estimates due to sample selections and estimated the costs of hypertension by using a regression model on the matched populations that controlled for subjects' age, sex, length of hospital stay, Charlson comorbidity index (CCI), region of residence, and urbanization of residence.

Results: For all patients with hypertension as a secondary diagnosis, the estimated average annual hospitalization cost per patient was $21,094, of which $2,734 (13%; P < 0.01) was associated with hypertension. The estimated average costs were $31,106 for patients with a primary diagnosis of IHD, $17,298 for those with a primary diagnosis of cerebrovascular disease, and $18,693 for those without a primary diagnosis of IHD or cerebrovascular disease; hypertension-associated costs for these patients were $3,540 (11.4%; P < 0.01), $1,133 (6.5%; P < 0.01), and $2,254 (12.1%; P < 0.01), respectively.

Conclusions: Hypertension-associated hospitalization costs are substantial among insured US patients aged 18-64 years with hypertension as a secondary diagnosis and suggest a need for cost-effective programs to prevent, manage, and control hypertension.

Effect of Intensive Versus Standard Blood Pressure Lowering on Diastolic Function in Patients With Uncontrolled Hypertension and Diastolic Dysfunction.

Hypertension. 2009 Dec 7. Solomon SD, Verma A, Desai A, Hassanein A, Izzo J, Oparil S, Lacourciere Y, Lee J, Seifu Y, Hilkert RJ, Rocha R, Pitt B; for the Exforge Intensive Control of Hypertension to Evaluate Efficacy in Diastolic Dysfunction Investigators. Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, State University of New York, Buffalo, NY; Department of Medicine, University of Alabama, Birmingham, Ala; Department of Medicine, Centre Hôspitalier de l'Université Laval, Québec, France; Novartis, East Hanover, N.J.; Department of Medicine, University of Michigan, Ann Arbor, Mich.

Diastolic dysfunction may precede development of heart failure in hypertensive patients.

We randomized 228 patients with uncontrolled hypertension, preserved ejection fraction, and diastolic dysfunction to 2 targeted treatment strategies: intensive, with a systolic blood pressure target of <130 mm Hg, or standard, with a systolic blood pressure target of <140 mm Hg, using a combination of valsartan, either 160 or 320 mg, plus amlodipine, either 5 or 10 mg, with other antihypertensive medications as needed. Echocardiographic assessment of diastolic function was performed at baseline and after 24 weeks in a prospective, open-label, blinded end point design.

Blood pressure was reduced significantly in both groups, from 161.2+/-13.9/90.1+/-12.0 to 130.8+/-12.3/74.9+/-9.1 mm Hg (P<0.0001) in the intensive arm and from 162.1+/-13.2/93.7+/-12.2 to 137.0+/-12.9/79.6+/-11.0 mm Hg (P<0.0001) in the standard arm (P<0.003 for between-group comparisons). Myocardial relaxation velocity improved from 7.6+/-1.1 to 9.2+/-1.7 cm/s (Delta 1.54+/-1.4 cm/s; P<0.0001) in the intensive arm and from 7.5+/-1.3 to 9.0+/-1.9 cm/s (Delta 1.48+/-1.6 cm/s; P<0.0001) in the standard arm, with no difference between the 2 strategies in the achieved improvement (P=0.58).

The degree of improvement in annular relaxation velocity was associated with the extent of systolic blood pressure reduction, and patients with the lowest achieved systolic blood pressure had the highest final diastolic relaxation velocities.

Hypertension in the Developing World: Challenges and Opportunities.

Am J Kidney Dis. 2009 Dec 3. Mittal BV, Singh AK. Renal Division, Brigham & Women's Hospital and Harvard Medical School Dubai Center Institute of Postgraduate Education and Research, Dubai, UAE.

Hypertension is a major public health problem and a leading cause of death and disability in developing countries. One-quarter of the world's adult population has hypertension, and this is likely to increase to 29% by 2025.

Modeled projections indicate an increase to 1.15 billion hypertensive patients by 2025 in developing countries. There is variability in the global prevalence of hypertension: hypertension is present in approximately 35% of the Latin American population, 20%-30% of the Chinese and Indian population, and approximately 14% in Sub-Saharan African countries. This heterogeneity has been attributed to several factors, including urbanization with its associated changes in lifestyle, racial ethnic differences, nutritional status, and birth weight. Compounding this high burden of hypertension is a lack of awareness and insufficient treatment in those with hypertension.

The public health response to this challenge should drive greater promotion of awareness efforts, studies of risk factors for hypertension, and understanding of the impact of lifestyle changes. Also important are efforts to develop multipronged strategies for hypertension management in developing nations.

High blood pressure in middle age is associated with a future decline in activities of daily living. NIPPON DATA80.

J Hum Hypertens. 2009 Aug;23(8):546-52. Hozawa A, Okamura T, Murakami Y, Kadowaki T, Okuda N, Takashima N, Hayakawa T, Kita Y, Miura K, Nakamura Y, Okayama A, Ueshima H; NIPPON DATA80 Research Group. Collaborators (28) Division of Epidemiology, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aobaku, Sendai 980-8575, Japan.

Although several studies have reported on the relation between high blood pressure (BP) and impaired activities of daily living (ADL), only a few studies have reported on the relation of high BP in middle-aged subjects with future impaired ADL. Furthermore, no studies reported an excess impaired ADL due to non-normal BP. Using ADL 1999 data, we compared data from NIPPON DATA80 survivors without impaired ADL (N=1816) with those with impaired ADL (N=75) using baseline BP information collected in 1980. We analysed participants who were aged 47-59 years at baseline. Multiple adjusted logistic regression analyses were used to estimate the risk of impaired ADL, according to baseline BP categories using Joint National Committee 7 guidelines (normal BP, prehypertension, stage 1 hypertension (HT) and stage 2 HT). Subjects who used antihypertensive medications were classified as having stage 2 HT. We calculated excess impaired ADL due to non-normal BP. Compared with normal BP categories, the adjusted odds ratio (OR) and 95% confidence interval (CI) of having impaired ADL was higher in subjects with prehypertension (OR=1.50, 95% CI: 0.55-4.09), stage 1 HT (OR=1.56, 95% CI: 0.56-4.32) and stage 2 HT (OR=2.96, 95% CI: 1.09-8.05). Non-normal BP explained 45% (33.7/75) of impaired ADL. A positive relation of BP categories with the composite end point of mortality and impaired ADL was also observed.

In conclusion, controlling BP in middle age may prevent deaths and future ADL decline

Antihypertensive drug therapy and blood pressure control in men and women: an international perspective

J Hum Hypertens. 2009 Oct 1. Thoenes M, Neuberger HR, Volpe M, Khan BV, Kirch W, Böhm M. [1] Medical Faculty Carl Gustav Carus, Institute for Clinical Pharmacology, Technical University Dresden, Dresden, Germany [2] Sanofi Aventis, Global Medical Affairs, Paris, France.

Cardiovascular death represents the single largest cause of mortality in women with 70% of deaths attributable to modifiable risk factors, such as hypertension. This analysis aims at evaluating, whether there are gender disparities in antihypertensive drug usage and blood pressure (BP) control. We included 18 017 patients with arterial hypertension from the International Survey Evaluating Microalbuminuria Routinely by Cardiologists in patients with Hypertension (I-SEARCH). The study was conducted between September 2005 and March 2006 in 26 countries, and data on patient demographics, cardiovascular disease and risk factors, BP, and cardiovascular drug treatment were collected. Mean systolic blood pressure (SBP) was 2.1 mm Hg higher in women (150.6+/-0.35 mm Hg, n=8357/18 017) than in men (148.5+/-0.35 mm Hg; P<0.0001, n=9526/18 017), whereas no difference in diastolic BP was seen (88.2+/-0.20 vs 88+/-0.20 mm Hg; P=0.198). Gender differences in SBP were more pronounced in diabetic as compared with non-diabetic patients (3.5 vs 1.7 mm Hg, n=4272 vs n=13 611; P<0.0001) and became evident at an age 55 years old. Overall BP-control rate was 33.6% in men and 30.6% in women (P<0.0001) and was lower in diabetic as compared with non-diabetic patients. In all, 30% of patients used one, 40% used two and 30% used >/=3 drugs without gender differences.

Response rates to different drug regimens appeared to be similar. However, women received more frequently thiazides and beta-blockers, and less frequently ACE-inhibitors as monotherapy. Major efforts are required to improve BP-management, especially in women.

Adherence to Antihypertensive Medications and Cardiovascular Morbidity Among Newly Diagnosed Hypertensive Patients

Circulation. 2009 Oct 5 Mazzaglia G, Ambrosioni E, Alacqua M, Filippi A, Sessa E, Immordino V, Borghi C, Brignoli O, Caputi AP, Cricelli C, Mantovani LG. Health Search, Italian College of General Practitioners, Florence.

BACKGROUND: Nonadherence to antihypertensive treatment is a common problem in cardiovascular prevention and may influence prognosis. We explored predictors of adherence to antihypertensive treatment and the association of adherence with acute cardiovascular events.

Methods and Results: Using data obtained from 400 Italian primary care physicians providing information to the Health Search/Thales Database, we selected 18 806 newly diagnosed hypertensive patients >/=35 years of age during the years 2000 to 2001. Subjects included were newly treated for hypertension and initially free of cardiovascular diseases. Patient adherence was subdivided a priori into 3 categories-high (proportion of days covered, >/=80%), intermediate (proportion of days covered, 40% to 79%), and low (proportion of days covered, </=40%)-and compared with the long-term occurrence of acute cardiovascular events through the use of multivariable models adjusted for demographic factors, comorbidities, and concomitant drug use. At baseline (ie, 6 months after index diagnosis), 8.1%, 40.5%, and 51.4% of patients were classified as having high, intermediate, and low adherence levels, respectively. Multiple drug treatment (odds ratio, 1.62; 95% CI, 1.43 to 1.83), dyslipidemia (odds ratio, 1.52; 95% CI, 1.24 to 1.87), diabetes mellitus (odds ratio, 1.40; 95% CI, 1.15 to 1.71), obesity (odds ratio, 1.50; 95% CI, 1.26 to 1.78), and antihypertensive combination therapy (odds ratio, 1.29; 95% CI, 1.15 to 1.45) were significantly (P<0.001) associated with high adherence to antihypertensive treatment. Compared with their low-adherence counterparts, only high adherers reported a significantly decreased risk of acute cardiovascular events (hazard ratio, 0.62; 95% CI, 0.40 to 0.96; P=0.032).

Conclusions: The long-term reduction of acute cardiovascular events associated with high adherence to antihypertensive treatment underscores its importance in assessments of the beneficial effects of evidence-based therapies in the population. An effort focused on early antihypertensive treatment initiation and adherence is likely to provide major benefits.

Prehypertension, obesity, and risk of kidney disease: 20-year follow-up of the HUNT I study in Norway.

Am J Kidney Dis. 2009 Oct;54(4):638-46. Munkhaugen J, Lydersen S, Widerøe TE, Hallan S. Faculty of Medicine, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway

BACKGROUND: The combined effect of blood pressure (BP) and body weight on risk of kidney disease has not been previously studied. To improve risk stratification in prehypertensive individuals (ie, BP, 120 to 139/80 to 89 mm Hg), we examined the interaction between BP and body weight on the risk of end-stage renal disease or chronic kidney disease (CKD)-related death.

STUDY DESIGN: Retrospective cohort study.

SETTING & PARTICIPANTS: 74,986 adults participating in the first Health Study in Nord-Trøndelag (88% participation rate) were linked to the Norwegian Renal Registry and Cause of Death Registry.

PREDICTORS: BP and body weight were measured by using standard procedures, and other relevant covariates were obtained from an extensive questionnaire.

OUTCOME & MEASUREMENTS: Hazard ratios for treated end-stage renal disease and CKD-related death were calculated.

RESULTS: Mean systolic BP and body mass index (BMI) were 136.8 +/- 23.3 (SD) mm Hg and 25.2 +/- 3.9 kg/m(2), whereas 12.9% had treated hypertension at baseline, respectively. During a median follow-up of 21 years (1,345,882 person-years), 507 men (1.4%) and 319 women (0.8%) initiated renal replacement therapy (n = 157) or died of CKD (n = 669). Multiadjusted risk of these kidney outcomes increased continuously with no lower threshold for BP. The risk associated with body weight started to increase from a BMI of 25.0 kg/m(2). In participants with BP less than 120/80 mm Hg, risk did not increase with increasing BMI. In prehypertensive participants, multivariate adjusted hazard ratios in the BMI categories 18.5 to 24.9, 25.0 to 29.9, 30.0 to 34.9, and 35.0 kg/m(2) or greater were 1.21 (95% confidence interval [CI], 0.67 to 2.17), 1.10 (95% CI, 59 to 2.00), 2.66 (95% CI, 1.28 to 5.53), and 5.94 (95% CI, 1.94 to 18.20) compared with BP less than 120/80 mm Hg and BMI of 18.5 to 24.9 kg/m(2), respectively (P = 0.02 for trend). Corresponding risks in hypertensive participants were 2.13 (95% CI, 1.23 to 3.70), 2.40 (95% CI, 1.40 to 4.15), 3.32 (95% CI, 1.89 to 5.81), and 5.53 (95% CI, 3.01 to 10.20), respectively (P < 0.001 for trend). LIMITATIONS: Baseline creatinine measurements were not available; hence, a secondary analysis was performed that excluded all individuals who experienced outcomes in the 5 years after the study start.

CONCLUSIONS: Participants with prehypertension are not at increased risk of serious kidney outcomes if BMI is less than 30.0 kg/m(2). However, the risk of kidney disease increases substantially if prehypertension is present in obese participants.

Blood Pressure Control Determines Improvement in Diastolic Dysfunction in Early Hypertension

Am J Hypertens. 2009 Sep 17 Almuntaser I, Mahmud A, Brown A, Murphy R, King G, Crean P, Feely J. Department of Cardiology, St James's Hospital, Dublin, Ireland.

Background: Diastolic dysfunction is common in early hypertension. We hypothesized that improvement in diastolic dysfunction is blood pressure (BP) dependent and may occur early with treatment in newly diagnosed untreated hypertensive patients.

Methods: Forty untreated hypertensive subjects (age 52 +/- 1.4 years, mean +/- s.e.m.) with diastolic dysfunction based on Canadian Consensus Guidelines, received either bendroflumethiazide 2.5 mg (1.25 mg for the first month), or candesartan 16 mg (8 mg for the first month). Left ventricular (LV) structure and function, early diastolic velocity (E') and systolic velocity, and systolic myocardial velocity (Sm) were assessed echocardiographically using M-mode, 2-dimensional, and tissue Doppler imaging (TDI) before and at 1 and 3 months following treatment.

Results: Antihypertensive treatment reduced BP significantly at 3 months (168 +/- 2/97 +/- 1-143 +/- 2/86 +/- 1 mm Hg, P < 0.0001). Both drugs had similar and significant effects on TDI E' which increased from 7.8 +/- 0.2 to 10 +/- 0.3 cm/s (P < 0.001). The improvement in TDI E' was independent of LV mass index (LVMI) regression but was significantly related to the improvement in Sm (r = 0.73, P < 0.0001) and the fall in systolic BP (R = 0.51, P < 0.001). Normalization of diastolic function was associated with better control of BP (130 +/- 4/81 +/- 2 mm Hg vs. 149 +/- 2/88 +/- 1 mm Hg, P < 0.05). In a stepwise regression model, reduction in systolic BP (P < 0.001) and TDI Sm (P < 0.0001) emerged as independent determinants of improvement in TDI E' with no contribution from age, gender or change in relative wall thickness (RWT) (R(2) = 0.68, P < 0.0001).

Conclusions: Achieving good BP control and enhancement in systolic function determines the improvement in diastolic function in early hypertension

Relation of alcohol consumption and coronary heart disease in hypertensive male physicians (from the Physicians' Health Study).

Am J Cardiol. 2009 Oct 1;104(7):932-5 Britton KA, Gaziano JM, Sesso HD, Djoussé L. Harvard Medical School, Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston Veterans Affairs Healthcare System, Boston, MA, USA.

Alcohol has diverse effects on the cardiovascular system. Moderate drinking is associated with a decreased risk of cardiovascular disease, yet increasing amounts of alcohol consumption are known to increase blood pressure. These opposing effects have led to interest in the effect of moderate alcohol consumption on the risk of coronary heart disease (CHD) in patients with hypertension. To test the hypothesis that moderate alcohol consumption decreases the risk of myocardial infarction (MI) in patients with hypertension, we used data on 5,164 participants in the Physicians' Health Study who were apparently healthy and free of CHD at baseline. Incident MI was ascertained by annual follow-up questionnaires and validated through review of medical records. Cox proportional hazard model was used to compute multivariable-adjusted hazard ratios with corresponding 95% confidence intervals. From 1982 to 2008, 623 cases of MI occurred. Compared to subjects consuming <1 drink per week, hazard ratios for MI were 1.05 (95% confidence interval 0.85 to 1.28), 0.78 (95% confidence interval 0.64 to 0.97), and 0.57 (95% confidence interval 0.35 to 0.95) for alcohol consumption of 1 to 4, 5 to 7, and >8 drinks per week adjusted for age, body mass index, smoking, exercise, diabetes, multivitamin use, vegetable intake, breakfast cereal intake, and cholesterol (p for trend <0.0022). Similar inferences could be made for the secondary outcomes of angina pectoris and any CHD (which included MI, angina pectoris, and previous revascularization).

In conclusion, our data demonstrated an inverse relation between moderate alcohol consumption and CHD in hypertensive men.

Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies

British Medical Journal 334:859-860; 24 November 2009 Pasquale Strazzullo, professor of medicine1, Lanfranco D’Elia, clinical lecturer in medicine1, Ngianga-Bakwin Kandala, principal research fellow in medical statistics2, Francesco P Cappuccio, professor of cardiovascular medicine and epidemiology2 1 Department of Clinical and Experimental Medicine, "Federico II" University of Naples Medical School, Naples, Italy, 2 University of Warwick, WHO Collaborating Centre for Nutrition, Warwick Medical School, Clinical Sciences Research Institute, Coventry CV2 2DX

Objective: To assess the relation between the level of habitual salt intake and stroke or total cardiovascular disease outcome.

Design: Systematic review and meta-analysis of prospective studies published 1966-2008.

Data sources: Medline (1966-2008), Embase (from 1988), AMED (from 1985), CINAHL (from 1982), Psychinfo (from 1985), and the Cochrane Library.

Review methods: For each study, relative risks and 95% confidence intervals were extracted and pooled with a random effect model, weighting for the inverse of the variance. Heterogeneity, publication bias, subgroup, and meta-regression analyses were performed. Criteria for inclusion were prospective adult population study, assessment of salt intake as baseline exposure, assessment of either stroke or total cardiovascular disease as outcome, follow-up of at least three years, indication of number of participants exposed and number of events across different salt intake categories.

Results: There were 19 independent cohort samples from 13 studies, with 177 025 participants (follow-up 3.5-19 years) and over 11 000 vascular events. Higher salt intake was associated with greater risk of stroke (pooled relative risk 1.23, 95% confidence interval 1.06 to 1.43; P=0.007) and cardiovascular disease (1.14, 0.99 to 1.32; P=0.07), with no significant evidence of publication bias. For cardiovascular disease, sensitivity analysis showed that the exclusion of a single study led to a pooled estimate of 1.17 (1.02 to 1.34; P=0.02). The associations observed were greater the larger the difference in sodium intake and the longer the follow-up.

Conclusions: High salt intake is associated with significantly increased risk of stroke and total cardiovascular disease. Because of imprecision in measurement of salt intake, these effect sizes are likely to be underestimated. These results support the role of a substantial population reduction in salt intake for the prevention of cardiovascular disease.

Home blood pressure monitoring in blood pressure control among haemodialysis patients: an open randomized clinical trial.

Nephrol Dial Transplant. 2009 Dec;24(12):3805-11 da Silva GV, de Barros S, Abensur H, Ortega KC, Mion D Jr; Cochrane Renal Group Prospective Trial Register: CRG060800146.

The Potency of Team-Based Care Interventions for Hypertension
A Meta-analysis

Arch Intern Med 169(19):1748-1755, 26 October 2009 Barry L. Carter, PharmD; Meaghan Rogers, PharmD; Jeanette Daly, RN, PhD; Shimin Zheng, PhD; Paul A. James, MD

Background: Team-based care is the strategy that has had the greatest effect on improving blood pressure (BP). The purpose of this systematic review was to determine the potency of interventions for BP involving nurses or pharmacists.

Methods: A MEDLINE search for controlled clinical trials that involved a nurse or pharmacist intervention was conducted. Mean reductions in systolic (S) and diastolic (D) BP were determined by 2 reviewers who independently abstracted data and classified the different intervention components.

Results: Thirty-seven articles met the inclusion criteria. Education about BP medications was significantly associated with a reduction in mean BP (–8.75/–3.60 mm Hg). Other strategies that had large effect sizes on SBP include pharmacist treatment recommendations (–9.30 mm Hg), intervention by nurses (–4.80 mm Hg), and use of a treatment algorithm (–4.00 mm Hg). The odds ratios (95% confidence intervals) for controlled BP were: nurses, 1.69 (1.48-1.93); pharmacists within primary care clinics, 2.17 (1.75-2.68); and community pharmacists, 2.89 (1.83-4.55). Mean (SD) reductions in SBP were: nursing studies, 5.84 (8.05) mm Hg; pharmacists in clinics, 7.76 (7.81) mm Hg; and community pharmacists, 9.31 (5.00) mm Hg. There were no significant differences between the nursing and pharmacy studies (/P/ ? .19).

Conclusions: Team-based care was associated with improved BP control, and individual components of the intervention appeared to predict potency. Implementation of new hypertension guidelines should consider changes in health care organizational structure to include important components of team-based care.

Association of Depressive Symptoms With All-Cause and Ischemic Heart Disease Mortality in Adults With Self-Reported Hypertension.

Am J Hypertens. 2009 Nov 5. Axon RN, Zhao Y, Egede LE. [1] Department of Medicine, Division of General Internal Medicine and Geriatrics, The Medical University of South Carolina, Charleston, South Carolina, USA [2] The Ralph Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA.

Background: Hypertension (HTN) is a prevalent and important risk factor for both cardiovascular and all-cause mortality. Depression is often present in hypertensive patients and has also been associated with increased mortality risk. The aim of this study was to evaluate the association of depressive symptoms with all-cause mortality and ischemic heart disease (IHD) mortality among adults with self-reported HTN.

Methods: We studied 10,025 participants in the National Health and Nutrition Epidemiologic Follow-up Study (NHANES I) who were alive and interviewed in 1982 and had complete data for the Center for Epidemiologic Studies Depression Scale (CES-D). Four groups were identified based screening status at initial interview: (i) no HTN, no depression (reference group); (ii) HTN, no depression; (iii) no HTN, depression; and (iv) both HTN and depression. Cox proportional hazards regression was used to calculate multivariate-adjusted hazard ratios (HRs) of death for each group.

Results: Over an average of 8 years (83,943 person-years) of follow-up, patients with both self-reported HTN and depressive symptoms had the highest multivariate-adjusted HR for all-cause mortality at 1.39 (95% confidence interval (CI) 1.14, 1.69) as well as for IHD mortality at 1.59 (95% CI 1.08, 2.34). In post hoc analysis, nondepressed hypertensive patients had significantly lower adjusted HR for all-cause mortality compared to depressed hypertensive patients (HR 0.85; 95% CI 0.73-1.00), but the HR for IHD mortality was not significant (HR 0.87, 95% CI 0.63-1.20).

Conclusion: Comorbid depressive symptoms are associated with increased all-cause mortality in patients with self-reported HTN.

The global cost of nonoptimal blood pressure.

J Hypertens. 2009 Jul;27(7):1472-7 Gaziano TA, Bitton A, Anand S, Weinstein MC; International Society of Hypertension. Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.

OBJECTIVE: Suboptimal blood pressure including established nonoptimal blood pressure has been shown to have significant economic consequences in developed countries. However, no exhaustive study has been done to evaluate its potential costs, globally. We, therefore, set out to estimate the global economic cost of nonoptimal blood pressure.

METHODS: Estimates for healthcare costs attributed to suboptimal blood pressure for those over the age of 30 were made for all the World Bank regions. Annual and 10-year estimates using Markov models were made for the cost of treating nonoptimal blood pressure and its main sequelae: stroke and myocardial infarction.

RESULTS: Suboptimal blood pressure cost US$370,000,000,000 globally in 2001. This represents about 10% of the world's overall healthcare expenditures. In the Eastern Europe and Central Asia region, high blood pressure consumed 25% of all health expenditures. Over a 10-year period, elevated blood pressure may cost nearly $1,000,000,000,000 globally in health spending, if current blood pressure levels persist. Indirect costs could be as high as $3,600,000,000,000 annually.

CONCLUSION: Suboptimal blood pressure is responsible for a large and an increasing economic and health burden in developing countries. Although the majority of the current absolute expenditure occurs in the high-income countries, an ever-increasing proportion of the cost is going to be carried by developing countries.

Blood pressure control among persons without and with chronic kidney disease: US trends and risk factors 1999-2006.

Hypertension. 2009 Jul;54(1):47-56. Plantinga LC, Miller ER 3rd, Stevens LA, Saran R, Messer K, Flowers N, Geiss L, Powe NR; Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team. Departments of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Recent guidelines recommending more aggressive blood pressure control in patients with chronic kidney disease have unknown impact. We assessed trends in and predictors of blood pressure control in 8829 adult National Health and Nutrition Examination Survey 1999-2006 participants with hypertension (self-report, measured blood pressure, or use of antihypertensive medications), without (n=7178) and with (n=1651) chronic kidney disease. Uncontrolled blood pressure was defined as follows: general definition, systolic blood pressure > or =140 mm Hg and diastolic blood pressure > or =90 mm Hg, and disease-specific definition, systolic blood pressure > or =130 mm Hg and diastolic blood pressure > or =85 mm Hg (1999-2002) and systolic blood pressure > or =130 mm Hg and diastolic blood pressure > or =80 mm Hg (2003-2006) for those with chronic kidney disease (estimated glomerular filtration rate: <60 mL/min per 1.73 m(2)) or diabetes mellitus (self-report). Proportions with uncontrolled blood pressure in 1999-2006 were greater in those with chronic kidney disease versus those without chronic kidney disease (51.5% versus 48.7% [general definition: P=0.122] and 68.8% versus 51.7% [disease-specific definition: P<0.001]). In those with chronic kidney disease, there were significant decreases in uncontrolled blood pressure over time (55.9% to 47.8% [general definition: P=0.011]). With adjustment for demographic, socioeconomic, and clinical variables, older age (P<0.001) and lack of antihypertensive treatment (P<0.001) were associated with uncontrolled blood pressure, regardless of chronic kidney disease status; nonwhite race (P=0.002) was associated in those without chronic kidney disease, whereas female sex (P=0.030) was associated in those with chronic kidney disease. Multiple medications (P<0.001) and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (P=0.001) were associated with less uncontrolled blood pressure.

Although some improvement has occurred over time, uncontrolled blood pressure remains highly prevalent, especially in subjects with chronic kidney disease and in nonwhites, older persons, and women. Therapy appears suboptimal

Home blood pressure monitoring in clinical practice: a review.

Am J Med. 2009 Sep;122(9):803-10 Mallick S, Kanthety R, Rahman M. Department of Medicine, St. Vincent's Charity Hospital, Cleveland, Ohio, USA.

Home blood pressure monitoring is a convenient and inexpensive technique to monitor blood pressure in hypertensive patients. There are convincing data that home blood pressure monitoring is a good predictor of future cardiovascular risk, perhaps better than office blood pressure.

Home blood pressure measurement can be standardized using validated instruments and systematic protocols; normative criteria have established home blood pressure >135/85 mm Hg as hypertensive. Home blood pressure monitoring has been shown to improve compliance and blood pressure control, and to reduce health care costs. Ongoing studies are evaluating management of hypertension based on home blood pressure readings compared with traditional office-based readings. Home blood pressure monitoring is particularly useful for evaluation of white coat hypertension and masked hypertension.

In this article, we discuss the methodology for measuring blood pressure at home, its comparison to the other measurement techniques, the advantages and disadvantages, cost benefit analyses, and ongoing clinical trials to help define the role of home blood pressure monitoring in the clinical management of hypertension.

Alcohol Consumption, Hypertension, and Total Mortality Among Women

Am J Hypertens. 2009 Sep 3. Freiberg MS, Chang YF, Kraemer KL, Robinson JG, Adams-Campbell LL, Kuller LL. University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Background: Moderate alcohol consumption is associated with a reduced risk of total mortality among Caucasian women. Whether moderate alcohol consumption is associated with a reduced risk of total mortality among African-American or hypertensive women is unclear.

Methods: We conducted a prospective study among 10,576 black and 105,610 white postmenopausal women from the Women's Health Initiative (WHI), without a history of cancer or cardiovascular disease, who completed the baseline examinations in 1994-1998.

Results: During the mean 8 years of follow-up, 5,608 women died. Moderate drinking (1 to <7 drinks/week) was associated with a lower risk of total mortality among Caucasians (hazard ratio (HR) = 0.81, 95% confidence interval (CI) = 0.72-0.91) and hypertensives (HR = 0.76, 95% CI = 0.65-0.87) as compared with lifetime abstention from alcohol. Among African-American moderate drinkers the risk of total mortality was HR = 0.94, 95% CI = 0.67-1.3. Current drinking (<1 drink/month or greater) was associated with a lower risk of mortality among Caucasians, including hypertensives and nonhypertensives, and hypertensive African Americans (HR = 0.74, 95% CI = 0.54-0.99) but not among nonhypertensive African Americans (HR = 1.31, 95% CI = 0.79-2.16). The stratified comparisons among African Americans were affected by the low prevalence of moderate drinking (14.6%) and the low mortality rate (37.5/10,000) among the nonhypertensive lifetime abstainers.

