Hg In Patients Research Articles

Residual Effect of Renal Denervation in Patients With Truly Resistant Hypertension

See related article, p 526–532 The SYMPLICITY investigators reported a 25- to 30-mm Hg decrease in office systolic blood pressure 6 to 12 months after renal sympathetic denervation in patients with resistant hypertension.1,2 In the SYMPLICITY studies,1,2 resistant hypertension was a systolic blood pressure of ≥160 mm Hg (150 mm Hg in patients with diabetes mellitus) on treatment with ≥3 different classes of antihypertensive drugs.1,2 This definition of resistant hypertension complies with current guidelines3 but is weak and urgently needs revision.4 Indeed, patients categorized as being apparently resistant according to this generic definition often cumulate clinical conditions that do not justify renal denervation as the preferred treatment option. These conditions include white-coat hypertension,5 poor adherence,6 suboptimal drug treatment, undiagnosed secondary hypertension,3 and isolated systolic hypertension in the elderly, a highly prevalent and difficult to treat form of hypertension driven by arterial stiffening rather than enhanced sympathetic drive.7 Neither the SYMPLICITY studies nor most nonrandomized observational reports published subsequently8 implemented a systematic strategy for differentiating between truly resistant hypertension and conditions that might benefit from an alternative approach, such as addressing the …

Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.

Only about half of patients with high blood pressure (BP) in the United States have their BP controlled. Practical, robust, and sustainable models are needed to improve BP control in patients with uncontrolled hypertension. To determine whether an intervention combining home BP telemonitoring with pharmacist case management improves BP control compared with usual care and to determine whether BP control is maintained after the intervention is stopped. A cluster randomized clinical trial of 450 adults with uncontrolled BP recruited from 14,692 patients with electronic medical records across 16 primary care clinics in an integrated health system in Minneapolis-St Paul, Minnesota, with 12 months of intervention and 6 months of postintervention follow-up. Eight clinics were randomized to provide usual care to patients (n = 222) and 8 clinics were randomized to provide a telemonitoring intervention (n = 228). Intervention patients received home BP telemonitors and transmitted BP data to pharmacists who adjusted antihypertensive therapy accordingly. Control of systolic BP to less than 140 mm Hg and diastolic BP to less than 90 mm Hg (<130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 and 12 months. Secondary outcomes were change in BP, patient satisfaction, and BP control at 18 months (6 months after intervention stopped). At baseline, enrollees were 45% women, 82% white, mean (SD) age was 61.1 (12.0) years, and mean systolic BP was 148 mm Hg and diastolic BP was 85 mm Hg. Blood pressure was controlled at both 6 and 12 months in 57.2% (95% CI, 44.8% to 68.7%) of patients in the telemonitoring intervention group vs 30.0% (95% CI, 23.2% to 37.8%) of patients in the usual care group (P = .001). At 18 months (6 months of postintervention follow-up), BP was controlled in 71.8% (95% CI, 65.0% to 77.8%) of patients in the telemonitoring intervention group vs 57.1% (95% CI, 51.5% to 62.6%) of patients in the usual care group (P = .003). Compared with the usual care group, systolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (-10.7 mm Hg [95% CI, -14.3 to -7.3 mm Hg]; P<.001), at 12 months (-9.7 mm Hg [95% CI, -13.4 to -6.0 mm Hg]; P<.001), and at 18 months (-6.6 mm Hg [95% CI, -10.7 to -2.5 mm Hg]; P = .004). Compared with the usual care group, diastolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (-6.0 mm Hg [95% CI, -8.6 to -3.4 mm Hg]; P<.001), at 12 months (-5.1 mm Hg [95% CI, -7.4 to -2.8 mm Hg]; P<.001), and at 18 months (-3.0 mm Hg [95% CI, -6.3 to 0.3 mm Hg]; P = .07). Home BP telemonitoring and pharmacist case management achieved better BP control compared with usual care during 12 months of intervention that persisted during 6 months of postintervention follow-up. clinicaltrials.gov Identifier: NCT00781365.