Conclusion: Moderate drinking is associated with a lower risk of total mortality among Caucasian women. Current drinking is associated with a lower risk of total mortality among Caucasians, regardless of hypertensive status, and hypertensive but not nonhypertensive African-American women. The latter observation was affected by the low mortality rate among the African-American nonhypertensive lifetime abstainers.

Association Between Morning Blood Pressure Surge and Cardiovascular Remodeling in Treated Elderly Hypertensive Subjects.

Am J Hypertens. 2009 Sep 3. Yano Y, Hoshide S, Inokuchi T, Kanemaru Y, Shimada K, Kario K. [1] Division of Internal Medicine, Nango National Health Insurance Hospital, Miyazaki, Japan [2] Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan [3] Division of Internal Medicine, Saigo National Health Insurance Hospital, Miyazaki, Japan.

Background: It has remained unclear whether or not morning blood pressure (BP) surge (MS) is associated with cardiovascular remodeling in elderly (>/=60 years) hypertensive patients being treated by antihypertensive medications.

Methods: In this cross-sectional study (n = 197; mean 74.6 years; 37% men), we evaluated the association between MS, defined as the highest quartile of morning BP increase from sleep (>/=48 mm Hg; n = 49), and extent of cardiac hypertrophy and carotid artery intima-media thickness (IMT).

Results: Although there were no differences in 24-h BP levels and the number of prescribed antihypertensive medications between MS and non-MS group, the use of thiazide diuretics was more frequent in MS group than non-MS group (35% vs. 19%; P < 0.05). The MS group had significantly higher levels of left ventricular mass index (LVMI) and internal-carotid artery (ICA)-IMT than the non-MS group (both P < 0.01), independent of 24-h BP levels, daytime BP variability, the degree of nocturnal BP decline, the plasma low-density lipoprotein levels, and the use of diuretics. Even in subjects with a well-controlled 24-h BP level (<130/80 mm Hg; n = 75), these relationships were similar. A multiple logistic regression analysis showed that the presence of MS was an independent determinant of LV hypertrophy (LVH) (>/=125 g/m(2) in men and >/=110 g/m(2) in women) and assignment to the highest quartile of ICA-IMT (both P < 0.05).

Conclusions: The MS in subjects being treated with antihypertensive medications was significantly associated with cardiovascular remodeling, independently of 24-h BP level, daytime BP variability, and nocturnal BP decline

Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea.

Ann Allergy Asthma Immunol. 2009 Jul;103(1):20-5. Kalpaklioğlu AF, Kavut AB, Ekici M. Department of Pulmonary Diseases, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey.

BACKGROUND: Although allergic rhinitis (AR) is accepted as a risk factor for obstructive sleep apnea syndrome (OSAS), the role of nonallergic rhinitis (NAR) is unknown.

OBJECTIVE: To compare OSAS in patients with AR vs NAR.

METHODS: We performed an observational study in 48 adults with AR and NAR that included a review of rhinitis and sleep symptoms, skin prick test results, self-administered questionnaire (Epworth Sleepiness Scale and 36-Item Short Form Health Survey) findings, and all-night polysomnography records.

RESULTS: The most frequent sleep symptom was snoring. Patients with AR had a significantly longer sleep duration and better sleep efficiency than did those with NAR. Both groups had frequent arousals. OSAS was diagnosed in 36% of patients with AR and in 83% of those with NAR (P = .001). Severe OSAS existed only in the NAR group. NAR showed a high correlation with OSAS (odds ratio, 6.4) and with apneas (odds ratio, 0.2). Body mass index, sex, and coexisting asthma did not have any predictable effect on OSAS, but age was correlated with OSAS. The impairment in quality of life was similar in both groups.

CONCLUSIONS: Both AR and NAR are risk factors for a high apnea-hypopnea index, and both can predispose to sleep apnea. However, NAR seems to have a greater risk according to impaired polysomnography results and higher Epworth Sleepiness Scale scores. Therefore, patients with rhinitis should be treated not only for nasal symptoms but also for a better quality of sleep.

Cardiovascular and Metabolic Predictors of Progression of Prehypertension Into Hypertension. The Strong Heart Study.

Hypertension. 2009 Aug 31 De Marco M, de Simone G, Roman MJ, Chinali M, Lee ET, Russell M, Howard BV, Devereux RB. Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Clinical and Experimental Medicine, Federico II University Hospital, Naples, Italy; University of Oklahoma Health Sciences Center, Oklahoma City, Okla; Medstar Research Institute, Washington, DC.

Prehypertension (defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) frequently evolves to hypertension (HTN) and increases cardiovascular risk. It is unclear whether metabolic and/or cardiac characteristics favor development of HTN in prehypertensive subjects. We evaluated baseline anthropometric, laboratory, and echocardiographic characteristics of 625 untreated prehypertensive participants in the Strong Heart Study, without prevalent cardiovascular disease (63% women; 22% with diabetes mellitus; mean age: 59+/-7 years) to identify predictors of the 4-year incidence of HTN. Diabetes mellitus was assessed by American Diabetic Association criteria, and a diabetes-specific definition of HTN was used. Four-year incidence of HTN was 38%. Incident HTN was independently predicted by baseline systolic blood pressure (odds ratio [OR]: 1.60 per 10 mm Hg; 95% CI: 1.30 to 2.00; P<0.0001), waist circumference (OR: 1.10 per 10 cm; 95% CI: 1.01 to 1.30; P=0.04), and diabetes mellitus (OR: 2.73; 95% CI=1.77 to 4.21; P<0.0001), with no significant effect for age, sex, hemoglobin A1c, homeostatic model assessment index, C-reactive protein, fibrinogen, low-density lipoprotein and high-density lipoprotein cholesterol, triglycerides, plasma creatinine, or urine albumin:creatinine ratio. Higher left ventricular mass index (OR: 1.15 per 5 g/m(2.7); 95% CI: 1.01 to 1.25; P=0.03) or stroke volume index (OR: 1.25 per 5 mL/m(2.04); 95% CI: 1.10 to 1.50; P=0.03) was also identified, together with baseline systolic blood pressure and the presence of diabetes mellitus, as an independent predictor of incident HTN, without an additional predictive contribution from other anthropometric, metabolic, or echocardiographic parameters (all P>0.10).

Thus, progression to HTN in 38% of Strong Heart Study prehypertensive participants could be predicted by higher left ventricular mass and stroke volume in addition to baseline systolic blood pressure and prevalent diabetes mellitus.

Self-measurement of blood pressure in arterial hypertension--preliminary results from the AMPA study.

Rev Port Cardiol. 2009 Jan;28(1):7-21. Maldonado J, Pereira T; Estudo AMPA. Collaborators (135) Instituto de Investigação e Formação Cardiovascular Penacova, Portugal.

INTRODUCTION: The clinical usefulness of home blood pressure monitoring (HBPM) is still uncertain, and is currently a major topic of scientific debate. Some studies have stressed its potential role in the clinical decision-making process, but there have been few prospective studies addressing this subject. The AMPA study is intended to contribute to this debate, exploring the potential usefulness of this methodology in the clinical setting of arterial hypertension using a prospective, observational and multicenter design.

METHODS: The study included 685 hypertensive patients (346 female), with a mean age of 54.2 +/- 11.1 years (range: 17-86 years). All patients were being followed in primary care centers by their family doctors, and were being treated for arterial hypertension and other comorbidities. Forty-seven patients were smokers (6%), 90 (13%) had a personal history of cardiovascular disease, 42 (6%) were diabetic, 255 (37%) had dyslipidemia, and 31 (5%) were both diabetic and dyslipidemic. Blood pressure (BP) was measured in the brachial artery with a validated automatic blood pressure measurement device (Colson MAM BP 3AA1-2; Colson, Paris). This device has solid state memory (sufficient for 60 measurements) and an adaptable printer. A cuff appropriate for the arm size of each patient was used. All patients were instructed on how to operate the device correctly and how to perform the measurements in compliance with the study protocol. BP was always measured after a 5-minute resting period in a seated position. The protocol consisted of an HBP program over a period of five working days. Each day the patient performed six BP measurements in two different periods: three in the morning (between 6 and 10 am) and three in the evening (between 6 and 10 pm). Other clinical and anthropometric data were also collected. The HBP reference values adopted were 135 mmHg for systolic and 85 mmHg for diastolic BP.

RESULTS: Analysis of BP behavior over time demonstrated a significant white-coat effect, with regression to the mean of BP levels after the first day of the HBP program. As a consequence, the first day values were excluded in determining mean HBP. This behavior was independent of gender, and was more pronounced in diabetic patients. Analysis of diagnostic concordance between office BP and HBP showed discrepancies in 27.4% of the patients. This prompted a change in diagnosis based on HBP values, with 133 patients (19.4%) presenting uncontrolled office BP levels but normal HBP values, while 55 patients (8%) had elevated HBP in contrast to normal office BP.

CONCLUSIONS: These first results of the AMPA study illustrate the superiority of HBP compared with office BP in the evaluation of hypertensive patients. HBP provides a better characterization of each patient's BP profile, and hence may help improve therapeutic and clinical decisions. Confirmation of the potential of HBP monitoring will be addressed in a prospective analysis (6-year follow-up) of the AMPA study in the near future.

A home blood pressure monitor equipped with a graphic function facilitates faster blood pressure control than the conventional home blood pressure monitor.

J Clin Hypertens (Greenwich). 2009 Aug;11(8):422-5. Kabutoya T, Ishikawa J, Hoshide S, Eguchi K, Shimada K, Kario K. From the Department of Medicine, Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.

In this study, we evaluated whether antihypertensive therapy using a home blood pressure monitor (HBPM) equipped with a graphic display of weekly and monthly averaged blood pressure (BP) can obtain better BP control than the conventional HBPM. Sixty-five hypertensive outpatients who had HBP >135/85 mm Hg were enrolled by 8 doctors in 2 different hospitals. The patients were randomly assigned either a graph-equipped HBPM (graph-equipped HBPM group; n=33) or an HBPM without the graph function (conventional HBPM group; n=32). The patients were treated with antihypertensive medications targeting HBP <135/85 mm Hg. After 2 months, the home systolic BP level was lower in the graph-equipped HBPM group than in the conventional HBPM group (141.3+/-15.4 vs 147.7+/-10.8 mm Hg; P<.05); its reduction was significantly larger in the former group (11.9 vs 5.6 mm Hg; P<.05).

Using an HBP device with a graphic display could accelerate the achievement of BP control.

DASH-style diet associates with reduced risk for kidney stones

J Am Soc Nephrol. 2009 Oct;20(10):2253-9 Taylor EN, Fung TT, Curhan GC. Renal Division and Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.

The impact of the Dietary Approaches to Stop Hypertension (DASH) diet on kidney stone formation is unknown. We prospectively examined the relation between a DASH-style diet and incident kidney stones in the Health Professionals Follow-up Study (n = 45,821 men; 18 yr of follow-up), Nurses' Health Study I (n = 94,108 older women; 18 yr of follow-up), and Nurses' Health Study II (n = 101,837 younger women; 14 yr of follow-up). We constructed a DASH score based on eight components: high intake of fruits, vegetables, nuts and legumes, low-fat dairy products, and whole grains and low intake of sodium, sweetened beverages, and red and processed meats. We used Cox hazards regression to adjust for factors that included age, BMI, and fluid intake. Over a combined 50 yr of follow-up, we documented 5645 incident kidney stones. Participants with higher DASH scores had higher intakes of calcium, potassium, magnesium, oxalate, and vitamin C and had lower intakes of sodium. For participants in the highest compared with the lowest quintile of DASH score, the multivariate relative risks for kidney stones were 0.55 (95% CI, 0.46 to 0.65) for men, 0.58 (95% CI, 0.49 to 0.68) for older women, and 0.60 (95% CI, 0.52 to 0.70) for younger women. Higher DASH scores were associated with reduced risk even in participants with lower calcium intake. Exclusion of participants with hypertension did not change the results.

In conclusion, consumption of a DASH-style diet is associated with a marked decrease in kidney stone risk.

Atherosclerotic renovascular disease among hypertensive adults.

J Vasc Surg. 2009 Sep;50(3):564-570, 571.e1-3; Davis RP, Pearce JD, Craven TE, Moore PS, Edwards MS, Godshall CJ, Hansen KJ. Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1095, USA.

PURPOSE: This report describes the change in atherosclerotic renovascular disease (AS-RVD) among hypertensive adults referred for renal duplex sonography (RDS) scan.

METHODS: >From Oct 1993 through July 2008, 20,994 patients had RDS at our center. A total of 434 hypertensive patients with two or more RDS exams without intervention comprised the study cohort. Patient demographics (blood pressures, medications, serum creatinine levels, and data from RDS) were collected. Analyses of longitudinal changes in Doppler scan parameters, blood pressures, and renal function were performed by fitting linear growth-curve models. After confirming the linearity of change in Doppler scan parameters among patients with variable number of studies, estimates of mean slopes were calculated using maximum likelihood techniques. For changes in renal function, quadratic growth curves were required to describe longitudinal change.

RESULTS: A total of 434 subjects (212 men [49%] and 222 women [51%]; mean age, 64.6 +/- 12.2 years) provided 1351 studies (mean, 3.2 +/- 2.4; range, 2 to 18) for 863 kidneys over a mean follow-up of 34.4 +/- 25.1 months. At baseline, 20.6% of kidneys demonstrated hemodynamically significant stenosis. On follow-up, 72 kidneys (9.1%) demonstrated anatomic progression of disease. A total of 54 kidneys (6.9%) progressed to significant stenosis and 18 (2.3%) progressed to occlusion. Controlling for progression of disease, baseline renal artery status demonstrated a strong association with baseline kidney length (P = .0006). Significant annualized change in renal length was observed (cm change/year +/- standard error of the mean [SEM]: 0.042 +/- 0.011; P = .0002) among both kidneys with and without critical disease at baseline, however, decline in length was significantly greater among kidneys exhibiting progression of renovascular disease (-0.152 +/- 0.028 cm/year; comparison of slopes between groups P = .0005). In the absence of progression, the presence or absence of critical renal artery stenosis at baseline did not affect the rate of decline in renal length. Fitted models for the natural log transform of serum creatinine demonstrated a significant increase during follow-up (P < .0001). No association was observed between change in serum creatinine and baseline renovascular disease status, or its progression.

CONCLUSION: A total of 32% of hypertensive adults referred for RDS demonstrated hemodynamically significant renal artery stenosis. Regardless of the presence or absence of baseline disease, a small percentage of patients demonstrated anatomic progression of AS-RVD. A total of 9.1% demonstrated anatomic progression and 2.3% progressed to occlusion. Although anatomic progression of AS-RVD was associated with an increased rate of decline in renal length, progression did not predict a decline in excretory renal function. Intervention for AS-RVD should be selective and reserved for strict indications

What is the optimal interval between successive home blood pressure readings using an automated oscillometric device?

J Hypertens. 2009 Jun;27(6):1172-7. Eguchi K, Kuruvilla S, Ogedegbe G, Gerin W, Schwartz JE, Pickering TG. Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University, Tochigi, Japan.

OBJECTIVES: To clarify whether a shorter interval between three successive home blood pressure (HBP) readings (10 s vs. 1 min) taken twice a day gives a better prediction of the average 24-h BP and better patient compliance.

DESIGN: We enrolled 56 patients from a hypertension clinic (mean age: 60 +/- 14 years; 54% female patients). The study consisted of three clinic visits, with two 4-week periods of self-monitoring of HBP between them, and a 24-h ambulatory BP monitoring at the second visit. Using a crossover design, with order randomized, the oscillometric HBP device (HEM-5001) could be programmed to take three consecutive readings at either 10-s or 1-min intervals, each of which was done for 4 weeks. Patients were asked to measure three HBP readings in the morning and evening. All the readings were stored in the memory of the monitors.

RESULTS: The analyses were performed using the second-third HBP readings. The average systolic BP/diastolic BP for the 10-s and 1-min intervals at home were 136.1 +/- 15.8/77.5 +/- 9.5 and 133.2 +/- 15.5/76.9 +/- 9.3 mmHg (P = 0.001/0.19 for the differences in systolic BP and diastolic BP), respectively. The 1-min BP readings were significantly closer to the average of awake ambulatory BP (131 +/- 14/79 +/- 10 mmHg) than the 10-s interval readings. There was no significant difference in patients' compliance in taking adequate numbers of readings at the different time intervals.

CONCLUSION: The 1-min interval between HBP readings gave a closer agreement with the daytime average BP than the 10-s interval.

Exercise capacity and all-cause mortality in prehypertensive men.

Am J Hypertens. 2009 Jul;22(7):735-41. Kokkinos P, Myers J, Doumas M, Faselis C, Manolis A, Pittaras A, Kokkinos JP, Singh S, Fletcher RD. Department of Cardiology, Veterans Affairs Medical Center, Washington, DC, USA.

BACKGROUND: Prehypertension is associated with increased risk for mortality, a fact that generated a debate regarding the use of antihypertensive therapy in prehypertensives. Increased exercise capacity is associated with lower mortality risk, but little is known about its effects in prehypertensives. Thus, we evaluated the association between exercise capacity and all-cause mortality in prehypertensives.

METHODS: A graded exercise test was performed in 4,478 prehypertensive men at the Veterans Affairs Medical Centers in Washington, DC and Palo Alto, CA. Four fitness categories (quartiles) were defined based on peak metabolic equivalents (METs) achieved. All-cause mortality was assessed for both younger (<or=60 years) and older individuals. The mean follow-up period was 9.0 +/- 6.0 years.

RESULTS: Exercise capacity was a strong predictor of all-cause mortality, independent of traditional risk factors. The adjusted risk for all-cause mortality was reduced by 15% for every 1-MET increase in exercise capacity in the entire cohort, 18% for younger and 12% for older individuals. Compared to the Very-Low-Fit individuals (<or=6 METs) the adjusted mortality risk was 40% lower in Low-Fit (6.1-8.0 METs); 58% lower in Moderate-Fit (8.1-10 METs), and 73% lower in High-Fit individuals (>10 METs). The trends were similar but more pronounced among younger than older individuals.

CONCLUSIONS: A strong, inverse and graded association between exercise capacity and all-cause mortality was observed in prehypertensive individuals. The protective effects of increased fitness were more pronounced in younger than older individuals, suggesting that age should be more closely considered when assessing fitness and mortality relationships.

The Cholesterol, Hypertension, and Glucose Education (CHANGE) study for African Americans with diabetes: study design and methodology.

Am Heart J. 2009 Sep;158(3):342-8. Powers BJ, King JL, Ali R, Alkon A, Bowlby L, Edelman D, Gentry P, Grubber JM, Koropchak C, Maciejewski ML, McCant F, McKoy G, Newell M, Oddone EZ, Olsen MK, Rose CM, Trujillo G, Bosworth HB. Center for Health Services Research in Primary Care, Durham VAMC, Durham, NC 27705, USA.

BACKGROUND: Cardiovascular disease (CVD) and diabetes account for over one third of the mortality difference between African Americans and white patients. The increased CVD risk in African Americans is due in large part to the clustering of multiple CVD risk factors.

OBJECTIVES: The current study is aimed at improving CVD outcomes in African-American adults with diabetes by addressing the modifiable risk factors of systolic blood pressure , glycosylated hemoglobin, and low-density lipoprotein cholesterol.

METHODS: A sample of African American patients with diabetes (N = 400) will receive written education material at baseline and be randomized to one of 2 arms: (1) usual primary care or (2) nurse-administered disease-management intervention combining patient self-management support and provider medication management. The nurse administered intervention is delivered monthly over the telephone. The nurses also interacts with the primary care providers at 3, 6, and 9 months to provide concise patient updates and facilitate changes in medical management. All patients are followed for 12 months after enrollment. The primary outcomes are change in glycosylated hemoglobin, systolic blood pressure, and low-density lipoprotein cholesterol over 12-months. Secondary outcomes include change in overall cardiovascular risk, aspirin use, and health behaviors.

CONCLUSION: Given the continued racial disparities in CVD, the proposed study could result in significant contributions to cardiovascular risk reduction in African-American patients.

Superior consistency of ambulatory blood pressure monitoring in children: implications for clinical trials

J Hypertens. 2009 Aug;27(8):1568-74 Gimpel C, Wühl E, Arbeiter K, Drozdz D, Trivelli A, Charbit M, Gellermann J, Dusek J, Jankauskiene A, Emre S, Schaefer F; ESCAPE Trial Group. Collaborators (53) Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg 69120, Germany.

BACKGROUND: Casual office blood pressure (CBP) measurements are still standard in antihypertensive drug trials. In pediatric hypertensive trials, ethical considerations, very low disease prevalence and the marked impact of white-coat hypertension create the need for very sensitive and reproducible techniques of BP assessment. We hypothesized that ambulatory BP monitoring (ABPM) may identify treatment effects more sensitively than CBP and thereby reduce sample sizes required in pediatric antihypertensive trials.

METHODS: Standard deviations (SDs) were used to assess population variability of CBP and ABPM at baseline and after 6 months standardized antihypertensive treatment from a trial investigating the BP-lowering effect of ramipril in children with chronic kidney disease.

RESULTS: In 157 hypertensive children, ramipril had a similar mean BP-lowering effect on clinic and ambulatory 24-h BP for systolic (-10 vs. -11 mmHg, P = NS) and diastolic values (-9 vs. -11 mmHg, P = NS). However, the SDs of the CBP responses were up to 39% larger than those of ABPM (SBP 15.5 vs. 9.4; DBP 13.8 vs. 8.8; both P < 0.0001). Using power analysis, we demonstrate that, depending on the magnitude of the expected antihypertensive effect and trial design, the utilization of ABPM in antihypertensive drug efficacy studies allows reduction of sample sizes by 57-75%. This reduction of cohort size with ABPM is substantially greater than previously observed for adults.

CONCLUSION: The primary use of ABPM can substantially reduce the number of children put at potential risk in blinded antihypertensive drug trials by up to three quarters.

Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe hypertension: the Studying the Treatment of Acute hyperTension (STAT) registry

Am Heart J. 2009 Oct;158(4):599-606.e1 Katz JN, Gore JM, Amin A, Anderson FA, Dasta JF, Ferguson JJ, Kleinschmidt K, Mayer SA, Multz AS, Peacock WF, Peterson E, Pollack C, Sung GY, Shorr A, Varon J, Wyman A, Emery LA, Granger CB; STAT Investigators. Collaborators (40) Duke Clinical Research Institute, Durham, NC 27705, USA.

BACKGROUND: Limited data are available on the care of patients with acute severe hypertension requiring hospitalization. We characterized contemporary practice patterns and outcomes for this population.

METHODS: STAT is a 25-institution, US registry of consecutive patients with acute severe hypertension (>180 mm Hg systolic and/or >110 mm Hg diastolic; >140 and/or >90 for subarachnoid hemorrhage) treated with intravenous therapy in a critical care setting.

RESULTS: One thousand five hundred eighty-eight patients were enrolled (January 2007 to April 2008). Median age was 58 years (interquartile range 49-70 years), 779 (49%) were women, and 892 (56%) were African American; 27% (n = 425) had a prior admission for acute hypertension and 486 (31%) had chronic kidney disease. Median qualifying blood pressure (BP) was 200 (186, 220) systolic and 110 (93, 123) mm Hg diastolic. Initial intravenous antihypertensive therapies used to control BP varied, with 1,009 (64%) patients requiring multiple drugs. Median time to achieve a systolic BP <160 mm Hg (<140 mm Hg for subarachnoid hemorrhage) was 4.0 (0.8, 12) hours; 893 (60%) had reelevation to >180 (>140 for subarachnoid hemorrhage) after initial control; and 63 (4.0%) developed iatrogenic hypotension. Hospital mortality was 6.9% (n = 109) with an aggregate 90-day mortality rate of 11% (174/1,588); 59% (n = 943) had acute/worsening end-organ dysfunction during hospitalization. The 90-day readmission rate was 37% (523/1,415), of which one quarter (132/523) was due to recurrent acute severe hypertension.

CONCLUSION: This study highlights heterogeneity in care, BP control, and outcomes of patients hospitalized with acute severe hypertension.

Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial.

Lancet. 2009 Aug 15;374(9689):525-33. Verdecchia P, Staessen JA, Angeli F, de Simone G, Achilli A, Ganau A, Mureddu G, Pede S, Maggioni AP, Lucci D, Reboldi G; Cardio-Sis investigators. Collaborators (102) Division of Cardiology, Hospital S Maria della Misericordia, Perugia, Italy.

BACKGROUND: The level to which systolic blood pressure should be controlled in hypertensive patients without diabetes remains unknown. We tested the hypothesis that tight control compared with usual control of systolic blood pressure would be beneficial in such patients.

METHODS: In this randomised open-label trial undertaken in 44 centres in Italy, 1111 non-diabetic patients with systolic blood pressure 150 mm Hg or greater were randomly assigned to a target systolic blood pressure of less than 140 mm Hg (usual control; n=553) or less than 130 mm Hg (tight control; n=558). After stratification by centre, we used a computerised random function to allocate patients to either group. Observers who were unaware of randomisation read electrocardiograms and adjudicated events. Open-label agents were used to reach the randomised targets. The primary endpoint was the rate of electrocardiographic left ventricular hypertrophy 2 years after randomisation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00421863.

RESULTS: Over a median follow-up of 2.0 years (IQR 1.93-2.03), systolic and diastolic blood pressure were reduced by a mean of 23.5/8.9 mm Hg (SD 10.6/7.0) in the usual-control group and by 27.3/10.4 mm Hg (11.0/7.5) in the tight-control group (between-group difference 3.8 mm Hg systolic [95% CI 2.4-5.2], p<0.0001; and 1.5 mm Hg diastolic [0.6-2.4]; p=0.041). The primary endpoint occurred in 82 of 483 patients (17.0%) in the usual-control group and in 55 of 484 patients (11.4%) of the tight-control group (odds ratio 0.63; 95% CI 0.43-0.91; p=0.013). A composite cardiovascular endpoint occurred in 52 (9.4%) patients in the usual-control group and in 27 (4.8%) in the tight-control group (hazard ratio 0.50, 95% CI 0.31-0.79; p=0.003). Side-effects were rare and did not differ significantly between the two groups.

INTERPRETATION: Our findings lend support to a lower blood pressure goal than is recommended at present in non-diabetic patients with hypertension.

Retinal vessel diameters and risk of hypertension: the Multiethnic Study of Atherosclerosis.

J Hypertens. 2009 Aug 12. Kawasaki R, Cheung N, Wang JJ, Klein R, Klein BE, Cotch MF, Sharrett AR, Shea S, Islam FA, Wong TY.

OBJECTIVE: To describe the prospective relationship of retinal vessel diameters with risk of hypertension in a multiethnic population-based cohort.

METHODS: The Multi-Ethnic Study of Atherosclerosis is a population-based study of subclinical cardiovascular disease among white, African-American, Hispanic, and Chinese American adults aged 45-84 years. Retinal vessel diameters were measured using a standardized imaging software at the second examination (considered baseline in this analysis) and summarized as the central retinal artery/vein equivalent. Presence of retinopathy and retinal focal arteriolar narrowing and arteriovenous nicking was assessed by trained graders. Incidence of hypertension was defined among participants at risk as systolic blood pressure at least 140 mmHg, diastolic blood pressure at least 90 mmHg, or use of an antihypertensive medication.

RESULTS: Of the initial 6237 participants at baseline, 2583 were at risk of hypertension. After 3.2 +/- 0.5 years of follow-up, 448 (17.3%) participants developed hypertension. After adjusting for age, sex, race/ethnicity, the average of mean arterial blood pressure in the first and second examination, and other vascular risk factors, persons with narrower retinal arteriolar diameter and wider venular diameter at baseline were more likely to develop hypertension [odds ratio per SD decrease in central retinal artery equivalent 1.20, 95% confidence intervals 1.02, 1.42; and odds ratio per SD increase in central retinal vein equivalent 1.18, 95% confidence interval 1.02, 1.37]. Persons with focal arteriolar narrowing were also more likely to develop hypertension (odds ratio 1.80, 95% confidence interval 1.09, 2.97).

CONCLUSION: Findings from this multiethnic population confirm that narrower retinal arteriolar diameter and wider venular diameter are associated with the development of hypertension independent of traditional risk factors.

QRS duration predicts sudden cardiac death in hypertensive patients undergoing intensive medical therapy: the LIFE study.

Eur Heart J. 2009 Aug 17. Morin DP, Oikarinen L, Viitasalo M, Toivonen L, Nieminen MS, Kjeldsen SE, Dahlöf B, John M, Devereux RB, Okin PM. Division of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA.

Aims: To determine whether QRS duration predicts sudden cardiac death (SCD) in patients with left ventricular hypertrophy and treated hypertension.

Methods and results: Over 4.8 +/- 0.9 years follow-up of 9193 hypertensive patients with electrocardiographic evidence of LVH who were treated with atenolol- or losartan-based regimens, 178 patients (1.9%) suffered SCD. In multivariable analysis including randomized treatment, changing blood pressure over time, and baseline differences between patients with and without SCD, QRS duration was independently predictive of SCD (HR per 10 ms increase = 1.22, P < 0.001). Baseline QRS duration remained a significant predictor of SCD even after controlling for the presence or absence of left bundle branch block (HR = 1.17, P = 0.001) and for changes in ECG LVH severity over the course of the study (HR = 1.16, P = 0.017).

Conclusion: In the setting of aggressive antihypertensive therapy, prolonged QRS duration identifies hypertensive patients at higher risk for SCD, even after controlling for left bundle branch block, other known risk factors for SCD, and changes in blood pressure and severity of left ventricular hypertrophy.

Relative risks for stroke by age, sex, and population based on follow-up of 18 European populations in the MORGAM Project.

Stroke. 2009 Jul;40(7):2319-26. Asplund K, Karvanen J, Giampaoli S, Jousilahti P, Niemelä M, Broda G, Cesana G, Dallongeville J, Ducimetriere P, Evans A, Ferrières J, Haas B, Jorgensen T, Tamosiunas A, Vanuzzo D, Wiklund PG, Yarnell J, Kuulasmaa K, Kulathinal S; MORGAM Project. Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden

BACKGROUND AND PURPOSE: Within the framework of the MOnica Risk, Genetics, Archiving and Monograph (MORGAM) Project, the variations in impact of classical risk factors of stroke by population, sex, and age were analyzed.

METHODS: Follow-up data were collected in 43 cohorts in 18 populations in 8 European countries surveyed for cardiovascular risk factors. In 93 695 persons aged 19 to 77 years and free of major cardiovascular disease at baseline, total observation years were 1 234 252 and the number of stroke events analyzed was 3142. Hazard ratios were calculated by Cox regression analyses.

RESULTS: Each year of age increased the risk of stroke (fatal and nonfatal together) by 9% (95% CI, 9% to 10%) in men and by 10% (9% to 10%) in women. A 10-mm Hg increase in systolic blood pressure involved a similar increase in risk in men (28%; 24% to 32%) and women (25%; 20% to 29%). Smoking conferred a similar excess risk in women (104%; 78% to 133%) and in men (82%; 66% to 100%). The effect of increasing body mass index was very modest. Higher high-density lipoprotein cholesterol levels decreased the risk of stroke more in women (hazard ratio per mmol/L 0.58; 0.49 to 0.68) than in men (0.80; 0.69 to 0.92). The impact of the individual risk factors differed somewhat between countries/regions with high blood pressure being particularly important in central Europe (Poland and Lithuania).

CONCLUSIONS: Age, sex, and region-specific estimates of relative risks for stroke conferred by classical risk factors in various regions of Europe are provided. From a public health perspective, an important lesson is that smoking confers a high risk for stroke across Europe.

Insufficient control of blood pressure and incident diabetes.

Diabetes Care. 2009 May;32(5):845-50. Izzo R, de Simone G, Chinali M, Iaccarino G, Trimarco V, Rozza F, Giudice R, Trimarco B, De Luca N. Department of Clinical Medicine, Cardiovascular, and Immunological Sciences, Federico II University-Naples, Naples, Italy.

OBJECTIVE: Incidence of type 2 diabetes might be associated with preexisting hypertension. There is no information on whether incident diabetes is predicted by blood pressure control. We evaluated the hazard of diabetes in relation to blood pressure control in treated hypertensive patients.

RESEARCH DESIGN AND METHODS: Nondiabetic, otherwise healthy, hypertensive patients (N = 1,754, mean +/- SD age 52 +/- 11 years, 43% women) participated in a network over 3.4 +/- 1 years of follow-up. Blood pressure was considered uncontrolled if systolic was >or=140 mmHg and/or diastolic was >or=90 mmHg at the last outpatient visit. Diabetes was defined according to American Diabetes Association guidelines.

RESULTS: Uncontrolled blood pressure despite antihypertensive treatment was found in 712 patients (41%). At baseline, patients with uncontrolled blood pressure were slightly younger than patients with controlled blood pressure (51 +/- 11 vs. 53 +/- 12 years, P < 0.001), with no differences in sex distribution, BMI, duration of hypertension, baseline blood pressure, fasting glucose, serum creatinine and potassium, lipid profile, or prevalence of metabolic syndrome. During follow-up, 109 subjects developed diabetes. Incidence of diabetes was significantly higher in patients with uncontrolled (8%) than in those with controlled blood pressure (4%, odds ratio 2.08, P < 0.0001). In Cox regression analysis controlling for baseline systolic blood pressure and BMI, family history of diabetes, and physical activity, uncontrolled blood pressure doubled the risk of incident diabetes (hazard ratio [HR] 2.10, P < 0.001), independently of significant effects of age (HR 1.02 per year, P = 0.03) and baseline fasting glucose (HR 1.10 per mg/dl, P < 0.001).

CONCLUSIONS: In a large sample of treated nondiabetic hypertensive subjects, uncontrolled blood pressure is associated with twofold increased risk of incident diabetes independently of age, BMI, baseline blood pressure, or fasting glucose.

A comprehensive review on salt and health and current experience of worldwide salt reduction programmes.

J Hum Hypertens. 2009 Jun;23(6):363-84. He FJ, MacGregor GA. Blood Pressure Unit, Cardiac and Vascular Sciences, St George's, University of London, London, UK.

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Raised blood pressure (BP), cholesterol and smoking, are the major risk factors. Among these, raised BP is the most important cause, accounting for 62% of strokes and 49% of coronary heart disease. Importantly, the risk is throughout the range of BP, starting at systolic 115 mm Hg. There is strong evidence that our current consumption of salt is the major factor increasing BP and thereby CVD. Furthermore, a high salt diet may have direct harmful effects independent of its effect on BP, for example, increasing the risk of stroke, left ventricular hypertrophy and renal disease. Increasing evidence also suggests that salt intake is related to obesity through soft drink consumption, associated with renal stones and osteoporosis and is probably a major cause of stomach cancer. In most developed countries, a reduction in salt intake can be achieved by a gradual and sustained reduction in the amount of salt added to food by the food industry. In other countries where most of the salt consumed comes from salt added during cooking or from sauces, a public health campaign is needed to encourage consumers to use less salt. Several countries have already reduced salt intake, for example, Japan (1960-1970), Finland (1975 onwards) and now the United Kingdom. The challenge is to spread this out to all other countries.

A modest reduction in population salt intake worldwide will result in a major improvement in public health.

Effects of Dietary Sodium Reduction on Blood Pressure in Subjects With Resistant Hypertension. Results From a Randomized Trial.

Hypertension. 2009 Jul 20. Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell'italia LJ, Calhoun DA. Endocrine Hypertension Research Centre and Clinical Centre of Research Excellence in Cardiovascular Disease and Metabolic Disorders, University of Queensland School of Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia; and the Vascular Biology and Hypertension Program, University of Alabama at Birmingham.

Observational studies indicate a significant relation between dietary sodium and level of blood pressure. However, the role of salt sensitivity in the development of resistant hypertension is unknown. The present study examined the effects of dietary salt restriction on office and 24-hour ambulatory blood pressure in subjects with resistant hypertension. Twelve subjects with resistant hypertension entered into a randomized crossover evaluation of low (50 mmol/24 hoursx7 days) and high sodium diets (250 mmol/24 hoursx7 days) separated by a 2-week washout period. Brain natriuretic peptide; plasma renin activity; 24-hour urinary aldosterone, sodium, and potassium; 24-hour ambulatory blood pressure monitoring; aortic pulse wave velocity; and augmentation index were compared between dietary treatment periods. At baseline, subjects were on an average of 3.4+/-0.5 antihypertensive medications with a mean office BP of 145.8+/-10.8/83.9+/-11.2 mm Hg. Mean urinary sodium excretion was 46.1+/-26.8 versus 252.2+/-64.6 mmol/24 hours during low- versus high-salt intake. Low- compared to high-salt diet decreased office systolic and diastolic blood pressure by 22.7 and 9.1 mm Hg, respectively. Plasma renin activity increased whereas brain natriuretic peptide and creatinine clearance decreased during low-salt intake, indicative of intravascular volume reduction.

These results indicate that excessive dietary sodium ingestion contributes importantly to resistance to antihypertensive treatment. Strategies to substantially reduce dietary salt intake should be part of the overall treatment of resistant hypertension.

Oral Magnesium Supplementation Reduces Ambulatory Blood Pressure in Patients With Mild Hypertension.

Am J Hypertens. 2009 Jul 16. Hatzistavri LS, Sarafidis PA, Georgianos PI, Tziolas IM, Aroditis CP, Zebekakis PE, Pikilidou MI, Lasaridis AN. Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University, Thessaloniki, Greece.

Background: Accumulating evidence implicates a role of Mg(2+) in the pathophysiology of essential hypertension. Previous studies evaluating the antihypertensive efficacy of Mg(2+) supplementation gave contradictory results. This study aimed to investigate the effect of oral Mg(2+) supplementation on 24-h blood pressure (BP) and intracellular ion status in patients with mild hypertension

Methods: A total of 48 patients with mild uncomplicated hypertension participated in the study. Among them, 24 subjects were assigned to 600 mg of pidolate Mg(2+) daily in addition to lifestyle recommendations for a 12-week period and another 24 age- and sex-matched controls were only given lifestyle recommendations. At baseline and study-end (12 weeks) ambulatory BP monitoring, determination of serum and intracellular ion levels, and 24-h urinary collections for determination of urinary Mg(2+) were performed in all study subjects

Results: In the Mg(2+) supplementation group, small but significant reductions in mean 24-h systolic and diastolic BP levels were observed, in contrast to control group (-5.6 +/- 2.7 vs. -1.3 +/- 2.4 mm Hg, P < 0.001 and -2.8 +/- 1.8 vs. -1 +/- 1.2 mm Hg, P = 0.002, respectively). These effects of Mg(2+) supplementation were consistent in both daytime and night-time periods. Serum Mg(2+) levels and urinary Mg(2+) excretion were significantly increased in the intervention group. Intracellular Mg(2+) and K(+) levels were also increased, while intracellular Ca(2+) and Na(+) levels were decreased in the intervention group. None of the intracellular ions were significantly changed in the control group

Conclusion: This study suggests that oral Mg(2+) supplementation is associated with small but consistent ambulatory BP reduction in patients with mild hypertension.

Home blood pressure monitoring in blood pressure control among haemodialysis patients: an open randomized clinical trial.

Nephrol Dial Transplant. 2009 Jul 8 da Silva GV, de Barros S, Abensur H, Ortega KC, Mion D Jr; Cochrane Renal Group Prospective Trial Register: CRG060800146. 1Nephrology Division, Hypertension Unit, University of São Paulo School of Medicine.

Long-Term Risk of Sustained Hypertension in White-Coat or Masked Hypertension.

Hypertension. 2009 Jun 29. Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Friz HP, Grassi G, Sega R. Clinica Medica, Dipartimento di Medicina Clinica, Prevenzione e Biotecnologie Sanitarie, Università Milano-Bicocca, Ospedale San Gerardo; and Istituto Scientifico Multimedica, Istituto Di Ricovero e Cura a Carattere Scientifico, Sesto San Giovanni, Milan, Italy.

It is debated whether white-coat (WCHT) and masked hypertension (MHT) are at greater risk of developing a sustained hypertensive state (SHT). In 1412 subjects of the Pressioni Arteriose Monitorate e Loro Associazioni Study, we measured office blood pressure (BP), 24-hour ambulatory BP, and home BP. The condition of WCHT was identified as office BP >140/90 mm Hg and 24-hour BP mean <125/79 mm Hg or home BP <132/82 mm Hg. Corresponding values for MHT diagnosis were office BP <140/90 mm Hg, 24-hour BP >/=125/79 mm Hg, and home BP >/=132/82 mm Hg. SHT was identified when both office and 24-hour BP means or home BP were over threshold values and normotension was under the threshold value. Subjects were reassessed 10 years later to evaluate the BP status of the various conditions defined previously. At the first examination, 758 (54.1%), 225 (16.1%), 124 (8.9%), and 293 (20.9%) subjects were normotensive, WCHT, MHT, and SHT subjects, respectively. At the second examination, 136 normotensives (18.2%), 95 WCHT (42.6%), and 56 MHT (47.1%) subjects became SHT. As compared with normotensives, adjusting for age and sex, the risk of becoming SHT was significantly higher for WCHT and MHT subjects (odds ratio: 2.51 and 1.78, respectively; P<0.0001). Similar results were obtained when the definition of the various conditions was based on home BP. Independent contributors of worsening of hypertension status were not only baseline BP, but also, although to a lesser extent, metabolic variables and age. Subjects with WCHT and MHT are at increased risk of developing SHT. This may contribute to their prognosis that appears to be worse as compared with that of normotensive subjects.

Masked, white coat and sustained hypertension: comparison of target organ damage and psychometric parameters.

J Hum Hypertens. 2009 Jul 2 Konstantopoulou AS, Konstantopoulou PS, Papargyriou IK, Liatis ST, Stergiou GS, Papadogiannis DE. st Department of Propaedeutic Medicine, Athens University Medical School, Laiko General Hospital, Athens, Greece

Masked hypertension is defined as low clinic and elevated out-of-clinic pressure (blood pressure, BP) assessed either by patients at home or by ambulatory monitoring. This study compared the cardiovascular status and psychometric characteristics of masked, white coat and sustained hypertensives. Three groups of consecutive subjects with masked (n=100, age 59+/-11 years), white coat (n=100, 60+/-10 years) and sustained hypertension (n=100, 60+/-11 years) diagnosed by ambulatory BP monitoring were compared. Masked hypertensives had higher educational level, exercised more frequently, received fewer drugs and sensed more responsibilities at work than at home. Their left ventricular hypertrophy indexes fall in-between those with white coat and sustained, the latter having the highest values. The estimated total cardiovascular risk was intermediate between white coat and sustained, whereas their cardiovascular morbidity and renal disease was higher than that of white coat and similar to sustained. Psychological profile analysis showed lower score for type-A personality and their mood behaviour in the hypomania-euthymia range compared with white coat and sustained hypertensives. The cardiovascular risk of masked hypertensives is higher than that of white coat and similar to sustained. Masked hypertensives have higher educational level, better physical training and different personality/mood pattern than white coat and sustained.

Relationship between hyperacute blood pressure and outcome after ischemic stroke: data from the VISTA collaboration.

Stroke. 2009 Jun;40(6):2098-103. Sare GM, Ali M, Shuaib A, Bath PM; VISTA Collaboration. Stroke Trials Unit, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Nottingham NG5 1PB UK.

BACKGROUND AND PURPOSE: High blood pressure (BP) is associated independently with poor outcome after acute ischemic stroke, although in most analyses "baseline" BP was measured 24 hours or more postictus, and not during the hyperacute period.

METHODS: Analyses included 1722 patients in hyperacute trials (recruitment <8 hours) from the Virtual Stroke International Stroke Trial Archive (VISTA) Collaboration. Data on BP at enrollment and after 1, 2, 16, 24, 48, and 72 hours, neurological impairment at 7 days (NIHSS), and functional outcome at 90 days (modified Rankin scale) were assessed using logistic regression models, adjusted for confounding variables; results are for 10-mm Hg change in BP.

RESULTS: Mean time to enrollment was 3.7 hours (range 1.0 to 7.9). High systolic BP (SBP) was significantly associated with increased neurological impairment (odds ratio, OR 1.06, 95% confidence interval, 95% CI 1.01 to 1.12), and poor functional outcome; odds ratios for both increased with later BP measurements made at up to 24 hours poststroke. Smaller (versus larger) declines in SBP over the first 24 hours were significantly associated with poor NIHSS scores (OR 1.16, 95% CI 1.05 to 1.27) and functional outcome (OR 1.23, 95% CI 1.13 to 1.34). A large variability in SBP was also associated with poor functional outcome.

CONCLUSIONS: High SBP and large variability in SBP in the hyperacute stages of ischemic stroke are associated with increased neurological impairment and poor functional outcome, as are small falls in SBP over the first 24 hours.

The changing face of hypertension treatment: treatment strategies from the 2007 ESH/ESC hypertension Guidelines

J Hypertens. 2009 Jun;27 Suppl 3:S19-26. Williams B. Department of Cardiovascular Sciences, University of Leicester School of Medicine, Leicester, UK.

Hypertension is one of the most important causes of cardiovascular morbidity and mortality and its treatment is a major focus of primary and secondary disease prevention strategies. The treatment of hypertension continues to evolve and the need for guidance on the use of newer screening tools, techniques for blood pressure measurement and different classes of drug therapies led to the first European guidelines for the management of arterial hypertension being issued in 2003 by the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC). The first update of these guidelines in 2007 crystallized much of the modern thinking about the evaluation and treatment of patients with hypertension with a sharp focus on detailed assessment of subclinical organ damage and cardiovascular disease risk, as well as differential blood pressure treatment targets and thresholds for those at different levels of risk. This review focuses on the 2007 ESH/ESC Guidelines, highlighting the evolution of treatment strategies in order to meet the challenge of improving blood pressure control in Europe. In particular, development of patient-centred treatment strategies, the benefits of blood pressure lowering, drug-specific influences over clinical outcomes, recommendations for the pharmacological treatment of hypertension and the role of combination therapies are discussed.

Application of hypertension guidelines in clinical practice: implementation of the 2007 ESH/ESC European practice Guidelines in Spain.

J Hypertens. 2009 Jun;27 Suppl 3:S27-32 de la Sierra A, Zamorano JL, Ruilope LM. Hypertension Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain.

Clinical practice guidelines on the management of hypertension such as the 2007 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) Guidelines were developed with the objective of allowing a greater number of patients with high blood pressure to be detected and effectively treated. The acceptance of hypertension guidelines and their implementation in clinical practice by 'front-line' physicians continues to be less than optimal for a variety of reasons, however, including the gap between academic guideline writers and those whose task it is to implement the guidelines, the physicians' own attitudes and knowledge, the characteristics of the guideline itself, patient-related factors, and external barriers such as a lack of adequate resources. In Spain, a survey of the opinions of Spanish physicians on the 2007 ESH/ESC hypertension Guidelines found that there was agreement that the guidelines allow a better stratification of cardiovascular risk, better control of risk factors related to hypertension, better implementation of an individualized treatment programme, and facilitate choice of the best therapeutic approach for each patient, but there was no consensus that adherence to the guidelines achieves better control of hypertension or that it is more likely to prevent future cardiovascular events. In future, there needs to be a continuous process involving education and audit that takes into account the full spectrum of barriers to acceptance and implementation of hypertension guidelines to ensure that their full potential in reducing the strain on healthcare delivery systems imposed by undiagnosed, untreated and uncontrolled hypertension can be realized.

2007 ESH/ESC Guidelines for the management of hypertension, from theory to practice: global cardiovascular risk concept

J Hypertens. 2009 Jun;27 Suppl 3:S3-11. Volpe M, Tocci G. Division of Cardiology, II Faculty of Medicine, University of Rome La Sapienza, Sant'Andrea Hospital, Rome, Italy.

Clinical evaluation of cardiovascular risk in patients with hypertension is evolving from independently assessing well-known, traditional risk factors (e.g. hypertension, hypercholesterolemia, obesity, diabetes mellitus, smoking) towards an integrated, multidisciplinary clinical approach, aimed at determining the global (or total) cardiovascular risk profile in each individual patient for planning early and effective strategies for cardiovascular prevention. A paradigmatic example is provided by hypertension, in which new clinical behaviour implies a shift from focusing only on high blood pressure levels towards a more integrated approach, aimed at identifying and reducing global cardiovascular risk, as is highlighted in the European Guidelines. This approach arises from the acknowledgement that a cluster of cardiovascular risk factors is the rule, rather than the exception in hypertension. In addition, major cardiovascular diseases often develop from a subclinical level, which can be discovered at an early stage, thus providing the opportunity promptly to intercept and treat high-risk patients early. Identification of organ damage and assessment of hypertension-related clinical conditions can further contribute to a more precise definition of an individual total cardiovascular risk profile, and to the decision on when, how and how much to treat patients with hypertension. Implementing a clinical behaviour based on global cardiovascular risk assessment will help to target global cardiovascular risk reduction, while maintaining specific therapeutic goals for individual risk factors. This synergistic approach holds the best promise for treating total cardiovascular risk and reducing the mounting global burden of cardiovascular disease associated with hypertension.

Blood pressure is lower in children and adolescents with a low-saturated-fat diet since infancy: the special turku coronary risk factor intervention project.

Hypertension. 2009 Jun;53(6):918-24. Niinikoski H, Jula A, Viikari J, Rönnemaa T, Heino P, Lagström H, Jokinen E, Simell O. Department of Pediatrics, Turku University Hospital, Turku, Finland.

Blood pressure was measured in the prospective randomized Special Turku Coronary Risk Factor Intervention Project Study with an oscillometric method every year from 7 months to 15 years of age in 540 children receiving a low-saturated-fat, low-cholesterol diet and in 522 control children. Dietary intakes, family history of parental hypertension, and grandparental vascular disease were recorded.

Systolic and diastolic blood pressures were 1.0 mm Hg lower (95% CI for systolic: -1.7 to -0.2 mm Hg; 95% CI for diastolic: -1.5 to -0.4 mm Hg) in children receiving low-saturated-fat counseling through childhood than in control children. Intakes of saturated fat were lower (P<0.001), those of polyunsaturated fat higher (P<0.001), and intakes of potassium slightly higher (P=0.002) in the intervention group, but sodium intakes were not influenced by the intervention (P=0.76). Children whose parents were hypertensive had 4- to 6-mm Hg higher systolic and 3- to 4-mm Hg higher diastolic blood pressures than children of normotensive parents (P<0.001). Diastolic blood pressure of children with grandparental vascular disease, ie, early cardiovascular or cerebrovascular disease, tended to be higher than that of children with no grandparental disease (P=0.051).

We conclude that restriction of saturated fat from infancy until 15 years of age decreases childhood and adolescent blood pressure with a meaningful population-attributable amount. The importance of childhood lifestyle counseling and primary prevention of hypertension should be emphasized, especially in those children with a family history of hypertension or atherosclerotic vascular disease.

Long term monitoring in patients receiving treatment to lower blood pressure: analysis of data from placebo controlled randomised controlled trial.

BMJ. 2009 Apr 30;338:b1492. doi: 10.1136/bmj.b1492. Keenan K, Hayen A, Neal BC, Irwig L. Screening and Test Evaluation Program (STEP), School of Public Health, Building A27, University of Sydney, New South Wales 2006, Australia.

OBJECTIVE: To determine the value of monitoring blood pressure by quantifying the probability that observed changes in blood pressure reflect true changes.

DESIGN: Analysis of blood pressure measurements of patients in the perindopril protection against recurrent stroke study (PROGRESS).

SETTING: Randomised placebo controlled trial carried out in 172 centres in Asia, Australasia, and Europe.

PARTICIPANTS: 1709 patients with history of stroke or transient ischaemic attack randomised to fixed doses of perindopril and indapamide. Measurements Mean of two blood pressure measurements in patients receiving treatment recorded to the nearest 2 mm Hg with a standard mercury sphygmomanometer at baseline and then at three months, six months, nine months, and 15 months and then every six months to 33 months.

RESULTS: There was no change in the mean blood pressure of the cohort during the 33 month follow-up. Six months after blood pressure was stabilised on treatment, if systolic blood pressure was measured as having increased by >10 mm Hg, six of those measurements would be false positives for every true increase of >or=10 mm Hg. The corresponding value for an increase of 20 mm Hg was over 200. Values for 5 mm Hg and 10 mm Hg increases in diastolic blood pressure were 3.5 and 39, respectively. The likelihood that observed increases in blood pressure reflected true increases rose with the time between measurements such that the ratio of true positives to false positives reached parity at 21 months.

CONCLUSIONS: Usual clinical approaches to the monitoring of patients taking drugs to lower blood pressure have a low probability of yielding reliable information about true changes in blood pressure. Evidence based guidelines for monitoring treatment response are urgently required to guide clinical practice.

Influence of guidelines on physicians' assessment of blood pressure lowering effects and achievement rate of blood pressure target during transitional period of guidelines.

Clin Exp Hypertens. 2009 Apr;31(2):116-26. Kushiro T, Saito I, Sato Y, Hirata K, Kobayashi F, Sagawa K, Hiramatsu K, Komiya M. Nihon University Health Planning Center, Chiyoda-ku, Tokyo, Japan.

We studied the agreement rate between achievement of blood pressure (BP) target according to the 2002 Japanese Guidelines for Treatment of Hypertension in the Elderly (EG 2002) and the Japanese Society of Hypertension Guidelines 2004 (JSH 2004) versus a physicians' assessment of BP-lowering efficacy of olmesartan medoxomil in elderly patients. The physicians' assessment more closely agreed with the achievement rate of the BP target according to the EG 2002 than that according to the JSH 2004. This study was started in July 2004, shortly after JSH 2004 was published.

Our data suggest that guidelines at the time strongly influence the physicians' assessment and their treatment strategy for individual patients in daily clinical practice.

Trends in blood pressure control and treatment among type 2 diabetes with comorbid hypertension in the United States: 1988-2004.

J Hypertens. 2009 May 30. Suh DC, Kim CM, Choi IS, Plauschinat CA, Barone JA. aErnest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey, USA bCollege of Medicine, Catholic University, Seoul, Korea cNovartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA.

OBJECTIVES: The objectives of this study were to examine the trends in the prevalence of type 2 diabetic patients with comorbid hypertension and blood pressure (BP) control rates in the United States and determine factors associated with these outcomes.

METHODS: We used data from National Health and Nutrition Examination Surveys (NHANES) III (1988-1994) and NHANES 1999-2004, a cross-sectional sample of the noninstitutionalized US populations. Type 2 diabetic patients were identified as patients at least 30 years of age with physician-diagnosed diabetes who were taking insulin or oral antidiabetic drugs to manage the condition. A diagnosis of hypertension was based on physician diagnosis, treatment with antihypertensive medications, or BP at least 140/90 mmHg. BP control was defined as diabetic patients who maintained BP <130/80 mmHg. Logistic regression was used to estimate risks of high BP, and odds of high BP treatment and control rates, after adjusting for demographic and clinical risk factors.

RESULTS: The age-adjusted prevalence of diabetic patients and those with hypertension increased significantly from 5.8 to 7.1% and 3.9 to 4.7%, respectively, from NHANES III to NHANES 1999-2004. Among diabetic patients with hypertension, patients who were treated with medication or lifestyle or behavioral modification therapy have increased significantly from 76.5 to 87.8% during the observation period. The proportion of patients who controlled BP increased from 15.9 to 29.6%, but 70% of patients still did not meet the target BP goal.

CONCLUSION: Aggressive public health efforts are needed to improve BP control in type 2 diabetic patients with hypertension.

Management of antihypertensive drugs in three European countries.

J Hypertens. 2009 Jun 5. Nicotra F, Wettermark B, Sturkenboom MC, Parodi A, Bellocco R, Ekbom A, Merlino L, Leimanis A, Mancia G, Fored M, Corrao G. aDepartment of Statistics, Unit of Biostatistics and Epidemiology, University of Milano-Bicocca, Milan, Italy bCentre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden cDepartment of Epidemiology and Biostatistics, Erasmus University Medical Centre, Rotterdam, The Netherlands dDepartment of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden eClinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden fOperative Unit of Territorial Health Services, Region Lombardia, Milan, Italy gCentre for Epidemiology, National Board of Health and Welfare, Stockholm, Sweden hDepartment of Medicine and Prevention, University of Milano-Bicocca, Milan, Italy.

OBJECTIVES: To compare rates of treatment discontinuation of and changes in initial antihypertensive drug therapy in the natural setting of treatment dispensation of Italy, Sweden and the Netherlands.

METHODS: The cohorts included all the 23 715 (Italy), 20 289 (Sweden), and 5801 (the Netherlands) patients aged 40-70 years who received their first antihypertensive drug prescription from July 1, 2006 to September 30, 2006. Discontinuation was assumed if no antihypertensive drug was issued within 90 days following the end of the latest antihypertensive dispensation. Addition or replacement of the initial medication during the 90-day interval were defined as treatment combination or treatment switching.

RESULTS: At 9 months after treatment initiation, the discontinuation rate of any antihypertensive drug was 24%. Compared with Italian patients, the discontinuation rate was significantly lower in Swedish [hazard ratios: 0.52, 95% confidence interval (CI): 0.50-0.54] and Dutch patients (hazard ratio: 0.79, 95% CI: 0.75-0.84). Almost 21 and 16% of patients who started on monotherapy respectively combined with and switched to another antihypertensive drug. Compared with Italian patients, the adjusted hazard rate of combining was lower in Swedish patients (hazard ratio: 0.83, 95% CI: 0.79-0.87). The hazard rate of switching was lower in Swedish and Dutch patients than in Italians (hazard ratios: 0.83, 95% CI: 0.79-0.88 and hazard ratio: 0.77, 95% CI: 0.71-0.84 respectively).

CONCLUSION: Management of hypertension is unsatisfactory worldwide due to a very high rate of treatment discontinuation or insufficient use of proper treatment strategies.

Association between the morning-evening difference in home blood pressure and cardiac damage in untreated hypertensive patients.

J Hypertens. 2009 Apr;27(4):712-20. Matsui Y, Eguchi K, Shibasaki S, Shimizu M, Ishikawa J, Shimada K, Kario K. Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.

OBJECTIVES: The present study investigated whether the morning-evening difference in self-measured blood pressure (BP) (MEdif) can be an independent determinant of cardiac damage in untreated hypertensive patients.

METHODS: In a cross-sectional study, the left ventricular (LV) mass, relative wall thickness, and diastolic function using echocardiography were assessed in 356 untreated hypertensive patients. Home BP measurements were taken in triplicate in the morning and evening, respectively, for 14 consecutive days with a memory-equipped device. Thereafter, the association between the MEdif in systolic BP (SBP) and the echocardiographic parameters was assessed.