On-target antihypertensive treatment in Italy: The ISPIT (Indagine Sicoa Paziente Iperteso a Target) survey study

Hypertension represents the most important risk factor forincident cardiovascular events [1], and as such it represents a majorproblem for the National Health Care systems. However, 30–40% ofhypertensivepatientslackanadequatebloodpressure(BP)control,asdefined by BP values b140/90 mm Hg [1], in spite of therapy.Notwithstanding optimal BP control represents the goal of treatmentindependently on drugs administered, the results of recent RCT gaveindications for using specific classes of drugs in specific patients'population[1]andthisshouldbeconsidered.Inaddition,otherfactorswhich have been poorly investigated systematically might beimplicated in the lack of adequate BP control, such as the presenceof risk factors, the frequency and modalities of BP measurements, lifestyle etc. The present survey was conceived to provide an overallpicture on the extent to which BP is at target in the Italian populationof hypertensive patients, and to ascertain what are the conditionslinked to the lack (or achievement) of BP control.29 cardiology units located in different Italian areas belonging toSICOA Association (Societa Italiana Cardiologia Ospedalita Accred-itata)onlyparticipatedtothestudythatincludedconsecutivepatientsreferred in a 3-month period. All information were collected at thetime of enrollment using a questionnaire. Target BP was defined as BPb140/90 mm Hg, as measured by sphygmomanometry at the time ofenrollment [1]. Patients were considered physically active if theyreferredtoperformregularaerobicphysicalactivityforatleast30 minatleast3 daysperweek.Agewassummarizedinthreeclasses(18 –65;66–75; ≥76), and drugs assumption in three categories (1, 2 and 3 or moredrugs). Group comparisons were performed using univariate non-parametric statistics. The association between failure in achieving BPcontrol and potential explanatory variables was modelled by means ofunconditional logistic regression. All estimates were adjusted forconfounders,e.g.,age,gender,etc.[2].APvalueofb0.05wasconsideredsignificant.TheauthorscompliedwiththePrinciplesofEthicalPublishingin the International Journal of Cardiology.The population consisted in 1539 patients, 45% females and 55%males. No significant difference in BP between center–south and northItalywasfound.ThepercentageofpatientsachievingtargetBPwas60%independently on geographic distribution and age class. SBP and DBPvalues were 127.5 ± 11.7/76.7 ± 7.4 mm Hg in patients at target vs152.4 ± 16.8/87.1 ± 9.7 mmHg in patients not at target, respectively.75%ofpatientsfeaturedatleastoneriskfactor,and36%twoormoreriskfactors. The most common was the lack of physical activity (70%).Diabetes and dyslipidemia were present in 48% and 24% of patients,respectively.17%ofpatientsweresmokers. Table1 summarizessignificantassociations from logistic regression analysis. Among all variablesinvestigated, diabetes and overweight were the only predictors of thelack of BP control. Odds ratio (OR) for BP not at target was 1.44 (IC 1.13 –1.82, P = 0.003) in patients with diabetes and 1.40 (IC 1.08 –1.82,P=0.01)and1.80(IC1.32–2.39, P = 0.001) in overweight and obesepatients, respectively. The lack of physical activity showed a strong trendforBPnotattarget,(OR0.81,IC0.64–1.02, P = 0.06).Fig.1 illustrates the modality and frequency of BP measurements.The majority of patients (67%) declared to measure BP by themselves,with a most common frequency of once a week (41%). Only a smallpercentage had BP measured by a specialist and a relatively largepercentage measured BP occasionally (8%). The univariate analysisrevealed as BP self-measurement was associated to a significantlygreater probability to reach BP target (56 vs 37%, P = 0.008). Beta-blockers were the drugsmore frequently prescribed(44%),followedbyACE-inhibitors (33%), ARBs (29%) and calcium channel blockers (28%).No relationship was found between the class of drugs or their numberand the achievement of target BP.ThissurveyconfirmsthatalsoinItalytheproportionofhypertensivepatients not at target for BP is around 40% [1], without differencesrelatedtogeographicaldistribution[3].Italsoconfirmsthatcomorbidity

Multimorbidity and Blood Pressure Control in 37 651 Hypertensive Patients From Danish General Practice

BackgroundPatients with hypertension are primarily treated in general practice. However, major studies of patients with hypertension are rarely based on populations from primary care. Knowledge of blood pressure (BP) control rates in patients with diabetes and/or cardiovascular diseases (CVDs), who have additional comorbidities, is lacking. We aimed to investigate the association of comorbidities with BP control using a large cohort of hypertensive patients from primary care practices.Methods and ResultsUsing the Danish General Practice Database, we included 37 651 patients with hypertension from 231 general practices in Denmark. Recommended BP control was defined as BP <140/90 mm Hg in general and <130/80 mm Hg in patients with diabetes. The overall control rate was 33.2% (95% CI: 32.7 to 33.7). Only 16.5% (95% CI: 15.8 to 17.3) of patients with diabetes achieved BP control, whereas control rates ranged from 42.9% to 51.4% for patients with ischemic heart diseases or cerebrovascular or peripheral vascular diseases. A diagnosis of cardiac heart failure in addition to diabetes and/or CVD was associated with higher BP control rates, compared with men and women having only diabetes and/or CVD. A diagnosis of asthma in addition to diabetes and CVD was associated with higher BP control rates in men.ConclusionIn Danish general practice, only 1 of 3 patients diagnosed with hypertension had a BP below target. BP control rates differ substantially within comorbidities. Other serious comorbidities in addition to diabetes and/or CVD were not associated with lower BP control rates; on the contrary, in some cases the BP control rates were higher when the patient was diagnosed with other serious comorbidities in addition to diabetes and/or CVD.

Good knowledge about hypertension is linked to better control of hypertension; A multicentre cross sectional study in Karachi, Pakistan

BackgroundAccording to the National Health survey only 3% of the population has controlled hypertension. This study was designed to elucidate the knowledge about hypertension in hypertensive patients at three tertiary care centers in Karachi. Secondly we sought to compare the knowledge of those with uncontrolled hypertension and controlled hypertension.MethodsIt was a cross-sectional study conducted at The Aga Khan University hospital (AKUH), Ziauddin Hospital (ZH) and Civil hospital, Karachi (CHK. All diagnosed Hypertensive patients (both inpatients and outpatients) coming to a tertiary care hospital in Pakistan aged > 18 years were included. Patients were categorized into 2 groups: controlled and uncontrolled hypertension based on their initial BP readings on presentation Uncontrolled Hypertension was defined as average BP ≥ 140/90 mm Hg in patients on treatment. Controlled Hypertension (HTN) was defined as average BP <140/90 mm Hg in patients on treatment. Standardized methods were used to record BP in the sitting position. Knowledge was recorded as a15 item question. Primary outcome was knowledge about hypertension.ResultsA total of 650 participants were approached and consented 447 were found eligible. 284(63.5%) were from Aga Khan University, 101(22.6) from Dow University of health sciences and 62(13.9) were from Ziauddin University. Mean (SD) age of participants was 57.7(12) years, 50.1(224) were men. Controlled hypertension was present in 323(72.3) and uncontrolled hypertension was present in 124(27.4). The total mean (SD) Knowledge score was 20.97(4.93) out of a maximum score of 38. On comparison of questions related to knowledge between uncontrolled and controlled hypertension, there was statistically significant different in; meaning of hypertension (p <0.001), target SBP(p0.001), target DBP(p 0.001), importance of SBP versus DBP, improvement of health with lowering of blood pressure (p 0.002), high blood pressure being asymptomatic (p <0.001), changing lifestyle improves blood pressure(p 0.003),hypertension being a lifelong disease (<0.001), lifelong treatment with antihypertensives(<0.001) and high blood pressure being part of aging(<0.001). On comparison of knowledge as a composite score between uncontrolled and controlled hypertensive; Mean (SD) score was 21.85(4.74) v18.67 (4.70) (p value: < 0.001). On multivariate analysis; gender β (95% CI) 1.67(0.75, 2.59) p <0.001, uncontrolled blood pressure; -2.70(−3.76,-1.67) p <0.001, Sindhi ethnicity; -1.79(−3.25,-3.27) p 0.01 and pukhtoon ethnicity; -2.72(−4.13,-1.32) p <0.001 were significantly associated with knowledge score.ConclusionKnowledge about hypertension in hypertensive patients is not adequate and is alarmingly poor in patients with uncontrolled hypertension. More emphasis needs to be made on target blood pressure and need for taking antihypertensives for life to patients by physicians.