RESULTS: The MEdif in SBP was significantly correlated with LV mass index (r = 0.28, P < 0.001), relative wall thickness (r = 0.21, P < 0.001), ratio of E-wave to A-wave (r = -0.24, P < 0.001), and the deceleration time of the E-wave velocity (r = 0.23, P < 0.001). In a multivariable regression analysis, the MEdif in SBP was a significant determinant of these parameters, independent of age, sex, duration of hypertension, current smoking, habitual drinking, diabetes mellitus, the average of morning and evening SBP, and the heart rate at echo. When the MEdif in SBP was divided into quartiles, the highest quartile had increased likelihood of LV concentric hypertrophy (odds ratio = 2.63, 95% confidence interval = 1.20-5.87, P = 0.008) in comparison with the lowest quartile after adjusting for confounding factors.

CONCLUSION: The MEdif is a significant determinant of LV hypertrophy, LV geometry, and diastolic function, and therefore, evaluation of the MEdif combined with the average of morning and evening SBP might be useful in the early stage assessment of hypertensive patients.

Ambulatory blood pressure monitoring predicts cardiovascular events in treated hypertensive patients--an Anglo-Scandinavian cardiac outcomes trial substudy.

J Hypertens. 2009 Apr;27(4):876-85. Dolan E, Stanton AV, Thom S, Caulfield M, Atkins N, McInnes G, Collier D, Dicker P, O'Brien E; ASCOT Investigators. Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.

BACKGROUND: Results of the Anglo-Scandinavian cardiac outcomes trial-blood pressure lowering arm (ASCOT-BPLA) showed significantly lower rates of coronary and stroke events in individuals allocated an amlodipine-perindopril combination drug regimen than in those allocated an atenolol-thiazide combination drug regimen. The aims of the ambulatory blood pressure (ABP) substudy of ASCOT were to examine the impact of the two blood pressure (BP)- lowering regimens on ambulatory pressures, test to what extent the between-treatment differences in cardiovascular outcome could be attributed to differences in ABP and assess whether ABP provides predictive information additional to that of clinic blood pressure (CBP) in treated hypertensive patients.

METHODS AND RESULTS: One thousand, nine hundred and five patients from four ASCOT centres had repeated ABPs performed over a median follow-up period of 5.5 years. As in the whole ASCOT population, CBP values were lower in amlodipine-perindopril-treated patients compared with those treated with atenolol-thiazide [between-regimen difference [95% confidence intervals (CIs)]]: [-1.5 (-2.4 to -0.5)/-1.2 (-1.8 to +0.5) mmHg]. Daytime BP during follow-up was higher in patients treated with amlodipine-perindopril therapy [+1.1 (0.1-2.1)/+1.6 (0.8-2.3) mmHg]; night-time systolic, but not diastolic BP, was lower in patients treated with amlodipine-perindopril therapy [-2.2 (-3.4 to +0.9)/+0.8 (0.0-1.6) mmHg]. The relative risk of a cardiovascular event associated with a 1 SD increment in accumulated mean BP was 1.35 (1.18-1.53) for clinic systolic BP, 1.30 (1.14-1.49) for daytime systolic BP and 1.42 (1.24-1.62) for night-time systolic BP. With adjustment for baseline variables, treatment regimen and clinic systolic BP, the hazard ratios were 1.17 (1.00-1.36) and 1.25 (1.08-1.47) for daytime and night-time systolic BP, respectively. The between-regimen adjusted hazard ratio for cardiovascular events (amlodipine-perindopril therapy versus atenolol-thiazide therapy) was 0.74 (0.55-1.01) and increased to 0.81 (0.60-1.10) after further adjustment for clinic systolic BP. Further, adjustment for night-time systolic BP increased the hazard ratio to 0.85 (0.62-1.16).

CONCLUSION: The amlodipine-perindopril and atenolol-thiazide regimens had different effects on daytime and night-time ABP, which may have contributed to the lower rates of events in patients treated with amlodipine-perindopril therapy. Both CBP and ABP were significantly associated with rates of cardiovascular events. ABP nocturnal pressures provided complimentary and incremental utility over CBP in the prediction of cardiovascular risk in treated hypertensive patients. These data support the use of ABP to assess the effect of antihypertensive treatment in clinical practice.

Short-term Aerobic Exercise Reduces Arterial Stiffness in Older Adults with Type 2 Diabetes, Hypertension and Hypercholesterolemia.

Diabetes Care. 2009 Jun 9. Madden KM, Lockhart C, Cuff D, Potter TF, Meneilly GS. VITALiTY (Vancouver Initiative to Add Life to Years) Research Laboratory, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Objective: The relationship between increased arterial stiffness and cardiovascular mortality is well established in Type 2 diabetes. We examined whether aerobic exercise could reduce arterial stiffness in older adults with Type 2 diabetes complicated by co-morbid hypertension and hyperlipidemia.

Research design and methods: 36 older adults (mean age 71.4+/-0.7) with diet-controlled or oral hypoglycemic-controlled Type 2 diabetes, hypertension, and hypercholesterolemia were recruited. Subjects were randomized to each of 2 groups: an aerobic group (AT, 3 months vigorous aerobic exercise), and a nonaerobic (NA, no aerobic exercise) group. Exercise sessions were supervised by a certified exercise trainer 3 times per week, and utilized a combination of cycle ergometers and treadmills. Arterial stiffness was measured using the Complior device.

Results: When the two groups were compared, aerobic training resulted in a decrease in measures of both radial (-20.7+/-6.3% versus +8.5+/-6.6%, p=0.005) and femoral (-13.9+/-6.7% versus +4.4+/-3.3%, p=0.015) pulse wave velocity despite the fact that aerobic fitness as assessed by VO(2max) (maximal oxygen consumption) did not demonstrate an improvement with training (p=0.026).

Conclusions: Our findings indicate that a relatively short aerobic exercise intervention in older adults can reduce multifactorial arterial stiffness (Type 2 diabetes, aging, hypertension and hypercholesterolemia).

Influence of systolic and diastolic blood pressure on the risk of incident atrial fibrillation in women.

Circulation. 2009 Apr 28;119(16):2146-52 Conen D, Tedrow UB, Koplan BA, Glynn RJ, Buring JE, Albert CM. Center for Arrhythmia Prevention, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass., USA.

BACKGROUND: The influence of systolic and diastolic blood pressure (BP) on incident atrial fibrillation (AF) is not well studied among initially healthy, middle-aged women.

METHODS AND RESULTS: A total of 34,221 women participating in the Women's Health Study were prospectively followed up for incident AF. The risk of AF across categories of systolic and diastolic BP was compared by use of Cox proportional-hazards models. During 12.4 years of follow-up, 644 incident AF events occurred. Using BP measurements at baseline, we discovered that the long-term risk of AF was significantly increased across categories of systolic and diastolic BP. Multivariable-adjusted hazard ratios for systolic BP categories (<120, 120 to 129, 130 to 139, 140 to 159, and > or =160 mm Hg) were 1.0, 1.00 (95% CI, 0.78 to 1.28), 1.28 (95% CI, 1.00 to 1.63), 1.56 (95% CI, 1.22 to 2.01), and 2.74 (95% CI, 1.77 to 4.22) (P for trend <0.0001). Adjusted hazard ratios across baseline diastolic BP categories (<65, 65 to 74, 75 to 84, 85 to 89, 90 to 94, and > or =95 mm Hg) were 1.0, 1.17 (95% CI, 0.81 to 1.69), 1.18 (95% CI, 0.84 to 1.65), 1.53 (95% CI, 1.05 to 2.23), 1.35 (95% CI, 0.82 to 2.22), and 2.15 (95% CI, 1.21 to 3.84) (P for trend=0.004). When BP changes over time were accounted for in updated models, multivariable-adjusted hazard ratios were 1.0, 1.14 (95% CI, 0.89 to 1.46), 1.37 (95% CI, 1.07 to 1.76), 1.71 (95% CI, 1.33 to 2.21), and 2.21 (95% CI, 1.45 to 3.36) (P for trend <0.0001) for systolic BP categories and 1.0, 1.12 (95% CI, 0.82 to 1.52), 1.13 (95% CI, 0.83 to 1.52), 1.30 (95% CI, 0.89 to 1.88), 1.50 (95% CI, 1.01 to 1.88), and 1.54 (95% CI, 0.75 to 3.14) (P for trend=0.026) for diastolic BP categories.

CONCLUSIONS: In this large cohort of initially healthy women, BP was strongly associated with incident AF, and systolic BP was a better predictor than diastolic BP. Systolic BP levels within the nonhypertensive range were independently associated with incident AF even after BP changes over time were taken into account.

Risk factors for abdominal aortic aneurysms: a 7-year prospective study: the Tromsø Study, 1994-2001.

Circulation. 2009 Apr 28;119(16):2202-8. Forsdahl SH, Singh K, Solberg S, Jacobsen BK. Institute of Community Medicine, University of Tromsø, 9037 Tromsø, Norway.

BACKGROUND: Abdominal aortic aneurysm is an asymptomatic condition with a high mortality rate related to rupture.

METHODS AND RESULTS: In a cohort of 2035 men and 2310 women in Tromsø, Norway, who were 25 to 82 years old in 1994, the authors identified risk factors for incident abdominal aortic aneurysm over the next 7 years. The impact of smoking was studied in particular. Ultrasound examination was performed initially in 1994/1995 and repeated in 2001. There were 119 incident cases of abdominal aortic aneurysms (an incidence of 0.4% per year). Male sex and increasing age were strong risk factors. In addition, the following variables were significantly associated with increased abdominal aortic aneurysm incidence: Smoking (OR=13.72, 95% CI 6.12 to 30.78, comparing current smokers of > or =20 cigarettes/d with never-smokers), hypertension (OR=1.54, 95% CI 1.03 to 2.30), hypercholesterolemia (OR=2.11, 95% CI 1.23 to 3.64, comparing subjects with serum total cholesterol > or =7.55 mmol/L with those with total cholesterol <5.85 mmol/L), and low high-density lipoprotein cholesterol (OR=3.25, 95% CI 1.68 to 6.27, comparing subjects with high-density lipoprotein cholesterol <1.25 mmol/L with those with high-density lipoprotein > or =1.83 mmol/L). In addition, use of statins was associated with increased risk of abdominal aortic aneurysm (OR=3.77, 95% CI 1.45 to 9.81), but this was probably a marker of high risk of cardiovascular diseases.

CONCLUSIONS: The results demonstrate strong associations between traditional atherosclerosis risk factors and the risk of incident abdominal aortic aneurysms.

Chronobiology of Arterial Hypertension in Hemodialysis Patients: Implications for Home Blood Pressure Monitoring

Am J Kidney Dis. 2009 Jun 9. Agarwal R, Light RP. Division of Nephrology, VA Medical Center, Indianapolis, IN; Richard L. Roudebush VA Medical Center, Indianapolis, IN.

BACKGROUND: Hemodialysis patients have a steady increase in blood pressure (BP) during the 44-hour interdialytic interval when ambulatory BP monitoring is used. Home BP recording allows for a longer period of monitoring between dialysis treatments and may better define the chronobiological characteristics of arterial hypertension. This study sought to determine the optimal time to perform home BP monitoring in hemodialysis patients to improve the strength of prediction of 44-hour interdialytic ambulatory BP.

STUDY DESIGN: Diagnostic test study.

SETTING & PARTICIPANTS: This is an ancillary analysis of patients participating in the Dry-weight Reduction in Hypertensive Hemodialysis Patients (DRIP) trial.

INDEX TEST: Home BP measured 3 times daily for 1 week by using a validated oscillometric monitor on 3 occasions at 4-week intervals after randomization. Home BP measured during the first third, second third, and last third of time elapsed after the dialysis treatment, as well as each third of the dialysis treatment, was compared with the overall ambulatory BP.

REFERENCE TESTS: Interdialytic ambulatory BP measured on 3 occasions at 4-week intervals after randomization.

RESULTS: During the interdialytic interval, we found an increase in systolic ambulatory BP of 0.30 +/- 0.36 mm Hg/h and an increase in systolic home BP of 0.40 +/- 0.25 mm Hg/h. This relationship in home BP reached a plateau after approximately 48 hours. A similar pattern was seen for diastolic home BP. Probing dry weight steepened the slope of ambulatory BP, but did not alter the time-dependent relationship of home BP. Home BP was on average higher (bias) by 14.1 (95% confidence interval, 12.0 to 16.2)/5.7 mm Hg (95% confidence interval, 4.6 to 6.9). The SD of differences between methods (precision) was 4.6/2.8 mm Hg. Measurement of BP during each third of the interdialytic interval gave the best precision, measured by using model fit compared with ambulatory BP measurements.

LIMITATIONS: Our cohort was overrepresented by African American hemodialysis patients. Whether African American participants have a different pattern of BP response than non-African American participants in the interdialytic period is not known.

CONCLUSIONS: Our findings suggest that time elapsed after a dialysis treatment must be considered in interpreting home BP recordings in hemodialysis patients. Home BP measured in each third of the interdialytic interval is likely to yield the most reliable BP estimate.

Prognostic Value of Different Indices of Blood Pressure Variability in Hypertensive Patients.

Am J Hypertens. 2009 Jun 4. Pierdomenico SD, Di Nicola M, Esposito AL, Di Mascio R, Ballone E, Lapenna D, Cuccurullo F. [1] Dipartimento di Medicina e Scienze dell'Invecchiamento, Università "Gabriele d'Annunzio", Chieti, Italy [2] Centro di Ricerca Clinica, Fondazione Università "Gabriele d'Annunzio", Chieti, Italy.

Background: The independent prognostic significance of different indices of blood pressure (BP) variability is not clear. We investigated the prognostic value of BP variability estimated as s.d. or average real variability (ARV) of daytime and night time BP, in hypertensive patients.

Methods: The occurrence of fatal and nonfatal cardiovascular events was evaluated in 1,280 sequential hypertensive patients (550 initially untreated and 730 initially treated) aged >/=40 years. Subjects with s.d. or ARV of daytime or night time systolic or diastolic BP below or above the median were classified as having low or high BP variability.

Results: During the follow-up (4.75 +/- 1.8 years), 104 cardiovascular events occurred. The event rate per 100 patient-years was 1.71 in the global population. After adjustment for other covariates, Cox regression analysis showed that cardiovascular risk was higher in subjects with high ARV of daytime systolic BP in initially untreated, initially treated, and all the subjects (high vs. low ARV, hazard ratio (HR) 2.29 (1.06-4.94), HR 1.90 (1.06-3.39), and HR 2.07 (1.31-3.28), respectively). ARV of daytime diastolic BP and night time BP, and s.d. of daytime and night time BP were not significantly associated with risk or were not independent predictors of outcome.

Conclusions: In this study, high ARV of daytime systolic BP resulted in an independent predictor of cardiovascular risk in hypertensive patients, while high s.d. did not. Our data suggest that, in comparison to s.d., ARV could be a more appropriate index of BP variability and a more useful predictor of outcomes.

Electronic monitoring of patient adherence to oral antihypertensive medical treatment: a systematic review.

J Hypertens. 2009 May 26 Christensen A, Osterberg LG, Hansen EH. aSection for Social Pharmacy, Department for Pharmacology and Pharmacotherapy, Faculty of Pharmaceutical Sciences, University of Copenhagen, Denmark bResearch Centre for Quality in Medicine Use, Copenhagen, Denmark cBang & Olufsen Medicom A/S, Struer, Denmark dSection of General Internal Medicine, Department of Medicine, Stanford University, USA eVA Palo Alto Healthcare System, Palo Alto, California, USA.

Poor patient adherence is often the reason for suboptimal blood pressure control. Electronic monitoring is one method of assessing adherence. The aim was to systematically review the literature on electronic monitoring of patient adherence to self-administered oral antihypertensive medications.

We searched the Pubmed, Embase, Cinahl and Psychinfo databases and websites of suppliers of electronic monitoring devices. The quality of the studies was assessed according to the quality criteria proposed by Haynes et al. Sixty-two articles were included; three met the criteria proposed by Haynes et al. and nine reported the use of electronic adherence monitoring for feedback interventions.

Adherence rates were generally high, whereas average study quality was low with a recent tendency towards improved quality. One study detected investigator fraud based on electronic monitoring data. Use of electronic monitoring of patient adherence according to the quality criteria proposed by Haynes et al. has been rather limited during the past two decades. Electronic monitoring has mainly been used as a measurement tool, but it seems to have the potential to significantly improve blood pressure control as well and should be used more widely.

Residual cardiovascular risk in treated hypertension and hyperlipidaemia: the PRIME Study

J Hum Hypertens. 2009 May 28. Blacher J, Evans A, Arveiler D, Amouyel P, Ferrières J, Bingham A, Yarnell J, Haas B, Montaye M, Ruidavets JB, Ducimetière P. [1] INSERM, Hôpital Paul Brousse, Villejuif, France [2] Hôtel-Dieu, APHP, Université Paris Descartes, Paris, France.

Although pharmacological treatments of hypertension and dyslipidaemia are both associated with a reduction in cardiovascular risk, little is known about the degree of cardiovascular risk remaining in treated individuals, by assessing the levels of their risk factors achieved, that is their 'residual cardiovascular risk'. We then used the data from the Prospective Epidemiological Study of Myocardial Infarction (PRIME), which involved 9649 men aged 50-59 years, from France and Northern Ireland with a 10-year follow-up, to test the presence of specific residual cardiovascular risks of coronary heart disease, stroke, total of fatal and non-fatal cardiovascular events and cardiovascular mortality, in patients treated with antihypertensive agents or lipid-lowering agents. In the whole cohort, a total of 796 patients developed a fatal or non-fatal cardiovascular event. Antihypertensive drug use at baseline was significantly associated (RR=1.50, 95% CI: 1.25-1.80) with total cardiovascular event risk, but not lipid-lowering drug use, after adjusting for classic risk factors (age, smoking, total cholesterol, high-density lipoprotein cholesterol, systolic blood pressure and diabetes). Similar results were obtained for coronary heart disease (RR=1.46, 95% CI: 1.18-1.80), stroke (RR=1.75, 95% CI: 1.14-2.70) and cardiovascular death (RR=1.62, 95% CI: 1.02-2.58), but neither for total death (RR=1.15, 95% CI: 0.89-1.48) nor for non-cardiovascular death (RR=1.00, 95% CI: 0.74-1.36). For any cardiovascular end point, residual risks did not globally differ according to the antihypertensive drug class prescribed at baseline.

In conclusion, treatment with antihypertensive agents, but not with lipid-lowering agents, was associated with a sizeable residual cardiovascular risk, suggesting that more efficient risk reduction strategies in hypertension should be developed as a priority.

Association of Passive Smoking With Masked Hypertension in Clinically Normotensive Nonsmokers.

Association of Passive Smoking With Masked Hypertension in Clinically Normotensive Nonsmokers. Am J Hypertens. 2009 May 28. Makris TK, Thomopoulos C, Papadopoulos DP, Bratsas A, Papazachou O, Massias S, Michalopoulou E, Tsioufis C, Stefanadis C. Department of Cardiology, Elena Venizelou Hospital, Athens, Greece.

Background: We investigated ambulatory blood pressure (BP) levels among clinically normotensive nonsmokers exposed (PS) and not exposed (SF) to passive smoking aiming to evaluate the relative prevalence of masked hypertension (MH).

Methods: From 790 consecutive never-treated subjects who were self-referred to an outpatient hypertensive clinic, we excluded active smokers and those having a mean clinic BP >140/90 mm Hg. In the remaining population, echocardiography and routine biochemical profile assessment was performed, whereas by the implementation of additional exclusion criteria, all clinically normotensive subjects eligible to participate (i.e., 154 PS and 100 SF) underwent to ambulatory BP monitoring.

Results: PS with respect to SF subjects were younger, followed a less hygienic diet and consumed more alcohol (all P < 0.05). Moreover, PS in comparison with SF showed higher 24-h systolic BP, standing diastolic BP, and clinic heart rate (126 +/- 6 mm Hg vs. 122 +/- 5 mm Hg, 89 +/- 4 mm Hg vs. 84 +/- 4 mm Hg and 79 +/- 5 beats/min vs. 73 +/- 4 beats/min, respectively, P < 0.05 for all) and higher prevalence of MH (23% vs. 8%, P < 0.01). After adjustment for confounders determinants of MH remained passive smoking, weekly duration and intensity of passive smoke exposure, younger age, clinic heart rate, low physical activity score, and standing/sitting difference of diastolic BP and heart rate (P < 0.05 for all).

Conclusions: MH is associated with passive smoking in a dose-related manner and low physical activity, increased heart rate and postural hemodynamic reaction may represent potential accelerators of that phenomenon.

What is the optimal interval between successive home blood pressure readings using an automated oscillometric device?

Self-measurement of blood pressure in arterial hypertension--preliminary results from the AMPA study.

Rev Port Cardiol. 2009 Jan;28(1):7-21. Maldonado J, Pereira T; Estudo AMPA. Collaborators (135) Instituto de Investigação e Formação Cardiovascular Penacova, Portugal.

Prehypertension and black-white contrasts in cardiovascular risk in young adults: Bogalusa Heart Study.

J Hypertens. 2009 Feb;27(2):243-50 Toprak A, Wang H, Chen W, Paul T, Ruan L, Srinivasan S, Berenson G. Tulane Center for Cardiovascular Health, New Orleans, Louisiana 70112, USA.

OBJECTIVE: The aim of this study was to examine the association of prehypertension with measures of cardiovascular disease risk in a biracial (black-white) population of young adults.

METHODS: As part of the Bogalusa Heart Study, echocardiography and carotid ultrasonography were performed along with cardiovascular risk factor measurements in 1379 young adult participants (age range 20-44 years, average 36 years; 43% men, 70% white). Participants were categorized as normotensives (60%), prehypertensives (27%) and hypertensives (13%).

RESULTS: The prevalence of prehypertension was significantly higher among men than women (35 vs. 22%) and among blacks than whites (29 vs. 27%). Compared with normotensives, prehypertensives had a greater adverse cardiovascular risk factor profile. Male sex and BMI equally and significantly contributed to the prehypertension status in both whites [odds ratio (OR) and 95% confidence interval 2.66 (1.88-3.74) and 1.10 (1.07-1.14)] and blacks [OR: 2.56 (1.51-4.33) and 1.05 (1.01-1.09)]. Additionally, prehypertensives compared with normotensives had significantly higher left ventricular (LV) mass index, LV internal diameter, and carotid artery intima-media thickness.

CONCLUSION: The condition of prehypertension in young adults shows men>women and black women>white women, and participants with prehypertension already have adverse profiles of risk factors and indices of subclinical cardiovascular disease. A greater percentage of blacks at a relatively young age fall into the hypertensive category. These findings underscore the need for aggressive management of cardiovascular risk in youth at levels below those considered as hypertension.

Renal and cardiac abnormalities in primary hypertension

J Hypertens. 2009 Apr 7. Leoncini G, Viazzi F, Conti N, Baratto E, Tomolillo C, Bezante GP, Deferrari G, Pontremoli R. Department of Internal Medicine, University of Genoa and Department of CardioNephrology, Azienda Ospedaliera Universitaria San Martino, Genoa, Italy.

OBJECTIVE: The relationship between mild reduction in renal function and cardiac structure and function have not yet been fully elucidated. We investigated cardiac and renal abnormalities in 400 untreated, nondiabetic patients (65% men, mean age 47 years) with primary hypertension and normal serum creatinine.

METHODS: Renal abnormalities were defined as creatinine clearance less than 75 ml/min per 1.73 m (Cockcroft-Gault formula) and/or the presence of microalbuminuria (albumin-to-creatinine ratio). Left ventricular structure and function were assessed by echocardiography.

RESULTS: The prevalence of microalbuminuria and reduced creatinine clearance was 13 and 31%, respectively. Patients with renal abnormalities shared greater left ventricular mass index, higher prevalence of left ventricular hypertrophy, and unfavorable geometric patterns. Microalbuminuria was also associated with inappropriate left ventricular mass and depressed midwall fractional shortening, whereas reduced creatinine clearance was associated with lower stroke volume and higher central pulse pressure/stroke volume ratio and total peripheral resistance. Stepwise regression analysis showed that both albuminuria and creatinine clearance were independently related to left ventricular mass. Logistic regression analysis of the reciprocal interaction of microalbuminuria and reduced creatinine clearance on the occurrence of subclinical cardiac damage showed that reduced creatinine clearance entailed a greater risk of left ventricular hypertrophy in patients with normal albuminuria alone, whereas the presence of microalbuminuria was associated with a greater risk of left ventricular hypertrophy independently of creatinine clearance.

CONCLUSIONS: These findings provide further proof of the role of cardiorenal interaction in the development of hypertension-related cardiovascular disease, and may have clinical implications.

Long-term decline in renal function is linked to initial pulse pressure in the essential hypertensive.

J Hypertens. 2009 Mar 19. Gosse P, Coulon P, Papaioannou G, Litalien J, Lemetayer P. Unité Cardiologie/Hypertension Artérielle, Hôpital Saint André, University Hospital of Bordeaux, Bordeaux, France.

OBJECTIVES: In the absence of malignant hypertension, the mechanisms for the decline in renal function in hypertensive patients are not well known. Several recent studies, essentially cross-sectional, point to a role for an increase in arterial stiffness and its corollary, the increased pulse pressure (PP), in barotrauma of the renal glomerulus.

METHODS: We examined relations between the PP measured on consultation or by 24-h ambulatory blood pressure monitoring and the long-term decline in renal function in a population of essential hypertensive patients initially untreated, with normal renal function and without proteinuria. We evaluated the renal outcome of 375 patients of mean age 49 years in a baseline state over a mean follow-up period of 14 years.

RESULTS: At follow up, the glomerular filtration rate estimated from the modification of diet in renal disease formula was below 60 ml/min per 1.73 m in 51 of these patients, two of whom required dialysis. The blood pressure parameter best correlated with subsequent renal failure, independently of other factors of risk such as age or type 2 diabetes, was the PP measured either in consultation or by ambulatory blood pressure monitoring before starting treatment.

CONCLUSION: The PP either measured on consultation or by ambulatory monitoring emerged as an independent determinant of the decline in renal functions in this population, pointing to the possibility of barotrauma of the glomeruli from increased arterial stiffness.

Body mass index and hypertension hemodynamic subtypes in the adult US population.

Arch Intern Med. 2009 Mar 23;169(6):580-6. Chirinos JA, Franklin SS, Townsend RR, Raij L. Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia Veterans Affairs Medical Center, 19104, USA.

BACKGROUND: Obesity produces various hemodynamic abnormalities that may impact hypertension subtypes. Similarly, the study of hypertension subtypes provides important information regarding the relative importance of hemodynamic abnormalities contributing to obesity-related hypertension.

METHODS: Cross-sectional analysis of adults enrolled in the Third National Health and Nutrition Examination Survey (NHANES III) (n = 16 545) and NHANES 1999-2004 (n = 12 137). We examined the relationship between body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) and the risk of hypertension and hemodynamic subtypes: isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systodiastolic hypertension (SDH).

RESULTS: In NHANES 1999-2004, the odds ratio (OR) for hypertension for every 5-unit increase in BMI was 1.45 (95% confidence interval [CI], 1.39-1.52) (P < .001). However, the magnitude of the relative increase in the odds of hypertension was higher among younger adults. Among patients with hypertension, increasing BMI was a significant predictor of IDH or SDH (OR for IDH or SDH, 1.04; 95% CI, 1.02-1.06) (P < .001), as opposed to ISH. Isolated systolic hypertension represented a minority of hypertension cases in obese men (38.9%; 95% CI, 30.9-47.6) but remained the most prevalent type in obese women (62.1%; 95% CI, 52.4%-71.0%) (P < .001), despite a significant relative decrease in the frequency of ISH with increasing BMI in both sexes. Findings in NHANES III were very similar.

CONCLUSIONS: Isolated diastolic hypertension and SDH account for most cases of obesity-related hypertension, suggesting that determinants of mean arterial pressure account for the major burden of obesity-related hypertension in US adult men. These findings should be considered in the design of clinical trials and therapeutic strategies for obesity-related hypertension. Further studies should assess determinants of mean arterial pressure in obesity and the role of sex in the pathogenesis of obesity-related hypertension.

Prevalence of cardiovascular disease risk factors among National Football League players.

JAMA. 2009 May 27;301(20):2111-9. Tucker AM, Vogel RA, Lincoln AE, Dunn RE, Ahrensfield DC, Allen TW, Castle LW, Heyer RA, Pellman EJ, Strollo PJ Jr, Wilson PW, Yates AP. Union Memorial Sports Medicine, Union Memorial Hospital, Baltimore, MD 21218, USA.

CONTEXT: Concern exists about the cardiovascular health implications of large size among professional football players and those players who aspire to professional status.

OBJECTIVES: To assess cardiovascular disease (CVD) risk factors in active National Football League (NFL) players and to compare these findings with data from the Coronary Artery Risk Development in Young Adults (CARDIA) study.

DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of 504 active, veteran football players from a convenience sample of 12 NFL teams at professional athletic training facilities between April and July 2007. Data were compared with men of the same age in the general US population (CARDIA study, a population-based observational study of 1959 participants aged 23 to 35 years recruited in 1985-1986).

MAIN OUTCOME MEASURES: Prevalence of CVD risk factors (hypertension, dyslipidemia, glucose intolerance, and smoking).

RESULTS: The NFL players were less likely to smoke when compared with the CARDIA group (0.1% [n = 1]; 95% confidence interval [CI], 0%-1.4%; vs 30.5% [n = 597]; 95% CI, 28.5%-32.5%; P < .001). Despite being taller and heavier, NFL players had significantly lower prevalence of impaired fasting glucose (6.7% [n = 24]; 95% CI, 4.6%-8.7%; vs 15.5% [n = 267]; 95% CI, 13.8%-17.3%; P < .001). The groups did not differ in prevalence of high total cholesterol and low-density lipoprotein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), or high triglycerides. Hypertension (13.8% [n = 67]; 95% CI, 11.0%-16.7%; vs 5.5% [n = 108]; 95% CI, 4.6%-6.6%) and prehypertension (64.5% [n = 310]; 95% CI, 58.3%-70.7%; vs 24.2% [n = 473]; 95% CI, 22.3%-26.1%) were significantly more common in NFL players than in the CARDIA group (both P < .001). Large size measured by body mass index (BMI) was associated with increased blood pressure, LDL-C, triglycerides, and fasting glucose, and decreased HDL-C.

CONCLUSIONS: Compared with a sample of healthy young-adult men, a sample of substantially larger NFL players had a lower prevalence of impaired fasting glucose, less reported smoking, a similar prevalence of dyslipidemia, and a higher prevalence of hypertension. Increased size measured by BMI was associated with increased CVD risk factors in this combined population.

Blood pressure screening of school children in a multiracial school district: the Healthy Kids Project.

Am J Hypertens. 2009 Apr;22(4):351-6. Moore WE, Eichner JE, Cohn EM, Thompson DM, Kobza CE, Abbott KE. University of Oklahoma Prevention Research Center, College of Public Health, Oklahoma City, Oklahoma, USA.

BACKGROUND: There are few studies of the prevalence of elevated blood pressure (BP) that include American Indian school children. Therefore, the intent of this study was to examine the relationships between BP and risk factors in a multiracial, predominantly American Indian, school district.

METHODS: A total of 1,829 American Indian, white, Hispanic, and African American students, 5-17 years old, were included in this study. The mean of two BP measurements, taken at the initial screening with an electronic BP monitor, were categorized as normal, prehypertensive, or hypertensive using the 2004 Fourth Report BP screening recommendations. Prevalence of prehypertensive and hypertensive BP measurements by race, gender, age, and body mass index (BMI) were determined, and their associations analyzed with logistic regression.

RESULTS: The prevalence of prehypertensive measurements was 16.7% and prevalence of hypertensive measurements was 13.8% at first screen. Obesity was a risk factor for elevated BP for females and males (adjusted odds ratio (OR) = 4.01 and 4.33, respectively). Older age was also significantly associated with prehypertensive and hypertensive BP measurements, especially among males (adjusted OR = 6.91). Among females, American Indian race was protective against elevated BP (adjusted OR = 0.61).

CONCLUSIONS: Obesity was consistently associated with an increased risk for elevated BP. American Indian race was associated with decreased risk of elevated BP measurements in females. The high prevalence of obesity-related hypertensive measurements in this population that includes American Indian children was similar to levels found in other multiracial populations of school children when using BP measurements from a single assessment.

Markers of inflammation and hemodynamic measurements in obesity: Copenhagen City Heart Study

Am J Hypertens. 2009 Apr;22(4):451-6. Asferg C, Jensen JS, Marott JL, Appleyard M, Møgelvang R, Jensen GB, Jeppesen J. Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Glostrup, Denmark.

BACKGROUND: Low-grade chronic inflammation has been proposed to play a major role in the pathogenesis of hypertension. Low-grade chronic inflammation is also closely associated with obesity, an established causative factor in the development of hypertension. The purpose of this study was to investigate the relationship between two markers of inflammation, C-reactive protein (CRP) and fibrinogen, and blood pressure (BP) and other hemodynamic variables in obese subjects.

METHODS: >From a large cardiovascular study based in the general population, we selected subjects with a body mass index (BMI) > or =30 kg/m2, free of major cardiovascular diseases, not taking BP-lowering or lipid-lowering drugs (n = 487; women = 51.1%; median (5th to 95th percentile) age = 62 years (36-80)). The cardiovascular study included measurements of traditional and new risk factors, including ankle brachial BP index, a measure of subclinical atherosclerosis. CRP was determined by a high-sensitive assay.

RESULTS: In partial Spearman rank correlation analysis, adjusted for age and sex, we found no significant relationships between either CRP or fibrinogen and systolic BP, diastolic BP, pulse pressure, or ankle brachial index (rho: -0.057 to 0.068; P > 0.13). However, fibrinogen and CRP were found to be significantly related to heart rate (rho: 0.127-0.169; P < 0.01).

CONCLUSIONS: In this study of generally healthy obese subjects from the general population, we found no significant relationships between markers of inflammation and systolic BP or diastolic BP, showing that obese subjects with higher levels of inflammatory markers do not have higher BP levels than their obese counterparts with lower levels of inflammatory markers.

Restriction of salt intake in the whole population promises great long-term benefits

Dtsch Med Wochenschr. 2009 May;134 Suppl 3:S108-18. Klaus D, Böhm M, Halle M, Kolloch R, Middeke M, Pavenstädt H, Hoyer J. Medizinische Klinik, Klinikum Dortmund.

Restricting salt intake not only leads to a decrease of blood pressure and a reduction in the incidence of arterial hypertension but also to a fall in cardiovascular morbidity and mortality. But high sodium intake is not only a risk factor for hypertension but also for cardiovascular diseases.

Moderate reduction of daily salt intake in the entire population of Germany from the present level of 8-10 mg to 5-6 mg is of great benefit for disease load and to the economy. Any possible risk for a few groups of persons is predictable and can be coped with. General sodium reduction cannot be achieved only by individual advice, instruction or information campaigns but requires a reduction in the sodium content of industrially processed foods, in fast-food chains, restaurants and canteens because they supply 80% of total daily sodium intake. To achieve the target of restricting the sodium intake of the whole population it is recommended that an interdisciplinary and interprofessional task force, "Less salt for all" be established. This is to bring together the expertise of scientific societies and institutions that see their main task in the reduction of cardiovascular mortality and morbidity by primary prevention.

Individual prevention in patients at risk can be very significantly improved by population-related preventive measures. These include, in addition to general limitation of sodium intake, continuing change in lifestyle.

Developmental programming and hypertension

Curr Opin Nephrol Hypertens. 2009 Mar;18(2):144-52. Nuyt AM, Alexander BT. Department of Pediatrics, Research Center, CHU Sainte-Justine, Université de Montréal, Canada.

PURPOSE OF REVIEW: There is a growing body of evidence linking adverse events or exposures during early life and adult-onset diseases. After important epidemiological studies from many parts of the world, research now focuses on mechanisms of organ dysfunction and on refining the understanding of the interaction between common elements of adverse perinatal conditions, such as nutrition, oxidants, and toxins exposures. This review will focus on advances in our comprehension of developmental programming of hypertension.

RECENT FINDINGS: Recent studies have unraveled important mechanisms of oligonephronia and impaired renal function, altered vascular function and structure as well as sympathetic regulation of the cardiovascular system. Furthermore, interactions between prenatal insults and postnatal conditions are the subject of intensive research. Prematurity vs. intrauterine growth restriction modulate differently programming of high blood pressure. Along with antenatal exposure to glucocorticoids and imbalanced nutrition, a critical role for perinatal oxidative stress is emerging.

SUMMARY: While the complexity of the interactions between antenatal and postnatal influences on adult blood pressure is increasingly recognized, the importance of postnatal life in (positively) modulating developmental programming offers the hope of a critical window of opportunity to reverse programming and prevent or reduce related adult-onset diseases.

Lifestyle interventions reduce coronary heart disease risk: results from the PREMIER Trial.

Circulation. 2009 Apr 21;119(15):2026-31. Maruthur NM, Wang NY, Appel LJ. Division of General Internal Medicine and the Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.

BACKGROUND: Although trials of lifestyle interventions generally focus on cardiovascular disease risk factors rather than hard clinical outcomes, 10-year coronary heart disease (CHD) risk can be estimated from the Framingham risk equations. Our objectives were to study the effect of 2 multicomponent lifestyle interventions on estimated CHD risk relative to advice alone and to evaluate whether differences can be observed in the effects of the lifestyle interventions among subgroups defined by baseline variables.

METHODS AND RESULTS: A total of 810 healthy adults with untreated prehypertension or stage I hypertension were randomized to 1 of 3 intervention groups: An "advice-only" group, an "established" group that used established lifestyle recommendations for blood pressure control (sodium reduction, weight loss, and increased physical activity), or an "established-plus-DASH" group that combined established lifestyle recommendations with the DASH (Dietary Approaches to Stop Hypertension) diet. The primary outcome was 10-year CHD risk, estimated from follow-up data collected at 6 months. A secondary outcome was 10-year CHD risk at 18 months. Of the 810 participants, 62% were women and 34% were black. Mean age was 50 years, mean systolic/diastolic blood pressure was 135/85 mm Hg, and median baseline Framingham risk was 1.9%. The relative risk ratio comparing 6-month to baseline Framingham risk was 0.86 (95% confidence interval 0.81 to 0.91, P<0.001) in the established group and 0.88 (95% confidence interval 0.83 to 0.94, P<0.001) in the established-plus-DASH group relative to advice alone. Results were virtually identical in sensitivity analyses, in each major subgroup, and at 18 months.

CONCLUSIONS: The observed reductions of 12% to 14% in estimated CHD risk are substantial and, if achieved, should have important public health benefits.

Prognostic value of nocturnal blood pressure reduction in resistant hypertension

Arch Intern Med. 2009 May 11;169(9):874-80. Muxfeldt ES, Cardoso CR, Salles GF. Department of Internal Medicine, University Hospital Clementino Fraga Filho, Medical School, Federal University of Rio de Janeiro, Rua Conde de Bonfim, Tijuca, Rio de Janeiro-RJ, Brazil.

BACKGROUND: The prognostic value of nocturnal blood pressure (BP) reduction in resistant hypertension (RH) is unknown. The objective of this prospective study was to evaluate its importance as a predictor of cardiovascular morbidity and mortality.

METHODS: At baseline, 556 patients with RH underwent clinical and laboratory examinations and 24-hour ambulatory BP monitoring. The primary end points were a composite of fatal or nonfatal cardiovascular events, all-cause mortality, and cardiovascular mortality. Multiple Cox regression was used to assess associations between the nocturnal BP reduction and the subsequent end points.

RESULTS: After a mean follow-up of 4.8 years (range, 1-103 months), 109 patients (19.6%) reached the composite end point, with 70 all-cause and 46 cardiovascular deaths. A nondipping pattern was present in 360 patients (65.0%). After adjustment for age, sex, body mass index, diabetes, smoking status, physical inactivity, dyslipidemia, previous cardiovascular disease, number of antihypertensive drugs in use, and office and 24-hour ambulatory BP readings, the nondipping pattern was an independent predictor of the composite end point (hazard ratio [HR], 1.74; 95% confidence interval [CI], 1.12-2.71) and of cardiovascular mortality (HR, 2.31; 95% CI, 1.09-4.92). In subgroup analysis, the reduced (HR, 1.71; 95% CI, 1.03-2.83) and reverted (HR, 1.89; 95% CI, 1.04-3.43) dipping patterns were predictive of total cardiovascular events. The effect of the nondipping pattern on cardiovascular prognosis was stronger in younger patients and in those with true RH.

CONCLUSIONS: The nocturnal BP variability patterns provide valuable prognostic information for stratification of cardiovascular morbidity and mortality risk in patients with RH, above and beyond other traditional cardiovascular risk factors and mean ambulatory BP levels.

Home blood pressure monitoring: a new standard method for monitoring hypertension control in treated patients.

Nat Clin Pract Cardiovasc Med. 2008 Dec;5(12):762-3. Pickering TG. Behavioral Cardiovascular Health and Hypertension Program, Columbia Presbyterian Medical Center, New York, NY 10032, USA.

Inadequate blood pressure (BP) control in patients with treated hypertension can be influenced by patient behavior, the inaccuracy of BP measurement in the clinical setting, and the fact that no single class of medication is universally effective. Home BP monitoring (HBPM) enables accurate measurement of BP and has been recommended (by multiple societies and associations) for the diagnosis of hypertension and the evaluation of antihypertensive treatment.

Although HBPM is thought to improve BP control as a result of patients' increased adherence to their medication, this improvement is limited. Green et al. have shown that HBPM in combination with regular internet correspondence with a medical professional is a highly effective therapeutic strategy for BP control, possibly because this strategy is associated with an increase in number of prescriptions. This strategy should, therefore, be routinely used in the management of patients with hypertension.

Association between refractory hypertension and obstructive sleep apnea.

J Hypertens. 2009 May 5. Ruttanaumpawan P, Nopmaneejumruslers C, Logan AG, Lazarescu A, Qian I, Bradley TD. aSleep Research Laboratory of the Toronto Rehabilitation Institute, Canada bDepartment of Medicine of the Mount Sinai Hospital and the University Health Network, Canada cCentre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada.

BACKGROUND: Obstructive sleep apnea (OSA) increases the risk for mild hypertension, but its relationship to refractory hypertension (RHT) has not been systematically examined. We previously reported a high prevalence of OSA in patients with RHT, but did not have a control group with which to compare. Rapid eye movement (REM) sleep deprivation can raise blood pressure in animals. However, a potential relationship of OSA and REM sleep time with RHT has not been examined.

OBJECTIVE: To determine whether, compared with patients with well controlled hypertension, those with RHT have a higher prevalence of OSA (apnea-hypopnea index >/=10 per hour of sleep) and shorter REM sleep time.

METHODS: We compared the prevalence of OSA and sleep structure in 42 patients with RHT with 22 patients with controlled hypertension, matched for age, sex and BMI.

RESULTS: Compared with the controlled hypertension group, the RHT group had a significantly higher prevalence of OSA (81 versus 55%, P = 0.03) and less REM sleep time (47.0 +/- 4.5 versus 63.2 +/- 4.9 min, P = 0.02). Multivariate analysis revealed significantly increased odds of having RHT associated with OSA independent of other risk factors (adjusted odds ratio, 3.994; 95% confidence interval, 1.191-13.388). Reduced REM sleep time was also independently associated with the presence of RHT (adjusted odds ratio, 1.025; 95% confidence interval, 1.002-1.049).

CONCLUSION: OSA and reduced REM sleep time are associated with increased odds of having RHT and, therefore, may play roles in its pathogenesis.

Impact of prehypertension on common carotid artery intima-media thickness and left ventricular mass

Stroke. 2009 Apr;40(4):1515-8 Manios E, Tsivgoulis G, Koroboki E, Stamatelopoulos K, Papamichael C, Toumanidis S, Stamboulis E, Vemmos K, Zakopoulos N. Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra Hospital, Athens, Greece.

BACKGROUND AND PURPOSE: Prehypertension has been recently introduced by JNC 7 as a new blood pressure (BP) category, associated with increased target-organ damage. Subclinical atherosclerosis by means of common artery intima-media thickness (CCA-IMT) has been incompletely investigated in prehypertensive patients. The aim of our study was to assess the extent of CCA-IMT and left ventricular mass (LVM) in prehypertensive adults in comparison to normotensive and untreated hypertensive subjects.

METHODS: >From a total of 5221 consecutive patients screened to our Hypertension Unit we selected 896 consecutive individuals according to prespecified inclusion criteria, who underwent 24-hour ambulatory BP monitoring, carotid artery ultrasonographic, and echocardiographic measurements. Patients who received antihypertensive treatment during the BP monitoring were excluded. According to the office BP levels, patients were divided into 3 subgroups: normotensives (office BP <120/80 mm Hg), prehypertensives (120/80 mm Hg<or=office BP<140/90 mm Hg), and hypertensives (office BP >or=140/90 mm Hg). Statistical analyses were performed by means of 1-way ANOVA, chi(2) test, and ANCOVA.

RESULTS: According to the office BP levels, the distribution of the study population was: normotensives (14.4%), prehypertensives (23.7%), and hypertensives (61.9%). Prehypertensive patients had higher CCA-IMT (P=0.038) and LVM (P=0.030) values than normotensive subjects, even after adjustment for baseline characteristics. Greater CCA-IMT values were observed in hypertensive patients in comparison to prehypertensives (P=0.002).

CONCLUSIONS: Prehypertensive patients had higher CCA-IMT and LVM than their normotensive counterparts. Prehypertension status is cross-sectionally associated with subclinical atherosclerosis and target-organ damage.

Orthostatic hypotension in genetically related hypertensive and normotensive individuals

J Hypertens. 2009 May;27(5):976-82 Fedorowski A, Burri P, Melander O. Department of Medicine, Malmö University Hospital, Malmö, Sweden.

OBJECTIVES: Prevalence and determinants of orthostatic hypotension remain largely unexplored in younger individuals without significant burden of chronic diseases.

METHODS: We investigated frequency and main associations of impaired orthostatic response in a cohort of 469 middle-aged hypertensive patients and 453 of their normotensive first-degree relatives.

RESULTS: 13.4% of hypertensive and 5.5% of normotensive study participants were found to have orthostatic hypotension. In a backward logistic regression the following determinants of orthostatic hypotension were identified: sex [female, odds ratio (OR) 2.45, 95% confidence interval (CI) 1.14-5.25, P=0.022], reduced glomerular filtration rate [OR (per ml/min/1.73 m2) 0.97, 95% CI 0.94-0.99, P=0.002], systolic [OR (per mmHg) 1.02, 95% CI 1.00-1.05, P=0.047] and diastolic blood pressure [OR (per mmHg) 1.04, 95% CI 1.00-1.09, P=0.033], and antihypertensive treatment (OR 0.41, 95% CI 0.18-0.93, P=0.034). In hypertensive patients use of angiotensin-converting enzyme inhibitors was related to lower orthostatic hypotension frequency. Percentage of orthostatic hypotension-positive patients in the highest blood pressure stratum (> or = 160 mmHg) decreased from 20.2 to 7.6, when diagnostic criteria of orthostatic hypotension were adjusted for mean systolic orthostatic reaction (2 SD value: 30 mmHg) . During follow-up (t=6.6 years) individuals with impaired orthostatic response showed a trend towards increased total mortality (OR 2.16, 95% CI 0.97-4.80, P=0.06) in a crude model.

CONCLUSION: Prevalence of orthostatic hypotension in hypertensive patients is higher than in their normotensive first-degree relatives. Independently of age, sex, and elevated blood pressure, orthostatic hypotension may be additionally determined by impaired renal function. Antihypertensive treatment seems to protect from orthostatic hypotension, in particular, use of angiotensin-converting enzyme inhibitors in hypertensive patients. The diagnostic criteria of orthostatic hypotension may need adjustment for initial supine systolic blood pressure to increase clinical accuracy. The prognostic value of impaired orthostatic response regarding risk of cardiovascular disease and mortality remains uncertain and requires further studies.

Masked nocturnal hypertension-a novel marker of risk in type 2 diabetes.

Diabetologia. 2009 Apr 25. Wijkman M, Länne T, Engvall J, Lindström T, Ostgren CJ, Nystrom FH. Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, 581 83, Linköping, Sweden,

AIMS/HYPOTHESIS: This study was designed to evaluate the prevalence of masked nocturnal hypertension (MNHT) and its impact on arterial stiffness and central blood pressure in patients with type 2 diabetes.

METHODS: Middle-aged patients (n = 414) with type 2 diabetes underwent clinic and ambulatory BP measurements and applanation tonometry.

RESULTS: MNHT (clinic BP < 130/80 mmHg and night-time BP >/= 120/70 mmHg) was found in 7.2% of patients (n = 30). Compared with patients with both clinical and nocturnal normotension (n = 70), patients with MNHT had higher aortic pulse wave velocity (PWV) (10.2 +/- 1.8 m/s vs 9.4 +/- 1.7 m/s; p = 0.03) and higher central BP (117.6 +/- 13.9/74.0 +/- 9.1 mmHg vs 110.4 +/- 16.4/69.7 +/- 9.6 mmHg, p = 0.04). In patients with clinical normotension, night-time systolic BP correlated significantly with PWV.

CONCLUSIONS/INTERPRETATION: Thirty per cent of patients with clinical normotension had nocturnal hypertension. This was accompanied by increased arterial stiffness and higher central BP. We conclude that in clinically normotensive patients with type 2 diabetes, ambulatory BP measurement may help clinicians to identify patients with increased cardiovascular risk.

Cognitive Impairment Is Related to Increased Arterial Stiffness and Microvascular Damage in Patients With Never-Treated Essential Hypertension.

Am J Hypertens. 2009 Mar 5 Triantafyllidi H, Arvaniti C, Lekakis J, Ikonomidis I, Siafakas N, Tzortzis S, Trivilou P, Zerva L, Stamboulis E, Kremastinos DT. 12nd Department of Cardiology, Medical School, University of Athens, Attikon Hospital, Athens, Greece.

Background: It is known that essential hypertension may be implicated in the development of cognitive impairment that is associated to microvascular disease of the brain. It has been hypothesized that increased arterial stiffness of the large arteries may lead to microvascular changes due to increased pulsatile flow. Our study tests the hypothesis that large artery stiffness and microvascular damage are related to brain microcirculation changes as reflected by impaired cognitive function

Methods: We studied 110 nondiabetic patients aged 40-80 years (mean age 53.8 +/- 11.2 years, 57 men) with recently diagnosed stage I-II essential hypertension. Mini-Mental State Examination (MMSE) was used as a screening test for global cognitive impairment. We performed both 2-D echocardiography and carotid-femoral pulse wave velocity (PWV) in order to evaluate arterial stiffness. Twenty-four hour urine microalbumin excretion was measured as a marker of microvascular damage

Results: In the entire population, MMSE was negatively correlated with age (r = -0.42, P < 0.001), 24-h pulse pressure (PP) (r = -0.18, P < 0.05), and PWV (r = -0.3, P = 0.003). Additionally, MMSE was not independently correlated with microalbuminuria in patients aged over 65 years (r = -0.58, P = 0.003)

Conclusions: Impaired cognitive function is associated with increased large artery stiffness and microalbumin excretion in newly diagnosed, untreated hypertensive patients. These findings support the hypothesis that cognitive impairment induced by impaired microcirculation is linked to large artery stiffness and microvascular

Call to action on use and reimbursement for home blood pressure monitoring: executive summary

A joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008 Jul;52(1):1-9. Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D; American Heart Association; American Society of Hypertension; Preventive Cardiovascular Nurses Association.

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (class IIa; level of evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of >or=12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.

Night-day blood pressure ratio and dipping pattern as predictors of death and cardiovascular events in hypertension

J Hum Hypertens. 2009 Feb 19. Fagard RH, Thijs L, Staessen JA, Clement DL, De Buyzere ML, De Bacquer DA. Hypertension and Cardiovascular Rehabilitation Unit, Faculty of Medicine, University of Leuven, Leuven, Belgium.

Our objective was to assess the prognostic significance of the night-time dipping pattern and the night-day blood pressure (BP) ratio for mortality and cardiovascular events in hypertensive patients without major cardiovascular disease at baseline. We performed a meta-analysis on individual data of 3468 patients from four prospective studies performed in Europe. Age of the subjects averaged 61+/-13 years; 45% were men and 61% were under antihypertensive treatment at the time of ambulatory BP monitoring. The night-day BP ratio and 24-h BP averaged, respectively, 0.907+/-0.085/0.866+/-0.095 and 138.1+/-16.4/82.3+/-11.0 mm Hg. Total follow-up time amounted to 23 164 patient-years. We used multivariable Cox regression analysis to assess the outcome of reverse dippers, non-dippers and extreme dippers vs dippers, and to assess the hazard ratios associated with 1 standard deviation higher night-day BP ratio. In comparison with dippers, and with adjustment for confounders and 24-h BP, the incidence of cardiovascular events was worse in reverse dippers (P
In conclusion, the dipping pattern and the night-day BP ratio significantly and independently predict mortality and cardiovascular events in hypertensive patients without history of major cardiovascular disease, even after adjustment for 24-h BP

Carotid artery stiffness, high-density lipoprotein cholesterol and inflammation in men with pre-hypertension.

J Hum Hypertens. 2009 Feb 19 Heffernan KS, Karas RH, Kuvin JT, Jae SY, Vieira VJ, Fernhall B. [1] 1Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL, USA [2] 2Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, MA, USA [3] 3Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA, USA.

Low circulating levels of high-density lipoprotein cholesterol (HDL-C) are associated with increased risk for cardiovascular events. HDL-C has a variety of poorly understood atheroprotective effects, including altering lipid metabolism and reducing inflammation. Increased arterial stiffness is an important predictor of subsequent cardiovascular risk. Therefore, in this study, we sought to determine whether HDL-C levels are associated with carotid arterial stiffness. In addition, we examined potential correlates of this association, such as inflammatory factors, cardiorespiratory fitness and body fat percentage. Carotid artery beta-stiffness was measured by ultrasound in 47 (23 years old) healthy pre-hypertensive men. Low HDL-C was defined as <1.0 mmol l(-1). Body fat was measured by air displacement plethysmography. Cardiorespiratory fitness was measured using a maximal exercise test, with metabolic gas analysis and inflammatory markers consisting of C-reactive protein (CRP), white blood cell (WBC) count and absolute neutrophil count. Men with a low HDL-C had significantly higher carotid artery stiffness, CRP, WBC count, neutrophil count, body fat, fasting glucose and lower cardiorespiratory fitness (P<0.05). Co-varying for cardiorespiratory fitness, % body fat and glucose had no effect on group differences in carotid artery stiffness. Co-varying for inflammatory markers resulted in groups having similar carotid artery stiffness. Pre-hypertensive men with low HDL-C have a higher carotid artery stiffness when compared with those with higher HDL-C.

The detrimental effects of low HDL-C on large artery stiffness in pre-hypertensive men may be mediated by inflammation and not by cardiorespiratory fitness or body fat levels

Suboptimal nutritional intake for hypertension control in 4 ethnic groups.

Arch Intern Med. 2009 Apr 13;169(7):702-7 Gao SK, Fitzpatrick AL, Psaty B, Jiang R, Post W, Cutler J, Maciejewski ML. Amgen Inc, 1 Amgen Center Dr, MS28-3A, Thousand Oaks, CA 91320-1799, USA.

BACKGROUND: This study compared intake of specific nutrients based on the Dietary Approaches to Stop Hypertension (DASH) guidelines for hypertension management among multiethnic middle-aged and older adults.

METHODS: We conducted quantitative analysis using baseline data of a prospective cohort study of 5972 adults aged 45 to 84 years recruited between July 2000 and August 2002 who participated in the Multi-Ethnic Study of Atherosclerosis (MESA). Diet information was collected using a 120-item food frequency questionnaire. Bivariate and multivariate methods were used to evaluate associations between DASH-accordant intake of each nutrient (fat, saturated fat, cholesterol, protein, fiber, calcium, magnesium, and potassium) with ethnicity and hypertension status.

RESULTS: Less than 30% of MESA participants met any DASH nutrient target. DASH accordance was lowest in saturated fat intake and highest in cholesterol intake (5.3% and 29.5% of the participants, respectively). Multivariate analyses showed significant ethnic differences in DASH accordance in all nutrients but saturated fat. Compared with white participants, Chinese American participants had greater DASH accordance in cholesterol (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.13-1.67) and protein intake (2.32; 1.55-3.49) but less in total fat (0.47; 0.30-0.74), magnesium (0.58; 0.51-0.67), and potassium intake (0.40; 0.20-0.81); African Americans and Hispanics had greater DASH accordance in fiber intake (1.36; 1.13-1.62; and 2.23; 1.53-3.23, respectively) but less in calcium intake (0.44; 0.37-0.52; and 0.79; 0.68-0.91, respectively). Diagnosed and uncontrolled hypertension was associated with less DASH accordance in saturated fat (OR, 0.80; 95% CI, 0.70-0.91) and magnesium (0.80; 0.71-0.91). DASH accordance differed significantly with and without inclusion of dietary supplements in the analysis.

CONCLUSIONS: There is significant variation in DASH goal attainment among different ethnic groups. Assessments of nutrient intake that exclude dietary supplements may be underestimating DASH accordance.

Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials.

Lancet. 2009 Mar 21;373(9668):1009-15 Heerspink HJ, Ninomiya T, Zoungas S, de Zeeuw D, Grobbee DE, Jardine MJ, Gallagher M, Roberts MA, Cass A, Neal B, Perkovic V. George Institute for International Health, University of Sydney, Sydney, Australia.

BACKGROUND: Patients undergoing dialysis have a substantially increased risk of cardiovascular mortality and morbidity. Although several trials have shown the cardiovascular benefits of lowering blood pressure in the general population, there is uncertainty about the efficacy and tolerability of reducing blood pressure in patients on dialysis. We did a systematic review and meta-analysis to assess the effect of blood pressure lowering in patients on dialysis.

METHODS: We systematically searched Medline, Embase, and the Cochrane Library database for trials reported between 1950 and November, 2008, without language restriction. We extracted a standardised dataset from randomised controlled trials of blood pressure lowering in patients on dialysis that reported cardiovascular outcomes. Meta-analysis was done with a random effects model.

FINDINGS: We identified eight relevant trials, which provided data for 1679 patients and 495 cardiovascular events. Weighted mean systolic blood pressure was 4.5 mm Hg lower and diastolic blood pressure 2.3 mm Hg lower in actively treated patients than in controls. Blood pressure lowering treatment was associated with lower risks of cardiovascular events (RR 0.71, 95% CI 0.55-0.92; p=0.009), all-cause mortality (RR 0.80, 0.66-0.96; p=0.014), and cardiovascular mortality (RR 0.71, 0.50-0.99; p=0.044) than control regimens. The effects seem to be consistent across a range of patient groups included in the studies.

INTERPRETATION: Treatment with agents that lower blood pressure should routinely be considered for individuals undergoing dialysis to reduce the very high cardiovascular morbidity and mortality rate in this population.

Isolated Systolic Hypertension and Incident Heart Failure in Older Adults. A Propensity-Matched Study.

Hypertension. 2009 Feb 2 Ekundayo OJ, Allman RM, Sanders PW, Aban I, Love TE, Arnett D, Ahmed A. University of Alabama at Birmingham and the Veterans' Affairs Medical Center, Birmingham, Ala; and Case Western Reserve University, Cleveland, Ohio.