Loss of Adrenergic Augmentation of Diastolic Intra-LV Pressure Difference in Patients With Diastolic Dysfunction: Evaluation by Color M-Mode Echocardiography

The aim of this study was to evaluate the hypothesis that the adrenergic response of the intraventricular pressure difference (IVPD) is reduced in patients with preserved ejection fraction (EF) and diastolic dysfunction (DD). In early diastole, there is a progressive IVPD extending from the left atrium (LA) to the left ventricular (LV) apex. In response to adrenergic stimulation, as occurs during exercise, the IVPD increases allowing rapid filling without an abnormal increase in LA pressure. Patients with heart failure with a reduced EF have impaired adrenergic augmentation of the IVPD. We studied 166 consecutive patients undergoing dobutamine stress echocardiography who had no inducible ischemia and an EF ≥50%, of which 21 had normal diastolic function, 14 had impaired relaxation (grade 1), 80 had pseudonormal filling (grade 2), and 51 had restrictive filling (grade 3). Color M-mode Doppler (CMMD) images of mitral inflow were obtained at rest and during low (10 μg/kg/min) and peak (20 to 40 μg/kg/min) doses of dobutamine. The total IVPD from the LA to LV apex, LA to mid-LV, and mid-LV to the LV apex were calculated using the CMMD data to integrate the Euler equation. Total IVPD was not different between groups at rest. With dobutamine, the total IVPD increased by 2.20 ± 1.95 mm Hg in normal subjects and by only 0.73 ± 1.33 mm Hg, 1.84 ± 1.63 mm Hg, and 1.08 ± 1.57 mm Hg in patients with grades 1, 2, and 3 DD, respectively. This difference was due to a failure in augmentation of IVPD from the mid-LV to the LV apex, indicating reduced apical ventricular suction with DD, whereas the IVPD from the LA to the mid-LV responded similarly to dobutamine in normal subjects and those with DD. In patients with preserved EF, DD is associated with a reduced adrenergic augmentation of the IVPD from the mid-LV to the LV apex, reflecting less apical suction.

Patients With Continuous-Flow Left Ventricular Assist Devices Provide Insight in Human Baroreflex Physiology

The superior clinical outcome of new continuous-flow left ventricular assist devices (LVADs) challenges the physiological dogma that cardiovascular autonomic homeostasis requires pulsatile blood flow and pressure. We tested the hypothesis that continuous-flow LVADs impair baroreflex control of sympathetic nerve traffic, thus further exacerbating sympathetic excitation. We included 9 male heart failure patients (26-61 years; 18.9-28.3 kg/m(2)) implanted with a continuous-flow LVAD. We recorded ECG, respiration, finger blood pressure, brachial blood pressure, and muscle sympathetic nerve activity. After baseline measurements had been taken, patients underwent autonomic function testing including deep breathing, a Valsalva maneuver, and 15° head-up tilt. Finally, we increased the LVAD speed in 7 patients. Spontaneous sympathetic baroreflex sensitivity was analyzed. Brachial blood pressure was 99±4 mm Hg with 14±2 mm Hg finger pulse pressure. Muscle sympathetic nerve activity bursts showed a normal morphology, were linked to the cardiac cycle, and were suppressed during blood pressure increases. Mean burst frequency was lower compared with age- and body mass index-matched controls in 2 patients, slightly increased in 4 patients, and increased in 2 patients (P=0.11). Muscle sympathetic nerve activity burst latency and the median values of the burst amplitude distribution were similar between groups. Muscle sympathetic nerve activity increased 4±1 bursts per minute with head-up tilt (P<0.0003) and decreased 3±4 bursts per minute (P<0.031) when LVAD speed was raised. The mean sympathetic baroreflex slope was -3.75±0.79%/mm Hg in patients and -3.80±0.55%/mm Hg in controls. We conclude that low pulse pressure levels are sufficient to restrain sympathetic nervous system activity through baroreflex mechanisms.