The association between isolated systolic hypertension (ISH) and incident heart failure (HF) has not been prospectively studied in a propensity-matched population of ambulatory older adults. Of the 5795 participants in the public-use copy of the Cardiovascular Health Study data set, 5248 had diastolic blood pressure <90 mm Hg and were free of HF at baseline. Of these, 2000 (38%) had ISH, defined as average seated systolic blood pressure >/=140 mm Hg. Propensity scores for baseline ISH were calculated for each participant (based on 64 baseline covariates) and were used to match 1260 pairs of participants with and without ISH. Matched Cox regression models were used to estimate the association of ISH with incident HF during a mean follow-up of 8.7 years. Matched participants (n=2520) had a mean (+/-SD) age of 74 (+/-6) years, 60% were women, 16% were nonwhites, 18% developed new-onset HF, and 35% died. Incident HF developed in 20% (rate: 242/10 000 person-years) and 16% (rate: 194/10 000 person-years) of participants with and without ISH, respectively (matched hazard ratio when ISH was compared with no ISH: 1.26; 95% CI: 1.04 to 1.51; P=0.016). Prematch unadjusted, multivariable-adjusted, and propensity-adjusted hazard ratios (95% CIs) for ISH-associated incident HF were, respectively, 1.72 (1.51 to 1.97; P<0.0001), 1.35 (1.18 to 1.56; P<0.0001), and 1.22 (1.04 to 1.44; P=0.016). ISH had no association with all-cause mortality (matched hazard ratio: 1.03; 95% CI: 0.88 to 1.19; P=0.732).

In conclusion, in a propensity-matched cohort of community-dwelling older adults who were well balanced in 64 baseline covariates, ISH was associated with increased risk of incident HF but had no association with all-cause mortality.

Body mass index and vigorous physical activity and the risk of heart failure among men.

Circulation. 2009 Jan 6;119(1):44-52. Kenchaiah S, Sesso HD, Gaziano JM. Physicians' Health Study, Brigham and Women's Hospital, Boston, MA 02215, USA.

BACKGROUND: Elevated body mass index (BMI; weight in kilograms divided by height in meters squared) in the obese range (> or =30 kg/m(2)) is associated with an excess risk of heart failure (HF). However, the impact of overweight or preobese (BMI, 25 to 29.9 kg/m(2)) status and physical activity on HF risk is unclear.

METHODS AND RESULTS: In a prospective cohort of 21,094 men (mean age, 53 years) without known coronary heart disease at baseline in the Physicians' Health Study, we examined the individual and combined effects of BMI and vigorous physical activity (exercise to the point of breaking a sweat) on HF incidence from 1982 to 2007. We evaluated BMI as both a continuous (per 1-kg/m(2) increment) and a categorical (lean, <25 kg/m(2); overweight, 25 to 29.9 kg/m(2); and obese, > or =30 kg/m(2)) variable; we evaluated vigorous physical activity primarily as a dichotomous variable (inactive [rarely/never] versus active [> or =1 to 3 times a month]). During follow-up (mean, 20.5 years), 1109 participants developed new-onset HF. In multivariable analyses, every 1-kg/m(2) increase in BMI was associated with an 11% (95% confidence interval [CI], 9 to 13) increase in HF risk. Compared with lean participants, overweight participants had a 49% (95% CI, 32 to 69) and obese participants had a 180% (95% CI, 124 to 250) increase in HF risk. Vigorous physical activity conferred an 18% (95% CI, 4 to 30) decrease in HF risk. No interaction was found between BMI and vigorous physical activity and HF risk (P=0.96). Lean active men had the lowest and obese inactive men had the highest risk of HF. Compared with lean active men, the hazard ratios were 1.19 (95% CI, 0.94 to 1.51), 1.49 (95% CI, 1.30 to 1.71), 1.78 (95% CI, 1.43 to 2.23), 2.68 (95% CI, 2.08 to 3.45), and 3.93 (95% CI, 2.60 to 5.96) in lean inactive, overweight active, overweight inactive, obese active, and obese inactive men, respectively.

CONCLUSIONS: In this cohort of men, elevated BMI, even in the preobese range, was associated with an increased risk of HF, and vigorous physical activity was associated with a decreased risk. Public health measures to curtail excess weight, to maintain optimal weight, and to promote physical activity may limit the scourge of HF.

Association Between a DASH-Like Diet and Mortality in Adults With Hypertension: Findings From a Population-Based Follow-Up Study.

Am J Hypertens. 2009 Feb 5. Parikh A, Lipsitz SR, Natarajan S. Department of Internal Medicine, New York University School of Medicine, New York, New York, USA.

Background: Although the Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure (BP) in hypertensive adults, its effect on mortality is unclear.

Methods: This prospective cohort study evaluated the association between diet and mortality in 5,532 hypertensive adults in the Third National Health and Nutrition Examination Survey. Hypertension was determined by self-report, medication use, or BP measurement. Diet was ascertained by 24-h dietary recall using nine nutrient targets. The primary outcome was all-cause mortality. Secondary outcomes included specific causes of mortality (cardiovascular disease (CVD), ischemic heart disease (IHD), stroke, and cancer).

Results: Of the 5,532 participants, 391 (7.1%) consumed a DASH-like diet. During an average of 8.2 person-years of follow-up, there were 1,537 all-cause deaths; this included 312 cancer deaths and 788 cardiovascular deaths, of which 447 were due to IHD and 142 were due to stroke. After adjusting for multiple confounders while accounting for the complex survey design by utilizing survey weights, strata, and clusters in Cox proportional hazards models, a DASH-like diet was associated with lower mortality from all causes (hazard ratio (HR) 0.69, 95% confidence interval (CI) 0.52-0.92, P = 0.01) and stroke (HR 0.11, 95% CI 0.03-0.47, P = 0.003). Mortality risk from CVD (HR 0.92, 95% CI 0.63-1.35, P = 0.67), IHD (HR 0.77, 95% CI 0.47-1.24, P = 0.28), and cancer (HR 0.51, 95% CI 0.23-1.10, P = 0.09) did not reach statistical significance.

Conclusions: Though findings for specific causes of mortality are mixed, consumption of a DASH-like diet is associated with lower all-cause mortality in adults with hypertension

The Association of Cardiorespiratory Fitness and Physical Activity With Incidence of Hypertension in Men.

Am J Hypertens. 2009 Feb 5 Chase NL, Sui X, Lee DC, Blair SN. Department of Exercise Science, University of South Carolina, Columbia, South Carolina, USA.

Background: Few prospective studies have simultaneously investigated the relationship between physical activity, cardiorespiratory fitness (CRF), and the development of hypertension in initially normotensive individuals. In the Aerobics Center Longitudinal Study (ACLS), we examined this association among initially healthy normotensive men

Methods: Participants were 16,601 men aged 20-82 years who completed a baseline examination during 1970-2002 and were followed for hypertension incidence. Physical activity was self-reported and CRF was quantified from the duration of a maximal treadmill test.

Results: A total of 2,346 men reported hypertension during a mean 18 years of follow-up. Event rates per 10,000 man-years adjusted for age and examination year were 86.2, 76.6, and 66.7 across physical activity groups of sedentary, walker/jogger/runner (WJR), and sport/fitness, respectively, and 89.8, 78.4, and 64.6 for low, middle, and high CRF, respectively (trend P < 0.0001). These associations persisted after further adjustment for body mass index (BMI), smoking, alcohol intake, resting systolic blood pressure, baseline health status, family history of diseases, and survey response patterns

Conclusion: Both physical activity and CRF are associated with lower risk of developing hypertension in a graded fashion. These findings provide a basis for health professionals to emphasize the importance of participating in regular physical activity to improve fitness for the primary prevention of hypertension in men.

High-normal blood pressure is associated with a cluster of cardiovascular and metabolic risk factors: a population-based study.

J Hypertens. 2009 Jan;27(1):102-8. Bo S, Gambino R, Gentile L, Pagano G, Rosato R, Saracco GM, Cassader M, Durazzo M, Cavallo-Perin P. Department of Internal Medicine, University of Turin, Turin, Italy.

OBJECTIVE: A Few population-based studies have shown that high-normal blood pressure clusters with other cardiovascular risk factors. Increased inflammation, endothelial dysfunction, oxidative stress, and reduced adiponectin values have sporadically been reported in these patients.

METHODS: We cross-sectionally compared blood pressure categories with cardiovascular risk factors in an adult population-based cohort (n = 1658) and evaluated the relationships between C-reactive-protein, nitrotyrosine, total antioxidant status, E-selectin, vascular adhesion molecule-1, intercellular adhesion molecule-1, resistin, adiponectin values and blood pressure categories in a subgroup of healthy lean individuals from this cohort (n = 107) in order to exclude the impact of obesity/insulin resistance on these variables.

RESULTS: Glucose, triglyceride, low-density lipoprotein-cholesterol, alanine aminotranferase, gamma-glutamyl transferase values, and diabetes and metabolic syndrome prevalence were significantly higher in high-normal compared with the optimal blood pressure category. In the healthy subgroup, adiponectin (beta = - 4315.3; 95% confidence interval - 5916.4 -2654.2), total antioxidant status (-0.15; -0.3 -0.04) were significantly lower, and nitrotyrosine (1.2; 0.3 2.1), E-selectin (11.7; 1.8 21.6), vascular adhesion molecule-1 (0.3; 0.1 0.5), and intercellular adhesion molecule-1 (0.3; 0.1 0.5) were higher in high-normal compared with the optimal blood pressure category, at multiple regression analyses.

CONCLUSIONS: Individuals with high-normal blood pressure had a higher prevalence of cardiovascular and metabolic risk factors than those with optimal, and, even if healthy, they showed reduced adiponectin values, early signs of endothelial dysfunction, and oxidative stress. Further research is needed to determine whether they will benefit from blood pressure reduction.

Exercise Capacity and Mortality in Hypertensive Men With and Without Additional Risk Factors.

Hypertension. 2009 Jan 26 Kokkinos P, Manolis A, Pittaras A, Doumas M, Giannelou A, Panagiotakos DB, Faselis C, Narayan P, Singh S, Myers J. Veterans Affairs Medical Center, Washington, DC; Georgetown University, Washington, DC; Asklepeion General Hospital, Athens, Greece; Harokopion University, Athens, Greece; Veterans Affairs Palo Alto Health Care System, Stanford, Calif; and Stanford University, Stanford, Calif.

We assessed the association between exercise capacity and mortality in hypertensive men with and without additional cardiovascular risk factors. A cohort of 4631 hypertensive veterans, who successfully completed a graded exercise test at the Veterans Affairs Medical Center in Washington, DC, and Palo Alto, California, was followed for 7.7+/-5.4 years (35 629 person-years) for all-cause mortality. Fitness categories were established based on peak metabolic equivalent (MET) levels achieved. In each fitness category, we defined individuals with and without additional cardiovascular risk factors.

Exercise capacity was the strongest predictor of all-cause mortality. The adjusted mortality risk was 13% lower for every 1-MET increase in exercise capacity. Compared with the very low fit (</=5.0 MET), the adjusted risk was 34% lower for those achieving 5.1 to 7.0 MET (low fit; hazard ratio: 0.66; CI: 0.58 to 0.76; P<0.001), 59% lower for the moderate fit (7.1 to 10.0 MET; hazard ratio: 0.41; CI: 0.35 to 0.50; P<0.001), and 71% lower for the high-fit category (>10.0 MET; hazard ratio: 0.29; CI: 0.21 to 0.40; P<0.001). Within the very-low-fit category, mortality risk was 47% higher for those with additional risk factors compared with individuals with no risk factors. This risk was eliminated for those in the next fitness category (5.1 to 7.0 MET) and was progressively reduced for the moderate and high-fit categories regardless of the presence or absence of additional risk factors.

In conclusion, exercise capacity was the strongest predictor of all-cause mortality in hypertensive men. The increased risk imposed by low fitness and additional cardiovascular risk factors was eliminated by relatively small increases in exercise capacity and declined progressively with higher exercise capacity.

Relationship between blood pressure and outdoor temperature in a large sample of elderly individuals: the Three-City study.

Arch Intern Med. 2009 Jan 12;169(1):75-80 Alpérovitch A, Lacombe JM, Hanon O, Dartigues JF, Ritchie K, Ducimetière P, Tzourio C. INSERM U708, Paris Cedex 13, France.

BACKGROUND: Seasonal variations of blood pressure-related diseases have been described in several populations. However, few studies have examined the seasonal variations of blood pressure in the elderly, a segment of the population particularly exposed to vascular diseases. The association of blood pressure with season and outdoor temperature was examined in 8801 subjects 65 years or older from the Three-City study, a population-based longitudinal study.

METHODS: Blood pressure was measured at baseline and 2-year follow-up examinations. Daily outdoor temperature measured at 11 am was provided by the local meteorological offices.

RESULTS: Both systolic and diastolic blood pressure values differed significantly across the 4 seasons and across the quintiles of the distribution of outdoor temperature. Systolic blood pressure decreased with increasing temperature, with an 8.0-mm Hg decrease between the lowest (< 7.9 degrees C) and the highest (> or = 21.2 degrees C) temperature quintile. Intraindividual differences in blood pressure between follow-up and baseline examinations were strongly correlated with differences in outdoor temperature. The higher the temperature at follow-up compared with baseline, the greater the decrease in blood pressure. Longitudinal changes in blood pressure according to difference in outdoor temperature were larger in subjects 80 years or older than in younger participants.

CONCLUSIONS: Outdoor temperature and blood pressure are strongly correlated in the elderly, especially in those 80 years or older. During periods of extreme temperatures, a careful monitoring of blood pressure and antihypertensive treatment could contribute to reducing the consequences of blood pressure variations in the elderly.

Pulse pressure and adverse outcomes in women: a report from the Women's Ischemia Syndrome Evaluation (WISE).

Am J Hypertens. 2008 Nov;21(11):1224-30. Anderson RD, Sizemore BC, Barrow GM, Johnson BD, Merz CN, Sopko G, von Mering GO, Handberg EM, Nichols WW, Pepine CJ. Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.

BACKGROUND: Recent data suggest that brachial pulse pressure (PP) may be a better predictor of outcome than systolic or diastolic blood pressure (SBP/DBP). We sought to investigate the relative contributions of these indices to risk for adverse outcomes in women with suspected coronary artery disease (CAD) and myocardial ischemia.

METHODS: Among 857 women referred for angiography for suspected myocardial ischemia, baseline evaluations were performed, and the women were followed for clinical outcome. Relationships between baseline characteristics, blood pressure components, and outcomes were evaluated. Separate multivariate stepwise Cox regression models for PP and SBP (expressed in 10 mm Hg increments) were constructed and included covariates significantly associated with adverse outcomes.

RESULTS: After 5.2 years (mean), univariate testing identified higher PP associated with higher risk for cardiovascular (CV) mortality and adverse CV outcomes than SBP, DBP, or mean arterial pressure (MAP). Multivariate modeling identified both PP and SBP associated with adverse CV outcomes, but only PP was significantly associated with higher CV mortality. When both PP and SBP were included in the model, only PP remained an independent predictor of adverse outcomes for CV events.

CONCLUSIONS: In women with suspected CAD and myocardial ischemia, PP is a stronger predictor of adverse outcomes than SBP, DBP, or MAP with an 18% excess mortality risk for every 10 mm Hg increase in PP. Further investigations into pathophysiologic mechanisms and specific pharmacologic approaches to modifying this novel target are warranted.

Trends of elevated blood pressure among children and adolescents: data from the National Health and Nutrition Examination Survey1988-2006.

Am J Hypertens. 2009 Jan;22(1):59-67. Ostchega Y, Carroll M, Prineas RJ, McDowell MA, Louis T, Tilert T. Division of Health Nutrition Examination Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA.

BACKGROUND: Elevated blood pressure (EBP) in children and adolescents increases future risk of cardiovascular disease. Among children and adolescents, increased weight is associated with EBP.

METHODS: National cross-sectional data for children and adolescents aged 8-17 years from the National Health and Nutrition Examination Surveys (NHANESs): 1988-1994, 1999-2002, and 2003-2006. The main outcome measures were EBP and pre-EBP estimates.

RESULTS: Overweight boys (odds ratio (OR) 1.54, confidence interval (CI) 1.11-2.13) and both obese boys and girls were significantly more likely to be classified as pre-EBP (boys, OR 2.81, CI 2.13-3.71; girls, OR 2.55, CI 1.75-3.73) and having EBP (boys aged 8-12 years, OR 6.06, CI 2.73-13.44, boys aged 13-17, OR 9.62 CI 4.86-19.06; girls, OR 2.33, CI 1.31-4.13) when compared to the reference weight and controlling for all other covariates.During 2003-2006, 13.6% (s.e. = 1.2) of boys aged 8-17 years and 5.7% (s.e. = 0.7) of the girls aged 8-17 years were classified as pre-EBP and 2.6% (s.e. = 0.5) of the boys aged 8-17 and 3.4% (s.e. = 0.7) of the girls aged 8-17 were having EBP. After controlling for age, race/ethnicity, and body mass index (BMI), girls only were significantly more likely to have EBP during 2003-2006 than during 1988-1994 (OR 2.17, CI 1.05-4.49). In contrast, adolescent boys aged 13-17 years were significantly less likely to be having EBP during 2003-2006 than during 1988-1994 (OR 0.32, CI 0.13-0.81).

CONCLUSIONS: Obesity is strongly, positively, and independently associated with EBP and pre-EBP among youths. However, controlling for all covariates including BMI, EBP has increased among girls but decreased among adolescent boys aged 13-17, during 2003-2006 when compared with 1988-1994.

Blood pressure in firefighters, police officers, and other emergency responders

Am J Hypertens. 2009 Jan;22(1):11-20. Kales SN, Tsismenakis AJ, Zhang C, Soteriades ES. Department of Environmental Health, Environmental & Occupational Medicine & Epidemiology (EOME), Harvard School of Public Health, Boston, Massachusetts, USA.

Elevated blood pressure is a major risk factor for cardiovascular morbidity and mortality. Increased risk begins in the prehypertensive range and increases further with higher pressures. The strenuous duties of emergency responders (firefighters, police officers, and emergency medical services (EMS) personnel) can interact with their personal risk profiles, including elevated blood pressure, to precipitate acute cardiovascular events. Approximately three-quarters of emergency responders have prehypertension or hypertension, a proportion which is expected to increase, based on the obesity epidemic. Elevated blood pressure is also inadequately controlled in these professionals and strongly linked to cardiovascular disease morbidity and mortality. Notably, the majority of incident cardiovascular disease events occur in responders who are initially prehypertensive or only mildly hypertensive and whose average premorbid blood pressures are in the range in which many physicians would hesitate to prescribe medications (140-146/88-92). Laws mandating public benefits for emergency responders with cardiovascular disease provide an additional rationale for aggressively controlling their blood pressure. This review provides a background on emergency responders, summarizes occupational risk factors for hypertension and the metabolic syndrome, their prevalence of elevated blood pressure, and evidence linking hypertension with adverse outcomes in these professions. Next, discrepancies between relatively outdated medical standards for emergency responders and current, evidence-based guidelines for blood pressure management in the general public are highlighted. Finally, a workplace-oriented approach for blood pressure control among emergency responders is proposed, based on the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Blood pressure and mortality risk on peritoneal dialysis

Am J Kidney Dis. 2009 Jan;53(1):70-8 Udayaraj UP, Steenkamp R, Caskey FJ, Rogers C, Nitsch D, Ansell D, Tomson CR. UK Renal Registry, Southmead Hospital, Southmead Road, Bristol, UK.

BACKGROUND: The association of baseline blood pressure (BP) and mortality in incident peritoneal dialysis patients has not been adequately studied.

STUDY DESIGN: Cohort study.

SETTING & PARTICIPANTS: 2,770 patients on PD therapy at 180 days from start of renal replacement therapy in England and Wales between 1997 and 2004.

PREDICTORS: Systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP) measured in the first 6 months of renal replacement therapy and other baseline demographic and laboratory variables.

OUTCOMES: All-cause mortality was studied using time-stratified Cox regression models (to account for nonproportionality) dividing follow-up time into 4 intervals: year 1 (days 180 to 365), years 2 to 3, years 4 to 5, and years 6+. Interactions between BP components and transplant waitlist and diabetes status were explored.

RESULTS: Median follow-up was 3.7 years (range, 0.1 to 9.9 years), and 1,104 deaths were observed. In fully adjusted analyses, greater SBP, DBP, MAP, and PP were associated with decreased mortality in the first year, but greater SBP and PP were associated with increased late mortality (in years 6+). However, in the subgroup of patients placed on the transplant waitlist within 6 months of starting renal replacement therapy, greater SBP, DBP, MAP, and PP were not associated with decreased mortality in the first year. LIMITATIONS: Exclusion of 3,086 patients because of missing BP data. No data were available for cardiac function or antihypertensive medication.

CONCLUSIONS: Although greater SBP, DBP, MAP, and PP appear protective against early mortality in the overall cohort, this effect is not seen in patients registered on the national transplant waiting list within 6 months of starting renal replacement therapy.

Hypertension and obstructive sleep apnoea syndrome: current perspectives.

J Hum Hypertens. 2009 Jan 8. Baguet JP, Barone-Rochette G, Pépin JL. [1] 1Department of Cardiology, University Hospital, Grenoble, France [2] 2Bioclinic Radiopharmaceutics Laboratory, INSERM U877, Joseph Fourier University, Grenoble, France.

Obstructive sleep apnoea syndrome (OSAS), due to the collapse of the upper airways, is a common but still underestimated condition. The 'dose-response' type relationship between OSAS and hypertension (HT) has now been clearly proven. There are multiple mechanisms explaining this relationship, the main one being an increase in sympathetic activity during the apnoeas. HT associated with OSAS has several characteristics: high prevalence, diastolic and nocturnal predominance, and frequent non-dipper status. Furthermore, as OSAS is found in the majority of subjects with refractory HT, it should be systematically investigated in this situation. HT associated with OSAS should be tested for by means of a clinical blood pressure (BP) measurement, to which 24-h ambulatory BP monitoring (ABPM) is often added due to the fact that BP anomalies are frequently present at night. HT during OSAS is frequently associated with metabolic anomalies (for example, obesity, dyslipidaemia and insulin resistance), therefore explaining the high prevalence of metabolic syndrome in this population. The reference treatment for OSAS-nasal continuous positive airway pressure (nCPAP)-seems to be able to lower the BP of hypertensive patients, especially if the HT is severe, untreated or refractory. Moreover, the BP response to nCPAP depends on the severity of the OSAS, in particular the scale of the nocturnal desaturations, and on patient tolerance of the treatment. Optimal treatment for HT associated with OSAS has not been evidenced. Antihypertensive drugs do not change the respiratory parameters during OSAS.

Contribution of obesity and abdominal fat mass to risk of stroke and transient ischemic attacks.

Stroke. 2008 Dec;39(12):3145-51. Winter Y, Rohrmann S, Linseisen J, Lanczik O, Ringleb PA, Hebebrand J, Back T. Department of Neurology, Klinikum Mannheim, University of Heidelberg, Germany.

BACKGROUND AND PURPOSE: Waist circumference has been shown to be a better predictor of cardiovascular risk than body mass index (BMI). Our case-control study aimed to evaluate the contribution of obesity and abdominal fat mass to the risk of stroke and transient ischemic attacks (TIA).

METHODS: We recruited 1137 participants: 379 cases with stroke/TIA and 758 regional controls matched for age and sex. Associations between different markers of obesity (BMI, waist-to-hip ratio, waist circumference and waist-to-stature ratio) and risk of stroke/TIA were assessed by using conditional logistic regression adjusted for other risk factors.

RESULTS: BMI showed a positive association with cerebrovascular risk which became nonsignificant after adjustment for physical inactivity, smoking, hypertension, and diabetes (odds ratio 1.18; 95% CI, 0.77 to 1.79, top tertile versus bottom tertile). Markers of abdominal adiposity were strongly associated with the risk of stroke/TIA. For the waist-to-hip ratio, adjusted odds ratios for every successive tertile were greater than that of the previous one (2nd tertile: 2.78, 1.57 to 4.91; 3rd tertile: 7.69, 4.53 to 13.03). Significant associations with the risk of stroke/TIA were also found for waist circumference and waist-to-stature ratio (odds ratio 4.25, 2.65 to 6.84 and odds ratio 4.67, 2.82 to 7.73, top versus bottom tertile after risk adjustment, respectively).

CONCLUSIONS: Markers of abdominal adiposity showed a graded and significant association with risk of stroke/TIA, independent of other vascular risk factors. Waist circumference and related ratios can better predict cerebrovascular events than BMI.

Ambulatory blood pressure monitoring and all-cause mortality in elderly people with diabetes mellitus.

Hypertension. 2009 Feb;53(2):120-7. Palmas W, Pickering TG, Teresi J, Schwartz JE, Moran A, Weinstock RS, Shea S. Department of Medicine, Columbia University, New York, NY 10032, USA.

In a multiethnic cohort of older people with diabetes (n=1178), we assessed whether ambulatory blood pressure (BP) monitoring improves prediction of all-cause mortality and cardiovascular mortality when added to baseline covariates, including office BP and heart rate (HR). Secondary analyses assessed whether albuminuria may mediate the association of pulse pressure with mortality. The ambulatory arterial stiffness index was calculated as "1-slope" from the within-person regression of diastolic-on-systolic ambulatory BP readings. Mean follow-up was 6.6+/-0.4 years.

There were 287 deaths; death certificates were available for 215 deaths (75%), and 110 of them were deemed of cardiovascular cause. Cox models were built incrementally. First, models using clinical and laboratory variables selected albuminuria and office HRs as independent predictors of all-cause and cardiovascular mortality. When ambulatory monitoring data were added, sleep:wake HR ratio and ambulatory arterial stiffness index added significantly to the prediction of all-cause mortality, but only sleep:wake HR ratio added to the prediction of cardiovascular mortality. Office HR and albuminuria retained significance as predictors of both types of mortality. Secondary analyses without adjustment for albuminuria confirmed the predictive value of office HR and sleep/wake HR, whereas 24-hour pulse pressure and sleep systolic BP were also independently predictive of all-cause and cardiovascular mortality, respectively.

In conclusion, office HR and albuminuria were strong predictors of mortality. Ambulatory monitoring improved the prediction of risk through its assessment of sleep HR dipping and of ambulatory arterial stiffness index, a measure of the dynamic relationship between systolic and diastolic BPs. Albuminuria may mediate the association between BP and mortality.

Relationship Between Blood Pressure and Outdoor Temperature in a Large Sample of Elderly Individuals

The Three-City Study Arch Intern Med. 2009;169(1):75-80. Annick Alpérovitch, MD; Jean-Marc Lacombe, MSc; Olivier Hanon, MD; Jean-François Dartigues, MD; Karen Ritchie, PhD; Pierre Ducimetière, PhD; Christophe Tzourio, MD

Background
Seasonal variations of blood pressure–related diseases have been described in several populations. However, few studies have examined the seasonal variations of blood pressure in the elderly, a segment of the population particularly exposed to vascular diseases. The association of blood pressure with season and outdoor temperature was examined in 8801 subjects 65 years or older from the Three-City study, a population-based longitudinal study.

Methods
Blood pressure was measured at baseline and 2-year follow-up examinations. Daily outdoor temperature measured at 11 AM was provided by the local meteorological offices.

Results
Both systolic and diastolic blood pressure values differed significantly across the 4 seasons and across the quintiles of the distribution of outdoor temperature. Systolic blood pressure decreased with increasing temperature, with an 8.0–mm Hg decrease between the lowest (<7.9°C) and the highest (≥21.2°C) temperature quintile. Intraindividual differences in blood pressure between follow-up and baseline examinations were strongly correlated with differences in outdoor temperature. The higher the temperature at follow-up compared with baseline, the greater the decrease in blood pressure. Longitudinal changes in blood pressure according to difference in outdoor temperature were larger in subjects 80 years or older than in younger participants.

Conclusions
Outdoor temperature and blood pressure are strongly correlated in the elderly, especially in those 80 years or older. During periods of extreme temperatures, a careful monitoring of blood pressure and antihypertensive treatment could contribute to reducing the consequences of blood pressure variations in the elderly.

Determinants of systemic vascular function in patients with stable chronic obstructive pulmonary disease.

Am J Respir Crit Care Med. 2008 Dec 15;178(12):1211-8. Eickhoff P, Valipour A, Kiss D, Schreder M, Cekici L, Geyer K, Kohansal R, Burghuber OC. St Anna Childrens Hospital, Vienna, Austria.

RATIONALE: Impaired vascular reactivity is an important factor in the pathogenesis of cardiovascular disease.

OBJECTIVES: We sought to assess vascular reactivity in patients with chronic obstructive pulmonary disease (COPD) and respective control subjects, and to investigate the relation between vascular function and airflow obstruction and systemic inflammation.

METHODS: We studied 60 patients with stable COPD; 20 smokers with normal lung function matched for age, sex, and body weight; and 20 similarly matched nonsmokers. Patients with cardiovascular comorbidities were excluded. The endothelium-dependent and endothelium-independent function of the vasculature was measured using flow-mediated and nitrogen-mediated dilation of the brachial artery, respectively. Systemic inflammatory markers, including C-reactive protein, fibrinogen, and interleukin (IL)-6, were determined in serum.

MEASUREMENTS AND MAIN RESULTS: Both flow-mediated and nitrogen-mediated dilation of the brachial artery were significantly lower in patients with stable COPD than in smoking and nonsmoking control subjects. Levels of inflammatory mediators such as IL-6 and fibrinogen were higher in patients than they were in control subjects. In patients with COPD, stepwise multiple regression analysis showed that age, sex, baseline brachial artery diameter, C-reactive protein level, leukocyte count, blood glucose level, and percentage of predicted forced expiratory volume in 1 s were independent predictors of flow-mediated dilation. There was no relation between flow-mediated dilation and pack-years of smoking. Baseline brachial artery diameter was the only independent predictor of nitrogen-mediated dilation in patients with COPD.