Extreme Obesity in the Intensive Care Unit

Extreme obesity is currently a common medical condition. It is defined as having a body mass index (BMI) of >40 kg/m and is associated with an increased risk of mortality. A review of the clinical literature has shown that extreme obese patients are commonly admitted to the intensive care unit (ICU) for obstructive airway disease, pneumonia, and sepsis. A recent study found that patients with a BMI of >40 kg/m required greater mechanical ventilation and, therefore, a corresponding prolonged stay in the ICU. What are the other factors affecting the outcome of extreme obese patients in the ICU? In this issue of the Journal of Intensive Care Medicine, a new obesity-related condition among patients in the ICU with obesity hypoventilation syndrome (OHS) is now being described. The OHS is defined as the triad of obesity, daytime hypoventilation, and sleep-disordered breathing in the absence of an alternative neuromuscular, mechanical, or metabolic explanation for the hypoventilation episodes. Given this definition, a subtype condition has been identified in the extreme obese patients who had hypercapnic respiratory failure and multiorgan system dysfunction related to obesity, labeled as malignant obesity hypoventilation syndrome (MOHS). Marik and Desai coined this new term using a retrospective electronic chart review of 61 patients admitted to the ICU with a BMI of >40 kg/m and a PaCO2 greater than 45 mm Hg in patients admitted with hypercapnic respiratory failure. Supporting the description of MOHS, a statistical analysis of the documentation from this study confirmed the presence of multisystem disorder in extreme obesity by finding that 86% of the patients had congestive heart failure treated with diuretics, 71% had left ventricular failure, 61% had left ventricular diastolic dysfunction, 77% had pulmonary hypertension above 45 mm Hg, 90% had essential hypertension, and 64% had abnormal liver function tests and diagnosed with nonalcoholic steatohepatitis. Moreover, this retrospective study showed that based on the clinical documentation, these patients fit the clinical criteria for OHS, however, only 3 were diagnosed with this condition and the remaining (75%) were diagnosed with and treated for chronic obstructive lung disease (COPD). A primary question that arises after reading the study of Marik and Desai is ‘‘Are patients with extreme obesity admitted to the ICU with a diagnosis of COPD/asthma being misdiagnosed when in fact they could have unrecognized OHS?’’ It is known that patients with extreme obesity statistically have hypercapnic respiratory failure that increases the length of stay in the ICU due to prolonged necessity for mechanical ventilation. It is also well known that hypoventilation and oxygen disturbances are related to obesity even if there is no intrinsic lung disease. Therefore, mechanical ventilation in the extreme obese patient is one of many challenges clinicians face since the increase in the prevalence of obesity, with a corresponding increase in ICU admissions. It is very concerning that only 3 of 61 patients had a confirmed diagnosis of OHS. More interestingly, the management of extreme obese patients with bilevel positive airway pressure (BiPAP) in this study failed in 23% of the patients, thus requiring mechanical ventilation. This was an unexpected finding which highlights again the challenge of managing respiratory failure and the use of mechanical ventilation in extremely obese patients. What would have happened if OHS was part of the medical history of these patients admitted to the ICU? It is well known that extremely obese patients with concomitant untreated obstructive sleep apnea (OSA) present

Systematic Review and Recommendations for Intracompartmental Pressure Monitoring in Diagnosing Chronic Exertional Compartment Syndrome of the Leg