CONCLUSIONS: Both endothelium-dependent and endothelium-independent vasodilation is significantly impaired in patients with stable COPD. Airflow obstruction and systemic inflammation may increase the risk of cardiovascular disease in patients with COPD.

Ambulatory blood pressure monitoring versus self-measurement of blood pressure at home: correlation with target organ damage.

J Hypertens. 2008 Oct;26(10):1919-27. Gaborieau V, Delarche N, Gosse P. Cardiology unit, Pau General Hospital, Pau, France.

OBJECTIVE: Ambulatory blood pressure (BP) monitoring and home blood pressure measurements predicted the presence of target organ damage and the risk of cardiovascular events better than did office blood pressure.

METHODS: To compare these two methods in their correlation with organ damage, we consecutively included 325 treated (70%) or untreated hypertensives (125 women, mean age = 64.5 +/- 11.3) with office (three measurements at two consultations), home (three measurements morning and evening over 3 days) and 24-h ambulatory monitoring. Target organs were evaluated by ECG, echocardiography, carotid echography and detection of microalbuminuria. Data from 302 patients were analyzed.

RESULTS: Mean BP levels were 142/82 mmHg for office, 135.5/77 mmHg for home and 128/76 mmHg for 24-h monitoring (day = 130/78 mmHg; night = 118.5/67 mmHg). With a 135 mmHg cut-off, home and daytime blood pressure diverged in 20% of patients. Ambulatory and Home blood pressure were correlated with organ damage more closely than was office BP with a trend to better correlations with home BP. Using regression analysis, a 140 mmHg home systolic blood pressure corresponded to a 135 mmHg daytime systolic blood pressure; a 133 mmHg daytime ambulatory blood pressure and a 140 mmHg home blood pressure corresponded to the same organ damage cut-offs (Left ventricular mass index = 50 g/m, Cornell.QRS = 2440 mm/ms, carotid intima media thickness = 0.9 mm). Home-ambulatory differences were significantly associated with age and antihypertensive treatment.

CONCLUSION: We showed that home blood pressure was at least as well correlated with target organ damage, as was the ambulatory blood pressure. Home-ambulatory correlation and their correlation with organ damage argue in favor of different cut-offs, that are approximately 5 mmHg higher for systolic home blood pressure.

Monitoring of the central pulse pressure is useful for detecting cardiac overload during antiadrenergic treatment: the Japan Morning Surge 1 study.

J Hypertens. 2008 Oct;26(10):1928-34. Matsui Y, Eguchi K, Shibasaki S, Ishikawa J, Hoshide S, Pickering TG, Shimada K, Kario K; JMS-1 Study Group. Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.

OBJECTIVE: Lowering of the central pulse pressure (PP) has been shown to contribute to an improvement of the cardiac damage beyond that of lowering the brachial PP. We assessed the hypothesis that the change in the central PP is more useful than that in the brachial PP in the assessment of the change in cardiac load.

METHODS: We studied 434 treated hypertensive patients whose home systolic blood pressure was 135 mmHg or higher. They were followed for 6 months after allocation to either a control group or an added treatment group (doxazosin 1-4 mg and atenolol when needed). We measured the brachial and central (carotid) blood pressure simultaneously using a validated device, and the B-type natriuretic peptide at baseline and at the sixth month of treatment.

RESULTS: In the added treatment group, the brachial systolic blood pressure was successfully reduced, but the central PP increased significantly, whereas the other blood pressure parameters did not change from the baseline. In the added treatment group, the change in the B-type natriuretic peptide was significantly correlated with the change in the brachial PP (r = 0.18), central systolic blood pressure (r = 0.18), central PP (r = 0.26), and PP amplification (r = -0.22) even after adjusting for the confounding factors. The correlation with the central PP was stronger than with the brachial PP (P = 0.018) or central systolic blood pressure (P = 0.002), and these relationships were essentially the same even after adjustment for the use of atenolol or the change in heart rate.

CONCLUSION: This study showed that the central PP measurement may be more important to assess cardiac load than the brachial PP during antiadrenergic treatment.

The impact of hyperacute blood pressure lowering on the early clinical outcome following intracerebral hemorrhage.

J Hypertens. 2008 Oct;26(10):2016-21 Itabashi R, Toyoda K, Yasaka M, Kuwashiro T, Nakagaki H, Miyashita F, Okada Y, Naritomi H, Minematsu K. Cerebrovascular Division, Department of Medicine, National Cardiovascular Center, Suita, Osaka, Japan.

OBJECTIVE: Blood pressure lowering in acute intracerebral hemorrhage patients may prevent hematoma growth and neurological deterioration. The optimal goal of hyperacute antihypertensive therapy for intracerebral hemorrhage patients to obtain a favorable early clinical outcome was investigated.

METHODS: Of 688 consecutive patients who were admitted to our stroke care units within 24 h after intracerebral hemorrhage onset, 244 patients who emergently received intravenous antihypertensive therapy due to admission blood pressure at least 180/105 mmHg were assessed. The average systolic and diastolic blood pressure values 6, 12, and 24 h after admission and the percentage reduction of the blood pressure value with respect to the admission blood pressure value were used for analysis.

RESULTS: At 3 weeks, 66 patients (27%) had a completely independent activity level corresponding to a modified Rankin Scale score of 1 or less. After adjustment for baseline characteristics, a favorable functional outcome was more common in patients with the lowest quartile of average systolic blood pressure in the initial 24 h (<138 mmHg, odds ratio 4.36, 95% confidence interval 1.10-17.22), and was similarly common in those with the middle two quartiles (138-148 mmHg, 148-158 mmHg) than in those with the highest quartile of systolic blood pressure (> or = 158 mmHg). Analyses using patient quartiles on the basis of the average diastolic blood pressure or the reduction of systolic or diastolic blood pressure did not show an association with early outcome.

CONCLUSION: Lowering the systolic blood pressure to less than 138 mmHg during the initial 24 h appears to be predictive of favorable early outcome in intracerebral hemorrhage patients. Randomized controlled trials to answer this question are needed.

Implications of persistent prehypertension for ageing-related changes in left ventricular geometry and function: the MONICA/KORA Augsburg study.

J Hypertens. 2008 Oct;26(10):2040-9. Markus MR, Stritzke J, Lieb W, Mayer B, Luchner A, Döring A, Keil U, Hense HW, Schunkert H. Medical Clinic II, University of Lübeck Medical School, Lübeck, Germany.

BACKGROUND: It is unclear whether persistent prehypertension causes structural or functional alterations of the heart.

METHODS: We examined echocardiographic data of 1005 adults from a population-based survey at baseline in 1994/1995 and at follow-up in 2004/2005. We compared individuals who had either persistently normal (<120 mmHg systolic and <80 mmHg diastolic, n = 142) or prehypertensive blood pressure (120-139 mmHg or 80-89 mmHg, n = 119) at both examinations using multivariate regression modeling.

RESULTS: Over 10 years, left ventricular end-diastolic diameters were stable and did not differ between the two groups. However, the prehypertensive blood pressure group displayed more pronounced ageing-related increases of left ventricular wall thickness (+4.7 versus +11.9%, P < 0.001) and left ventricular mass (+8.6 versus +15.7%, P = 0.006). Prehypertension was associated with a raised incidence of left ventricular concentric remodeling (adjusted odds ratio 10.7, 95% confidence interval 2.82-40.4) and left ventricular hypertrophy (adjusted odds ratio 5.33, 1.58-17.9). The ratio of early and late diastolic peak transmitral flow velocities (E/A) decreased by 7.7% in the normal blood pressure versus 15.7% in the prehypertensive blood pressure group (P = 0.003) and at follow-up the ratio of early diastolic peak transmitral flow and early diastolic peak myocardial relaxation velocities (E/EM) was higher (9.1 versus 8.5, P = 0.031) and left atrial size was larger (36.5 versus 35.3 mm, P = 0.024) in the prehypertensive blood pressure group. Finally, the adjusted odds ratio for incident diastolic dysfunction was 2.52 (1.01-6.31) for the prehypertensive blood pressure group.

CONCLUSIONS: Persistent prehypertension accelerates the development of hypertrophy and diastolic dysfunction of the heart.

Regular physical activity prevents development of left ventricular hypertrophy in hypertension.

Eur Heart J. 2008 Dec 11. Palatini P, Visentin P, Dorigatti F, Guarnieri C, Santonastaso M, Cozzio S, Pegoraro F, Bortolazzi A, Vriz O, Mos L; on behalf of the HARVEST Study Group. Clinica Medica 4, University of Padova, via Giustiniani, 2, 35128 Padova, Italy.

Aims: The longitudinal relationship between aerobic exercise and left ventricular (LV) mass in hypertension is not well known. We did a prospective study to investigate the long-term effect of regular physical activity on development of LV hypertrophy (LVH) in a cohort of young subjects screened for Stage 1 hypertension.

Methods and results: We assessed 454 subjects whose physical activity status was consistent during the follow-up. Echocardiographic LV mass was measured at entry, every 5 years, and/or at the time of hypertension development before starting treatment. LVH was defined as an LV mass >/=50 g/m(2.7) in men and >/=47 g/m(2.7) in women. During a median follow-up of 8.3 years, 32 subjects developed LVH (sedentary, 10.3%; active, 1.7%, P = 0.000). In a logistic regression, physically active groups combined (n = 173) were less likely to develop LVH than sedentary group with a crude OR = 0.15 (CI, 0.05-0.52). After controlling for sex, age, family history for hypertension, hypertension duration, body mass, blood pressure, baseline LV mass, lifestyle factors, and follow-up length, the OR was 0.24 (CI, 0.07-0.85). Blood pressure declined over time in physically active subjects (-5.1 +/- 17.0/-0.5 +/- 10.2 mmHg) and slightly increased in their sedentary peers (0.0 +/- 15.3/0.9 +/- 9.7 mmHg, adjusted P vs. active = 0.04/0.06). Inclusion of changes in blood pressure over time into the logistic model slightly decreased the strength of the association between physical activity status and LVH development (OR = 0.25, CI, 0.07-0.87).

Conclusion: Regular physical activity prevents the development of LVH in young stage 1 hypertensive subjects. This effect is independent from the reduction in blood pressure caused by exercise.

Effect of comprehensive therapeutic lifestyle changes on prehypertension

Am J Cardiol. 2008 Dec 15;102(12):1677-80. Bavikati VV, Sperling LS, Salmon RD, Faircloth GC, Gordon TL, Franklin BA, Gordon NF. Emory University School of Medicine, Atlanta, Georgia, USA.

Although national clinical guidelines promulgate therapeutic lifestyle changes (TLC) as a cornerstone in the management of prehypertension, there is a perceived ineffectiveness of TLC in the real world. In this study of 2,478 ethnically diverse (African Americans n = 448, Caucasians n = 1,881) men (n = 666) and women (n = 1,812) with prehypertension and no known atherosclerotic cardiovascular disease, diabetes mellitus, or chronic kidney disease, we evaluated the clinical effectiveness of TLC in normalizing blood pressure (BP) without antihypertensive medications. Subjects were evaluated at baseline and after an average of 6 months of participation in a community-based program of TLC. TLC included exercise training, nutrition, weight management, stress management, and smoking cessation interventions.

Baseline BP (125 +/- 8/79 +/- 3 mm Hg) decreased by 6 +/- 12/3 +/- 3 mm Hg (p <or=0.001), with 952 subjects (38.4%) normalizing their BP (p <or=0.001). In subjects with a baseline systolic BP of 120 to 139 mm Hg (n = 2,082), systolic BP decreased by 7 +/- 12 mm Hg (p <or=0.001). In subjects with a baseline diastolic BP of 80 to 89 mm Hg (n = 1,504), diastolic BP decreased by 6 +/- 3 mm Hg (p <or=0.001). There were no racial differences in the magnitude of reduction in BP; however, women had greater BP reductions than men (p <or=0.001). Also, subjects with a baseline body mass index (BMI) <30 kg/m(2) had a greater reduction in BP than those with a BMI >or=30 kg/m(2).

In conclusion, the present study adds to previous research by reporting on the effectiveness, rather than the efficacy, of TLC when administered in a real-world, community-based setting.

The metabolic syndrome and risk of myocardial infarction in familial hypertension (Hypertension Heredity in Malmö Evaluation study).

J Hypertens. 2009 Jan;27(1):109-17. Fedorowski A, Burri P, Hulthén L, Melander O. aDepartment of Medicine, Sweden bDepartment of Clinical Sciences, Lund University, Sweden cDepartment of Endocrinology, Malmö University Hospital, Malmö, Sweden.

OBJECTIVES: The aim of this study was to examine whether three main definitions of the metabolic syndrome (MetS) - WHO, National Cholesterol Education Program-Adult Treatment Panel III and International Diabetes Federation - identify the same individuals and are able to predict incident myocardial infarction (MI) in families with essential hypertension.

METHODS: The tested definitions were prospectively related to data on MI in a cohort of approximately 1700 individuals with overt essential hypertension and their normotensive first-degree relatives.

RESULTS: At baseline, 616 participants had MetS, yet only 209 of them (33.9%) were identified by all definitions, and compatibility rate for each pair of definitions was approximately 50%. During follow-up (Tmean approximately 6.6 years) 53 participants developed MI and they were generally older and more dysmetabolic than the rest of the cohort. There were also more men, smokers and diabetic individuals in this group. After adjustment for all conventional cardiovascular risk factors, including hypertension and diabetes, only the National Cholesterol Education Program definition could predict the increased risk of MI [odds ratio (OR) = 2.2, confidence interval (CI) = 1.2-4.0, P = 0.01]. Among individual MetS components, incident MI was independently associated with three of them: low high-density lipoprotein-cholesterol (OR = 2.03, CI = 1.09-3.78, P = 0.025) insulin resistance (OR = 2.02, CI = 1.08-3.78, P = 0.028) and increased albumin excretion rate (OR = 1.24, CI = 0.99-1.55, P = 0.060).

CONCLUSION: The presence of MetS in hypertensive and genetically hypertension prone individuals may signal the increased risk of future MI. However, only the National Cholesterol Education Program criteria appear to have a sufficient predictive accuracy.

Disparate Estimates of Hypertension Control From Ambulatory and Clinic Blood Pressure Measurements in Hypertensive Kidney Disease.

Hypertension. 2008 Dec 1. Pogue V, Rahman M, Lipkowitz M, Toto R, Miller E, Faulkner M, Rostand S, Hiremath L, Sika M, Kendrick C, Hu B, Greene T, Appel L, Phillips RA; for the African American Study of Kidney Disease Hypertension Collaborative Research Group. Division of Nephrology, Department of Medicine, Columbia University Medical Center at Harlem Hospital, New York, NY; Division of Hypertension, Case Western Reserve University, Cleveland, Ohio; Division of Nephrology, Mount Sinai Medical School, New York, NY; Division of Nephrology, University of Texas Southwestern Medical Center, Dallas; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Md; Department of Medicine, Meharry Medical College, Nashville, Tenn; Division of Nephrology, University of Alabama at Birmingham; Division of Nephrology Ohio State University, Columbus; Division of Nephrology, Vanderbilt University, Nashville, Tenn; Department of Biostatistics and Epidemiology, Cleveland Clinic Foundation, Ohio; Division of Clinical Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City; and the Heart and Vascular Center of Excellence, University of Massachusetts Medical School, Worcester.

Ambulatory blood pressure (ABP) monitoring provides unique information about day-night patterns of blood pressure (BP). The objectives of this article were to describe ABP patterns in African Americans with hypertensive kidney disease, to examine the joint distribution of clinic BP and ABP, and to determine associations of hypertensive target organ damage with clinic BP and ABP. This study is a cross-sectional analysis of baseline data from the African American Study of Kidney Disease Cohort Study. Masked hypertension was defined by elevated daytime (>/=135/85 mm Hg) or elevated nighttime (>/=120/70 mm Hg) ABP in those with controlled clinic BP (<140/90 mm Hg); nondipping was defined by a </=10% decrease in mean nighttime systolic BP; reverse dipping was defined by a higher nighttime than daytime systolic BP. Of the 617 participants (mean age: 60.2 years; 62% male; mean estimated glomerular filtration rate: 43.8 mL/min per 1.73 m(2)) with both clinic BP and ABP, 498 participants (80%) had a nondipping or reverse dipping profile. Of the 377 participants with controlled clinic BP (61%), 70% had masked hypertension. Compared with those with controlled clinic BP or white-coat hypertension, target organ damage (proteinuria and left ventricular hypertrophy) was more common in those with elevated nighttime BP, masked hypertension, or sustained hypertension

In conclusion, clinic BP provides an incomplete and potentially misleading assessment of the severity of hypertension in African Americans with hypertensive kidney disease, in large part because of increased nighttime BP. Whether lowering nighttime BP improves clinical outcomes is unknown but should be tested given the substantial burden of BP-related morbidity in this population.

The environmental and genetic evidence for the association of hyperlipidemia and hypertension

J Hypertens. 2009 Feb;27(2):251-258. Ruixing Y, Jinzhen W, Weixiong L, Yuming C, Dezhai Y, Shangling P. aDepartment of Cardiology, Institute of Cardiovascular Diseases, the First Affiliated Hospital, Republic of China bDepartment of Molecular Biology, Medical Scientific Research Center, Republic of China cDepartment of Pathophysiology, School of Premedical Sciences, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.

OBJECTIVE: Both hyperlipidemia and hypertension are the risk factors for coronary heart disease. Although studies have shown that there is an association between plasma lipid and blood pressure levels, the association of hyperlipidemia and hypertension is still not well established. The present study was undertaken to compare the differences in several environmental and genetic factors between hyperlipidemia and hypertension in the Guangxi Hei Yi Zhuang population.

METHODS: A total of 1669 participants were surveyed by a stratified randomized cluster sampling. Information on environmental factors was collected with standardized questionnaires. Genotyping of angiotensin-converting enzyme, angiotensinogen, angiotensin receptor 2, apolipoprotein (apo) A-I, apoB, apoE, cholesteryl ester transfer protein, G-protein beta-3 subunit, hepatic lipase, lipoprotein lipase, microsomal triglyceride transfer protein, regulator of G-protein signaling 2, and sterol regulatory element-binding protein-2 was also performed.

RESULTS: There were 358 (21.45%) participants with isolated hyperlipidemia, 257 (15.40%) with isolated hypertension, 189 (11.32%) with both conditions, and 865 (51.83%) normals. Hyperlipidemia was positively correlated with age, BMI, alcohol consumption, total energy and total fat intake, apoE, and microsomal triglyceride transfer protein genotypes, and negatively associated with total dietary fiber intake, apoA-I, and lipoprotein lipase genotypes. Hypertension was positively correlated with male sex, age, hyperlipidemia, total energy, total fat, and sodium intake, apoE, angiotensin receptor 2, and microsomal triglyceride transfer protein genotypes, and negatively associated with education level, total dietary fiber intake, angiotensin-converting enzyme, apoA-I, and lipoprotein lipase genotypes.

CONCLUSION: These findings suggest that hyperlipidemia and hypertension have many common risk factors. Hyperlipidemia is associated with hypertension in many aspects.

Blood pressure variability and prevalence of hypertension using automated readings from multiple visits to a pharmacy-based community-wide programme.

J Hum Hypertens. 2009 Jan 22. Karwalajtys T, Kaczorowski J, Hutchison B, Myers MG, Sullivan SM, Chambers LW, Lohfeld L. 1Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.

Blood pressure (BP) measurements taken outside the routine office context may be a useful adjunct strategy to monitor BP. Community-based BP data can also provide estimates of the prevalence of elevated BP.
We compared multiple readings taken on different days in pharmacies using an automated BpTRU device during a cardiovascular health programme targeting community-dwelling older adults.

Mean systolic (S) and diastolic (D) BP values were compared over time using repeated measures analysis of variance for all participants with at least three separate sets of readings (n=317). BP variability was then examined among four subgroups based on report of antihypertensive medication or no treatment, and normal or elevated SBP at the initial visit (< or >/=140, or 130 if diabetes reported). Prevalence of elevated BP was compared across visits. Overall, mean SBP decreased between visits 1 and 2 (140.4 vs 137.1 mm Hg; P<0.001). Among participants with normal SBP at the initial visit, SBP did not vary significantly, whether or not antihypertensive treatment was reported. Those with initially elevated SBP experienced a significant decrease between visits 1 and 2, also regardless of treatment status. Prevalence of elevated BP decreased from visits 1 to 2 (55.8 vs 48.9%; P=0.026) and from visits 1 to 3 (55.8 vs 42.9%; P<0.001).

Analyses of BP data from a community-based programme using an accurate device showed that initial readings may inflate the population estimate of elevated BP. Findings suggest that more than one set of BP readings measured on different occasions are needed, particularly if the first set is elevated

The message for World Kidney Day 2009: hypertension and kidney disease- a marriage that should be prevented.

J Hum Hypertens. 2009 Jan 22. Bakris GL, Ritz E. 1Department of Medicine, Hypertensive Diseases Unit, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA.

The prevalence of chronic kidney disease (CKD) continues to increase worldwide as does end stage renal disease. The most common, but not the only, causes of CKD are hypertension and diabetes. CKD is associated with a significant increase in cardiovascular (CV) risk as most patients with CKD die of a CV cause. Moreover, CV risk increases proportionally as eGFR falls below 60 mlmin(-1). CV causes of death in CKD are more prevalent than those from cancer are; as a result, the identification and reduction of CKD is a public health priority. High blood pressure is a key pathogenic factor that contributes to the deterioration of kidney function. The presence of kidney disease is a common and underappreciated pre-existing medical cause of resistant hypertension. Therefore, treatment of hypertension has become the most important intervention in the management of all forms of CKD. For this reason, the forthcoming World Kidney Day on 12 March 2009 will emphasize the role of hypertension.

Day-by-day variability of blood pressure and heart rate at home as a novel predictor of prognosis: the Ohasama study.

Hypertension. 2008 Dec;52(6):1045-50. Kikuya M, Ohkubo T, Metoki H, Asayama K, Hara A, Obara T, Inoue R, Hoshi H, Hashimoto J, Totsune K, Satoh H, Imai Y. Department of Clinical Pharmacology and Therapeutics, Graduate School of Medicine and Pharmaceutical Sciences, Tohoku University, Sendai, Japan

Day-by-day blood pressure and heart rate variability defined as within-subject SDs of home measurements can be calculated from long-term self-measurement.

We investigated the prognostic value of day-by-day variability in 2455 Ohasama, Japan, residents (baseline age: 35 to 96 years; 60.4% women). Home blood pressure and heart rate were measured once every morning for 26 days (median). A total of 462 deaths occurred over a median of 11.9 years, composing 168 cardiovascular deaths (stroke: n=83; cardiac: n=85) and 294 noncardiovascular deaths. Using Cox regression, we computed hazard ratios while adjusting for baseline characteristics, including blood pressure and heart rate level, sex, age, obesity, current smoking and drinking habits, history of cardiovascular disease, diabetes mellitus, hyperlipidemia, and treatment with antihypertensive drugs. An increase in systolic blood pressure variability of +1 between-subject SD was associated with increased hazard ratios for cardiovascular (1.27; P=0.002) and stroke mortality (1.41; P=0.0009) but not for cardiac mortality (1.13; P=0.26). Conversely, heart rate variability was associated with cardiovascular (1.24; P=0.002) and cardiac mortality (1.30; P=0.003) but not stroke mortality (1.17; P=0.12). Similar findings were observed for diastolic blood pressure variability. Additional adjustment of heart rate variability for systolic blood pressure variability and vice versa produced confirmatory results. Coefficient of variation, defined as within-subject SD divided by level of blood pressure or heart rate, displayed similar prognostic value.

In conclusion, day-by-day blood pressure variability and heart rate variability by self-measurement at home make up a simple method of providing useful clinical information for assessing cardiovascular risk.

Increases in Antihypertensive Prescriptions and Reductions in Cardiovascular Events in Canada

Hypertension. 2008 Dec 29. Campbell NR, Brant R, Johansen H, Walker RL, Wielgosz A, Onysko J, Gao RN, Sambell C, Phillips S, McAlister FA; for the Canadian Hypertension Education Program Outcomes Research Task Force. Departments of Medicine, Community Health Sciences, and Pharmacology and Therapeutics, and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division, Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario, Canada; Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.

The Canadian Hypertension Education Program, an extensive professional education program to improve the management of hypertension, was started in 1999. There were very large increases in diagnosis and treatment of hypertension in the first 4 years after initiation of the program. The purpose of this study was to examine the association between the changes in antihypertensive therapy with changes in hospitalization and death from major hypertension-related cardiovascular diseases in Canada between 1992 and 2003.

Using various national databases, Canadian standardized yearly mortality and hospitalization rates per 1000 for stroke, heart failure, and acute myocardial infarction were calculated for individuals aged >/=20 years and regressed against antihypertensive prescription rates. Changes in rates were examined in a time series analysis.

There were significant reductions (P<0.0001) in the rate of death from stroke, heart failure, and myocardial infarction starting in 1999. There was also a reduction in hospitalization rate from stroke (P<0.0001) and heart failure (P<0.0001) but not myocardial infarction in 1999. The changes in death (P<0.001 for all 3 diseases) and hospitalization (P<0.0001 for stroke and heart failure; P=0.018 for acute myocardial infarction) were associated with the increases in antihypertensive prescriptions.

This study demonstrates that the reduction in cardiovascular death and hospitalization rates is associated with an increase in antihypertensive prescriptions and that it coincides with the introduction of the Canadian Hypertension Education Program. The Canadian Hypertension Education Program educational model for improving health care could be adopted by other countries with well-developed professional and scientific societies.

Can an electronic device with a single cuff be accurate in a wide range of arm size? Validation of the Visomat Comfort 20/40 device for home blood pressure monitoring.

J Hum Hypertens. 2008 Nov;22(11):796-800. Stergiou GS, Tzamouranis D, Nasothimiou EG, Protogerou AD. Hypertension Center, Third University Department of Medicine, Sotiria Hospital, Athens, Greece

An appropriate cuff according to the individual's arm circumference is recommended with all blood pressure (BP) monitors. An electronic device for home monitoring has been developed (Visomat Comfort 20/40) that estimates the individual's arm circumference by measuring the cuff filing volume and makes an adjustment of measured BP taking into account the estimated arm circumference. Thus the manufacturer recommends the use of a single cuff for arm circumference 23-43 cm.

The device accuracy was assessed using the European Society of Hypertension International Protocol. Simultaneous BP measurements were obtained in 33 adults by two observers (connected mercury sphygmomanometers) four times, sequentially with three measurements taken using the tested device. Absolute device-observer BP differences were classified into < or =5, < or =10 and < or =15 mm Hg zones. For each participant the number of measurements with a difference < or =5 mm Hg was calculated. The device produced 60/89/97 measurements within 5/10/15 mm Hg respectively for systolic BP, and 72/97/98 for diastolic. Twenty-three subjects had at least two of their systolic BP differences < or =5 mm Hg and three had no differences < or =5 mm Hg (for diastolic 27 and 1, respectively). Mean device-observer BP difference (systolic/diastolic) was 3.7 +/- 5.6/-1.5 +/- 4.7 mm Hg (4.7 +/- 4.9/ - 1.7 +/- 4.3 in arm circumference 23-29 cm [39 readings] and 3.1 +/- 5.9/-1.4 +/- 5.0 in arm 30-34 cm [60 readings], P=NS).

In conclusion, the device fulfils the International Protocol requirements and can be recommended for clinical use. Interestingly, the device was accurate using a single cuff in a wide range of arm circumference (23-34 cm). This study provides no information about the device accuracy in larger arms.

Prevalence, Awareness, Treatment, and Control of Hypertension in China: Data from the China National Nutrition and Health Survey 2002.

Circulation. 2008 Dec 16;118(25):2679-2686 Wu Y, Huxley R, Li L, Anna V, Xie G, Yao C, Woodward M, Li X, Chalmers J, Gao R, Kong L, Yang X; for the China NNHS Steering Committee and the China NNHS Working Group. National Institute of Nutrition and Food Safety, Chinese Centre for Disease Control and Prevention, No. 29 Nanweilu, Xuanwu District, Beijing 100050, China.

BACKGROUND: The present article aims to provide accurate estimates of the prevalence, awareness, treatment, and control of hypertension in adults in China.

METHODS AND RESULTS: Data were obtained from sphygmomanometer measurements and an administered questionnaire from 141 892 Chinese adults >/=18 years of age who participated in the 2002 China National Nutrition and Health Survey. In 2002, approximately 153 million Chinese adults were hypertensive. The prevalence was higher among men than women (20% versus 17%; P<0.001) and was higher in successive age groups. Overall, the prevalence of hypertension was higher in urban compared with rural areas in men (23% versus 18%; P<0.01) and women (18% versus 16%; P<0.001). Of the 24% affected individuals who were aware of their condition, 78% were treated and 19% were adequately controlled. Despite evidence to suggest improved levels of treatment in individuals with hypertension over the past decade, compared with estimates from 1991, the ratio of controlled to treated hypertension has remained largely unchanged at 1:4.

CONCLUSIONS: One in 6 Chinese adults is hypertensive, but only one quarter are aware of their condition. Despite increased rates of blood pressure-lowering treatment, few have their hypertension effectively controlled. National hypertension programs must focus on improving awareness in the wider community, as well as treatment and control, to prevent many tens of thousands of cardiovascular-related deaths.

Home blood pressure measurement: a systematic review.

J Am Coll Cardiol. 2005 Sep 6;46(5):743-51. Verberk WJ, Kroon AA, Kessels AG, de Leeuw PW. Department of Medicine, University Hospital Maastricht and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.

The purpose of this research was to review the literature on home blood pressure measurement (HBPM) and to provide recommendations regarding HBPM assessment. Observational studies on HBPM, published after 1992, as identified by PubMed, EMBASE, and Cochrane literature searches were reviewed. Studies were selected if they met the following criteria: 1) self-measurements had been performed with validated devices; 2) measurement procedures were described in sufficient detail; and 3) papers clearly explained how final HBPM results were calculated upon which conclusions and/or treatment decisions were based.

Office blood pressure measurement (OBPM) yields higher blood pressure values than HBPM. For systolic blood pressure, differences between OBPM and HBPM increase with age and the height of office pressure. Differences also tend to be greater in men than in women and greater in patients without than in those with antihypertensive treatment. Furthermore, HBPM can diagnose normotension with almost absolute certainty; it correlates better with target organ damage and cardiovascular mortality than OBPM, it enables prediction of sustained hypertension in patients with borderline hypertension, and it proves to be an appropriate tool for assessing drug efficacy.

Despite some limitations and although more data are needed, HBPM is suitable for routine clinical practice.

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

Vasc Health Risk Manag. 2007;3(6):959-66. Verberk WJ, Kroon AA, Jongen-Vancraybex HA, de Leeuw PW. University Hospital Maastricht, Department of Internal Medicine and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands.

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.

Improving blood pressure control in hypertensive hemodialysis patients.

CANNT J. 2007 Oct-Dec;17(4):24-8, 31-6; Kauric-Klein Z, Artinian N. University of Detroit, Mercy College of Health Professions, McCauley School of Nursing, 4001 W. McNichols Rd., Detroit, MI 48221-3038, USA.

Hypertension is very prevalent among patients undergoing chronic hemodialysis. The purpose of this randomized controlled study was to determine if home blood pressure (BP) monitoring could improve BP control in a sample of 34 outpatient hemodialysis patients.

Seventeen participants were randomized to a home BP monitor intervention (HBPM) plus usual care group and the other 17 participants were randomized to usual care only. Average weekly BPs and fluid gains were monitored for both groups over 12 weeks.

The results indicated that HBPM significantly lowered SBP (p = .018) in the HBPM group compared to the usual care group. No significant differences were found between groups in terms of DBP or fluid gains.

These findings indicate that HBPM could help improve BP control in the hemodialysis population. Nephrology nurses can be instrumental in helping hemodialysis patients monitor their BP and providing education on interventions that may improve BP control.

Hypertension and heart failure: a dysfunction of systole, diastole or both?

J Hum Hypertens. 2008 Nov 27. Yip GW, Fung JW, Tan YT, Sanderson JE. Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China.

The pathological myocardial hypertrophy associated with hypertension contains the seed for further maladaptive development. Increased myocardial oxygen consumption, impaired epicardial coronary perfusion, ventricular fibrosis and remodelling, abnormalities in long-axis function and torsion, cause, to a varying degree, a mixture of systolic and diastolic abnormalities. In addition, chronotropic incompetence and peripheral factors such as lack of vasodilator reserve and reduced arterial compliance further affect cardiac output particularly on exercise. Many of these factors are common to hypertensive heart failure with a normal ejection fraction as well as systolic heart failure.

There is increasing evidence that these apparently separate phenotypes are part of a spectrum of heart failure differing only in the degree of ventricular remodelling and volume changes. Furthermore, dichotomizing heart failure into systolic and diastolic clinical entities has led to a paucity of clinical trials of therapies for heart failure with a normal ejection fraction. Therapies aimed at reversing myocardial fibrosis, and targets outside the heart such as enhancing vasodilator reserve and improving chronotropic incompetence deserve further study and may improve the exercise capacity of hypertensive heart failure patients.

Hypertension heart disease with heart failure is simply not a dysfunction of systole and diastole. Other peripheral factors including heart rate and vasodilator response with exercise may deserve equal attention in an attempt to develop more effective treatments for this disorder.

Genetic Effect on Blood Pressure Is Modulated by Age. The Hypertension Genetic Epidemiology Network Study.

Hypertension. 2008 Nov 24. Shi G, Gu CC, Kraja AT, Arnett DK, Myers RH, Pankow JS, Hunt SC, Rao DC. Divisions of Biostatistics and Statistical Genomics and the Departments of Genetics and Psychiatry, Washington University School of Medicine, Saint Louis, MO; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham; Department of Neurology, Boston University School of Medicine, Massachusetts; Division of Epidemiology and Community Health, University of Minnesota, Minneapolis; and Cardiovascular Genetics Division, University of Utah School of Medicine, Salt Lake City.

Genome-wide linkage analysis was performed for systolic and diastolic blood pressures in the Hypertension Genetic Epidemiology Network. We investigated the role of gene-age interactions using a recently developed variance components method that incorporates age variation in genetic effects. Substantially improved linkage evidence, in terms of both the number of linkage peaks and their significance levels, was observed. Twenty-six linkage peaks were identified with maximum logarithm of odds scores ranging between 3.0 and 4.6, 15 of which were cross-validated by the literature. The chromosomal region 1p36 that showed the highest logarithm of odds score in our study was found to be supported by evidence from 3 studies. The new method also led to vastly improved validation across ethnic groups. Ten of the 15 supported linkage peaks were cross-validated between 2 different ethnic groups, and 2 peaks on chromosomal region 1q31 and 16p11 were validated in 3 ethnic groups.

In conclusion, this investigation demonstrates that genetic effects on blood pressure vary by age. The improved genetic linkage results presented here should help to identify the specific genetic variants that explain the observed results.

Gender differences in office and ambulatory control of hypertension.

Am J Med. 2008 Dec;121(12):1078-84. Banegas JR, Segura J, de la Sierra A, Gorostidi M, Rodríguez-Artalejo F, Sobrino J, de la Cruz JJ, Vinyoles E, Del Rey RH, Graciani A, Ruilope LM; Spanish Society of Hypertension ABPM Registry Investigators. Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, CIBER en Epidemiología y Salud Pública, Madrid, Spain.

BACKGROUND: Gender differences in hypertension control have not been explored fully.

METHODS: We studied 15,212 white men and 13,936 white women with treated hypertension who were drawn from the Spanish Ambulatory Blood Pressure Registry. For each participant, we obtained office blood pressure (BP) (average of 2 readings) and 24-hour ambulatory BP (average of measurements performed every 20 minutes during day and night).

RESULTS: Only 16.4% of women and 14.7% of men had both office (<140/90 mm Hg) and ambulatory (<130/80 mm Hg) BP controlled (P<.001). Women had a lower frequency of masked hypertension (office BP<140/90 mm Hg and ambulatory BP>/=130/80 mm Hg) than men (5.9% vs 7.9%, P<.001). Women had a higher frequency of isolated office hypertension (office BP>/=140/90 mm Hg and ambulatory BP<130/80 mm Hg) (32.5% vs 24.2%, P<.001). Although office BP control (office BP<140/90 mm Hg, regardless of ambulatory values) was similar in women and men (22.3% vs 22.6%, P=.542), ambulatory BP control (ambulatory BP<130/80 mm Hg, regardless of office values) was higher in women than in men (48.9% vs 38.9%, P<.001). After adjustment for age, number of antihypertensive drugs, hypertension duration, and risk factors, gender differences in BP control remained practically unchanged.

CONCLUSION: Ambulatory BP control was higher in women than in men. This may be due to the higher frequency of isolated office hypertension in women, and it is not explained by gender differences in other important clinical characteristics.

Lifestyle and Metabolic Determinants of Incident Hypertension, With Special Reference to Cigarette Smoking: A Longitudinal Population-Based Study.

Am J Hypertens. 2008 Nov 27. Onat A, Uğur M, Hergenç G, Can G, Ordu S, Dursunoğlu D. [1] 1Turkish Society of Cardiology, Istanbul, Turkey [2] 2Department of Cardiology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey [3] 3Department of Public Health, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey.

Background: Lifestyle and metabolic determinants of incident hypertension in a population with a high prevalence of metabolic syndrome (MetS) need to be further assessed

Methods: A representative sample of middle-aged and elderly Turkish adults was prospectively evaluated over a mean 7.4 years, after exclusion of prevalent hypertension and major renal dysfunction

Results: In 2,427 men and women, aged 45.8 +/- 11.7 years, Kaplan-Meier analysis showed in combined genders mean time to incident hypertension to be 7.23 years in never, 7.78 years in current smokers (P < 0.001). Age and female sex were major determinants of subsequent hypertension after adjustment for physical activity grade, family income bracket, smoking status, usage of alcohol and of hormone replacement or birth control pill. Relative risk (RR) for incident hypertension of current vs. never smoking was reduced in women (P = 0.058) and both genders combined (P = 0.054). Former smokers uniformly exhibited significantly higher risk for the development of hypertension than both never (P = 0.054) and current (P < 0.001) smokers, whereby abdominally obese individuals were at increased risk. In further multivariable models, circulating C-reactive protein (CRP) and fasting insulin emerged as modest independent determinants and waist girth, modulated by current smoking, as a major determinant of subsequent hypertension.

Conclusions: Age, female sex, and waist circumference are major and serum insulin and CRP modest determinants of incident hypertension in middle-aged Turkish adults in whom current cigarette smoking plays a protective role at borderline significance, largely by modulating waist girth. Former smokers with abdominal obesity are under higher risk of subsequent hypertension than current smokers.

Anthropometric and dietary determinants of blood pressure in over 7000 Mediterranean women: the European Prospective Investigation into Cancer and Nutrition-Florence cohort.

J Hypertens. 2008 Nov;26(11):2112-20 Masala G, Bendinelli B, Versari D, Saieva C, Ceroti M, Santagiuliana F, Caini S, Salvini S, Sera F, Taddei S, Ghiadoni L, Palli D. Molecular and Nutritional Epidemiology Unit, ISPO, Florence, Italy.

BACKGROUND: Anthropometric characteristics and dietary habits are widely recognized to influence blood pressure. We evaluated their role in a large series of Mediterranean adult women.

METHODS: In Florence, in the European Prospective Investigation into Cancer and Nutrition, we recruited 10 083 women, aged 35-64 years. Detailed information on diet, lifestyle, physical activity, and medical history were collected. Anthropometric indices and systolic and diastolic blood pressures were measured at recruitment using standardized procedures. Overall, after excluding those women who reported a clinical diagnosis of hypertension and/or an antihypertensive treatment and those without measurements, 7601 women were available for analyses with an average systolic and diastolic blood pressure value of 123.2+/-16.0 and 78.7+/-9.4 mmHg, respectively.

RESULTS: Multivariate regression models showed that body mass index (P<0.0001) and waist circumference (>or=88 cm, P<0.0001), as well as processed meat, potatoes, and wine consumption, were directly associated with both systolic and diastolic values. In contrast, a high consumption of selected foods resulted inversely associated with systolic (total vegetables, yoghurt, and eggs), diastolic (olive oil) or both systolic and diastolic values (leafy vegetables, milk, coffee). Analyses performed on nutrients showed a positive association with alcohol and sodium intake, and an inverse one with potassium and micronutrients derived from fruits and vegetables.

CONCLUSION: In this large series of women from Tuscany, Central Italy, we confirm the independent influence of anthropometric characteristics on blood pressure. The role of specific foods and nutrients in modulating blood pressure also emerged, suggesting a central role for lifestyle modifications in blood pressure control.

Hypertension and Cognitive Function.

Clin Exp Hypertens. 2008 Nov;30(8):701-710 Paglieri C, Bisbocci D, Caserta M, Rabbia F, Bertello C, Canade A, Veglio F. Department of Medicine and Experimental Oncology, Hypertension Unit, University of Torino, Italy.

Arterial hypertension, cerebrovascular disease, and dementia are related pathologies. This paper has reviewed comparatively the incidence of arterial hypertension and adult-onset dementia disorders. Hypertension is associated with cerebrovascular disease, which is in turn associated with dementia. It is the most important modifiable risk factor for stroke, which is a recognized cause of vascular dementia. In terms of pathophysiology of hypertensive brain damage, several hypotheses were developed, such as that vascular alterations induced by hypertension can induce lacunar or cortical infarcts and leucoaraiosis, that hypertension is responsible for cerebrovascular disease and acts into the contest of a pre-existing subclinic Alzheimer's disease (AD), that hypertension determines neurobiologic alterations (such as beta-amyloid accumulation) resulting in neuropathologic damage, and that aging and cerebrovascular risk factors act together to cause cerebral capillary degeneration, mitochondrial disruption, reduced glucose oxidation, and reduced ATP synthesis. The consequence of these alterations are neuronal death and dementia. Macroscopic results of these mechanisms are the so-called white matter lesions (WML), the significance of which is analyzed. Increasing clinical evidence suggests a close relationship between the reduction of elevated blood pressure and countering of both vascular dementia and AD. Antihypertensive treatment probably influences cognitive performances and prevents cognitive function alterations and the development of dementia. It is therefore important to evaluate as soon as possible cognitive functions of hypertensive patients.

Franz Volhard lecture: should doctors still measure blood pressure? The missing patients with masked hypertension.

J Hypertens. 2008 Dec;26(12):2259-67. Pickering TG, Gerin W, Schwartz JE, Spruill TM, Davidson KW. College of Physicians and Surgeons, Columbia University Medical Center, New York, USA.

The traditional reliance on blood pressure (BP) measurement in the medical setting misses a significant number of individuals with masked hypertension, who have normal clinic BP but persistently high daytime BP when measured out of the office.

We suggest that masked hypertension may be a precursor of clinically recognized sustained hypertension and is associated with increased cardiovascular risk compared with consistent normotension.

We discuss factors that may contribute to clinic-daytime BP differences as well as the changing relationship between these two measures over time. Anxiety at the time of BP measurement and having been diagnosed as hypertensive appear to be two possible mechanisms.

The identification of individuals with masked hypertension is of great clinical importance and requires out-of-office BP screening. Ambulatory BP monitoring is the best established technique for doing this, but home monitoring may be applicable in the future.

Does obesity modify the effect of blood pressure on the risk of cardiovascular disease? A population-based cohort study of more than one million Swedish men.

Circulation. 2008 Oct 14;118(16):1637-42. Silventoinen K, Magnusson PK, Neovius M, Sundström J, Batty GD, Tynelius P, Rasmussen F. Department of Public Health, University of Helsinki, Helsinki, Finland.

BACKGROUND: Some studies have suggested that increased blood pressure has a stronger effect on the risk of cardiovascular disease (CVD) in lean persons than in obese persons, although this is not a universal finding. Given the inconsistency of this result, we tested it using a large population-based cohort data set.

METHODS AND RESULTS: Systolic and diastolic blood pressures (BPs) and body mass index were measured in 1 145 758 Swedish men born between 1951 and 1976 who were in young adulthood (median age 18.2 years). During the register-based follow-up, which lasted until the end of 2006, 65 611 new CVD events took place, including 6799 myocardial infarctions and 8827 strokes. Hazard ratios (HRs) per 1-SD increase in systolic and diastolic BP were computed within established body mass index categories (underweight, normal, overweight, or obese) with Cox proportional hazards models. The strongest associations of diastolic BP with CVD (HR 1.18), myocardial infarction (HR 1.22), and stroke (HR 1.13) were observed in the obese category. For systolic BP, the strongest associations were observed in the obese category with CVD (HR 1.16) and stroke (HR 1.29) but in the overweight category with myocardial infarction (HR 1.19). We observed statistically significant interactions (P<0.0001) with body mass index for diastolic BP in relation to CVD and for systolic BP in relation to CVD and stroke.

CONCLUSIONS: In contrast to the findings of previous studies, we observed a general increase in the magnitude of the association between blood pressure and subsequent CVD with increasing body mass index. Hypertension should not be regarded as a less serious risk factor in obese than in lean or normal-weight persons.

The misdiagnosis of hypertension: the role of patient anxiety.

Arch Intern Med. 2008 Dec 8;168(22):2459-65. Ogedegbe G, Pickering TG, Clemow L, Chaplin W, Spruill TM, Albanese GM, Eguchi K, Burg M, Gerin W. Department of Biobehavioral Health, The Pennsylvania State University, 315 Health and Human Development East, University Park, PA 16802.

BACKGROUND: The white coat effect (defined as the difference between blood pressure [BP] measurements taken at the physician's office and those taken outside the office) is an important determinant of misdiagnosis of hypertension, but little is known about the mechanisms underlying this phenomenon. We tested the hypothesis that the white coat effect may be a conditioned response as opposed to a manifestation of general anxiety.

METHODS: A total of 238 patients in a hypertension clinic wore ambulatory blood pressure monitors on 3 separate days 1 month apart. At each clinic visit, BP readings were manually triggered in the waiting area and the examination room (in the presence and absence of the physician) and were compared with the mercury sphygmomanometer readings taken by the physician in the examination room. Patients completed trait and state anxiety measures before and after each BP assessment.

RESULTS: A total of 35% of the sample was normotensive, and 9%, 37%, and 19% had white coat, sustained, and masked hypertension, respectively. The diagnostic category was associated with the state anxiety measure (F(3,237) = 6.4, P < .001) but not with the trait anxiety measure. Patients with white coat hypertension had significantly higher state anxiety scores (t = 2.67, P < .01), with the greatest difference reported during the physician measurement. The same pattern was observed for BP changes, which generally paralleled the changes in state anxiety (t = 4.86, P < .002 for systolic BP; t = 3.51, P < .002 for diastolic BP).

CONCLUSIONS: These findings support our hypothesis that the white coat effect is a conditioned response. The BP measurements taken by physicians appear to exacerbate the white coat effect more than other means. This problem could be addressed with uniform use of automated BP devices in office settings.

Lower Systolic Blood Pressure Is Associated with Greater Mortality in People Aged 85 and Older

Journal of the American Geriatrics Society published online 22 Sep 2008 Vol 56 Issue 10 Pp 1853 - 1859 Lena Molander, Bsc * , Hugo Lövheim, MD, PhD * , Tove Norman, MD * , Peter Nordström, MD, PhD * , and Yngve Gustafson, MD, PhD * From the*Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden

OBJECTIVES: To investigate the association between blood pressure and mortality in very old people.

DESIGN: Population-based cohort study.

SETTING: County of Västerbotten, Sweden.

PARTICIPANTS: Half of all subjects aged 85 and all of those aged 90 and 95 and older (N=348) in one urban and five rural municipalities in the north of Sweden.

MEASUREMENTS: Among others, supine blood pressure, Mini-Mental State Examination, Barthel Index of activities of daily living, Mini Nutritional Assessment, and body mass index. Information on diagnoses, medications, and 4-year mortality was collected. Associations between blood pressure and mortality were investigated using Cox regression analyses, controlling for a number of diagnoses and health factors.

RESULTS: Baseline systolic blood pressure (SBP), diastolic blood pressure, and pulse pressure were all inversely associated with mortality within 4 years according to univariate analysis. SBP was the strongest predictor. In Cox regression analyses, low SBP (≤120 mmHg) correlated with greater 4-year all-cause mortality alone and when controlling for health status. This connection persisted after exclusion of deaths within the first year. There was a tendency toward a U-shaped mortality curve for the adjusted model, with SBP of 164.2 mmHg (95% confidence interval=154.1–183.8 mmHg) being associated with the lowest mortality.

CONCLUSION: Lower SBP seems to be associated with greater mortality in people aged 85 and older, irrespective of health status. There are indications of a U-shaped correlation between SBP and mortality, and the optimal SBP for this age group could be above 140 mmHg.

Can validated wrist devices with position sensors replace arm devices for self-home blood pressure monitoring? A randomized crossover trial using ambulatory monitoring as reference

Am J Hypertens. 2008 Jul;21(7):753-8. Stergiou GS, Christodoulakis GR, Nasothimiou EG, Giovas PP, Kalogeropoulos PG. Hypertension Center, Third University Department of Medicine, Sotiria Hospital, Athens, Greece.

BACKGROUND: Electronic devices that measure blood pressure (BP) at the arm level are regarded as more accurate than wrist devices and are preferred for home BP (HBP) monitoring. Recently, wrist devices with position sensors have been successfully validated using established protocols. This study assessed whether HBP values measured with validated wrist devices are sufficiently reliable to be used for making patient-related decisions in clinical practice.

METHODS: This randomized crossover study compared HBP measurements taken using validated wrist devices (wrist-HBP, Omron R7 with position sensor) with those taken using arm devices (arm-HBP, Omron 705IT), and also with measurements of awake ambulatory BP (ABP, SpaceLabs), in 79 subjects (36 men and 43 women) with hypertension. The mean age of the study population was 56.7 +/- 11.8 years, and 33 of the subjects were not under treatment for hypertension.

RESULTS: The average arm-HBP was higher than the average wrist-HBP (mean difference, systolic 5.2 +/- 9.1 mm Hg, P < 0.001, and diastolic 2.2 +/- 6.7, P < 0.01). Twenty-seven subjects (34%) had a > or =10 mm Hg difference between systolic wrist-HBP and arm-HBP and twelve subjects (15%) showed similar levels of disparity in diastolic HBP readings. Strong correlations were found between arm-HBP and wrist-HBP (r 0.74/0.74, systolic/diastolic, P < 0.0001). However, ABP was more strongly correlated with arm-HBP (r 0.73/0.76) than with wrist-HBP (0.55/0.69). The wrist-arm HBP difference was associated with systolic ABP (r 0.34) and pulse pressure (r 0.29), but not with diastolic ABP, sex, age, arm circumference, and wrist circumference.

CONCLUSIONS: There might be important differences in HBP measured using validated wrist devices with position sensor vs. arm devices, and these could impact decisions relating to the patient in clinical practice. Measurements taken using arm devices are more closely related to ABP values than those recorded by wrist devices. More research is needed before recommending the widespread use of wrist monitors in clinical practice.

Do psychological attributes matter for adherence to antihypertensive medication? The Finnish Public Sector Cohort Study.

J Hypertens. 2008 Nov;26(11):2236-2243 Nabi H, Vahtera J, Singh-Manoux A, Pentti J, Oksanen T, Gimeno D, Elovainio M, Virtanen M, Klaukka T, Kivimaki M. aDepartment of Epidemiology and Public Health, University College London, London, UK bINSERM U687-IFR69, Villejuif, France cFinnish Institute of Occupational Health, Turku, Finland dHôpital Ste Périne, Centre de Gérontologie, Paris, France eNational Research and Development Centre of Welfare and Health (STAKES), Finland fSocial Insurance Institution of Finland, Research Department, Finland gDepartment of Psychology, University of Helsinki, Helsinki, Finland.

OBJECTIVE: Psychological factors may be important determinants of adherence to antihypertensive medication, as they have been repeatedly found to be associated with an increased risk of hypertension, coronary heart disease, and health-damaging behaviours. We examined the importance of several psychological attributes (sense of coherence, optimism, pessimism, hostility, anxiety) with regard to antihypertensive medication adherence assessed by pharmacy refill records.

METHODS: A total of 1021 hypertensive participants, aged 26-63 years, who were employees in eight towns and 12 hospitals in Finland were included in the analyses.

RESULTS: We found 60% of patients to be totally adherent, 36% partially adherent, and 4% totally nonadherent. Multinomial regression analyses revealed high sense of coherence to be associated with lower odds of being totally nonadherent in contrast of being totally adherent (odds ratio = 0.55; 95% confidence interval: 0.31-0.96). This association was independent of factors that influenced adherence to antihypertensive medication, such as sociodemographic characteristics, health-related behaviours, self-reported medical history of doctor-diagnosed comorbidity, and anteriority of hypertension status. The association was not specific to certain types of antihypertensive drugs.

CONCLUSION: High sense of coherence may influence antihypertensive medication-adherence behaviour. Aspects characterizing this psychological attribute, such as knowledge (comprehensibility), capacity (manageability), and motivation (meaningfulness) may be important determinants of adherence behaviour for asymptomatic illnesses, such as hypertension, in which patients often do not feel or perceive the immediate consequences of skipping medication doses.

Clinical profile and management of hypertensive patients with chronic ischemic heart disease and renal dysfunction attended by cardiologists in daily clinical practice

J Hypertens. 2008 Nov;26(11):2230-2235. Barrios V, Escobar C, Murga N, de Pablo C, Bertomeu V, Calderón A, Echarri R. aDepartment of Cardiology, Hospital Ramon y Cajal, Spain bDepartment of Cardiology, Hospital Infanta Sofia, Madrid, Spain cDepartment of Cardiology, Hospital de Basurto, Bilbao, Spain dDepartment of Cardiology, Hospital Universitario San Juan, Alicante, Spain ePrimary Care Center Rosa Luxemburgo, Spain fDepartment of Nephrology, Hospital Infanta Sofia, Madrid, Spain.

OBJECTIVE: The present study was designed to assess the influence of renal function on the clinical profile and management of the hypertensive outpatients with chronic ischemic heart disease.

METHODS: A total of 112 investigators, all cardiologists, were asked to consecutively enrol outpatients of at least 18 years of age, both sexes, with an established diagnosis of hypertension and chronic ischemic heart disease. Renal function was assessed by serum creatinine levels and estimated glomerular filtration rate using the Modification of Diet in Renal Disease formula. Renal impairment was considered a serum creatinine of at least 1.2/1.3 mg/dl (women/men) or an estimated glomerular filtration rate less than 60 ml/min/1.73 m. Blood pressure was considered controlled when it was less than 140/90 mmHg and less than 130/80 mmHg in diabetic patients or patients with chronic kidney disease.

RESULTS: A total of 2024 patients (66.8 +/- 10.1 years; 31.7% women) were included. A total of 666 (32.9%) and 498 (24.6%) patients exhibited renal function impairment assessed by estimated glomerular filtration rate and serum creatinine, respectively. The subgroup of patients with renal dysfunction was older, with a higher proportion of women with atrial fibrillation, diabetes, organ damage, associated clinical conditions and a worse blood pressure control. No differences were found in clinical profile when the two subgroups of patients with impaired renal function [serum creatinine >/=1.2/>/=1.3 mg/dl (women/men) vs. estimated glomerular filtration rate <60 ml/min per 1.73 m] were compared.

CONCLUSION: Renal function impairment is frequent in the hypertensive population with coronary artery disease. Patients with renal dysfunction represent a subgroup of very high-risk population with more risk factors and comorbidities and worse blood pressure control. The clinical profiles of hypertensive patients with renal function impairment are similar whether renal dysfunction is detected by high serum creatinine or by low estimated glomerular filtration rate.

Sexual dysfunction: the 'prima ballerina' of hypertension-related quality-of-life complications

J Hypertens. 2008 Nov;26(11):2074-84 Manolis A, Doumas M. aDepartment of Cardiology, Asklepeion Hospital, Athens, Greece b2nd Propedeutic Department of Internal Medicine, Thessaloniki, Greece.

Sexual dysfunction is currently considered a serious quality-of-life-related health problem, exerting a major impact on patients' and their sexual partners' life. Available data indicate that essential hypertension is a risk factor for sexual dysfunction, as male and female sexual dysfunction is more prevalent in hypertensive patients than normotensive individuals. Several mechanisms have been implicated in the pathogenesis of sexual dysfunction in hypertensive patients, and major determinants include severity and duration of hypertension, age, and antihypertensive therapy. Female sexual dysfunction, although more frequent than its male counterpart, remains largely under-recognized. Older antihypertensive drugs (diuretics, beta-blockers, centrally acting) exert negative results, whereas newer drugs have either neutral (calcium antagonists, angiotensin-converting enzyme inhibitors) or beneficial effects (angiotensin receptor blockers). Erectile dysfunction is related to ischemic heart disease and might be an 'early therapeutic window' of asymptomatic coronary artery disease. It seems of utmost importance for every physician treating hypertensive patients to become familiar with sexual dysfunction (through better education and specific seminars) for the proper management of these patients.

Idiopathic intracranial hypertension in men.

Neurology. 2008 Oct 15. Bruce BB, Kedar S, Van Stavern GP, Monaghan D, Acierno MD, Braswell RA, Preechawat P, Corbett JJ, Newman NJ, Biousse V. From the Departments of Ophthalmology (B.B.B., N.J.N., V.B.), Neurology (N.J.N., V.B.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA; Departments of Neurology (S.K., D.M., J.J.C.) and Ophthalmology (J.J.C.), University of Mississippi, Jackson, MS; Department of Ophthalmology (G.P.V.S.), Wayne State University, Detroit, MI; Department of Ophthalmology (M.D.A.), Louisiana State University, New Orleans, LA; Department of Ophthalmology (R.A.B.), University of Alabama, Birmingham, AL; and Department of Ophthalmology (P.P.), Ramathibodi Hospital, Mahidol University, Thailand.

OBJECTIVE: To compare the characteristics of idiopathic intracranial hypertension (IIH) in men vs women in a multicenter study.

METHODS: Medical records of all consecutive patients with definite IIH seen at three university hospitals were reviewed. Demographics, associated factors, and visual function at presentation and follow-up were collected. Patients were divided into two groups based on sex for statistical comparisons.

RESULTS: We included 721 consecutive patients, including 66 men (9%) and 655 women (91%). Men were more likely to have sleep apnea (24% vs 4%, p < 0.001) and were older (37 vs 28 years, p = 0.02). As their first symptom of IIH, men were less likely to report headache (55% vs 75%, p < 0.001) but more likely to report visual disturbances (35% vs 20%, p = 0.005). Men continued to have less headache (79% vs 89%, p = 0.01) at initial neuro-ophthalmologic assessment. Visual acuity and visual fields at presentation and last follow-up were significantly worse among men. The relative risk of severe visual loss for men compared with women wa