Although all intracompartmental pressure (ICP) measurement, magnetic resonance imaging, and near-infrared spectroscopy seem to be useful in confirming the diagnosis of chronic exertional compartment syndrome (CECS), no standard diagnostic procedure is currently universally accepted. We reviewed systematically the relevant published evidence on diagnostic criteria commonly in use for CECS to address 3 main questions: (1) Is there a standard diagnostic method available? (2) What ICP threshold criteria should be used for diagnosing CECS? (3) What are the criteria and options for surgical management? Finally, we made statements on the strength of each diagnostic criterion of ICP based on a rigorous standardized process. We searched for studies that investigated ICP measurements in diagnosing CECS in the leg of human subjects, using PubMed, Score, PEDRO, Cochrane, Scopus, SportDiscus, Web of Knowledge, and Google Scholar. Initial searches were performed using the phrase, "chronic exertional compartment syndrome." The phrase "compartment syndrome" was then combined, using Boolean connectors ("OR" and "AND") with the words "diagnosis," "parameters," "levels," "localisation," or "measurement." Data extracted from each study included study design, number of subjects, number of controls, ICP instrument used, compartments measured, limb position during measurements, catheter position, exercise protocol, timing of measurements, mean resting compartment pressures, mean maximal compartment pressures, mean postexercise compartment pressures, diagnostic criteria used, and whether a reference diagnostic standard was used. The quality of studies was assessed based on the approach used by the American Academy of Orthopaedic Surgeons in judging the quality of diagnostic studies, and recommendations were made regarding each ICP diagnostic criteria in the literature by taking into account the quality and quantity of the available studies proposing each criterion. In the review, 32 studies were included. The studies varied in the ICP measurement techniques used; the most commonly measured compartment was the anterior muscle compartment, and the exercise protocol varied between running, walking, and ankle plantarflexion and dorsiflexion exercises. Preexercise, mean values ranged from 7.4 to 50.8 mm Hg for CECS patients, and 5.7 to 12 mm Hg in controls; measurements during exercise showed mean pressure readings ranging from 42 to 150 mm Hg in patients and 28 to 141 mm Hg in controls. No overlap between subjects and controls in mean ICP measurements was found at the 1-minute postexercise timing interval only showing values ranging from 34 to 55.4 mm Hg and 9 to 19 mm Hg in CECS patients and controls, respectively. The quality of the studies was generally not high, and we found the evidence for commonly used ICP criteria in diagnosing CECS to be weak. Studies in which an independent, blinded comparison is made with a valid reference standard among consecutive patients are yet to be undertaken. There should also be an agreed ICP test protocol for diagnosing CECS because the variability here contributes to the large differences in ICP measurements and hence diagnostic thresholds between studies. Current ICP pressure criteria for CECS diagnosis are therefore unreliable, and emphasis should remain on good history. However, clinicians may consider measurements taken at 1 minute after exercise because mean levels at this timing interval only did not overlap between subjects and controls in the studies we analyzed. Levels above the highest reported value for controls here (27.5 mm Hg) along with a good history, should be regarded as highly suggestive of CECS. It is evident that to achieve an objective recommendation for ICP threshold there is a need to set up a multi-center study group to reach an agreed testing protocol and modify the preliminary recommendations we have made.

Transapical transcatheter aortic valve-in-valve implantation: Clinical and hemodynamic outcomes beyond 2 years

The feasibility of transapical valve-in-valve aortic valve implantation into a failed aortic surgical bioprosthesis has been confirmed. The purpose of the present study was to investigate the clinical and hemodynamic outcomes more than 2 years after transapical valve-in-valve aortic valve implantation. From April 2007 to May 2010, 8 consecutive patients underwent transapical valve-in-valve aortic valve implantation of either 23- or 26-mm Edwards-SAPIEN balloon-expandable bioprostheses into failed surgical tissue valves (21- to 25-mm valves). Clinical and echocardiographic follow-up was performed in all patients. The mean follow-up duration was 27.8±15.7 months (range, 18-55 months). Transapical valve-in-valve aortic valve implantation was successful in all patients (mean age, 84.1±1.6 years). The predicted operative mortality was 42.1%±15.7% by logistic European System for Cardiac Operative Risk Evaluation and 14.4%±9.6% using the Society of Thoracic Surgeons risk calculator. The observed 30-day mortality was 12.5%. No strokes or valve embolization/migrations occurred. The mean hospital stay was 9.0±9.1 days. The New York Heart Association class decreased from preoperative class III-IV to postoperative class I in 6 of 7 survivors. The 2-year survival was 87.5%. No late mortality occurred during the follow-up period. The echocardiographic results at 1 to 4 years of follow-up demonstrated stable valve position and function in all patients. The transaortic valve pressure gradients after valve-in-valve aortic valve implantation were greater than 20 mm Hg and less than 15 mm Hg in patients with 21- or 23-mm and 25-mm surgical valves, respectively. Transapical valve-in-valve aortic valve implantation provides good clinical outcomes and stable valve function beyond 2 years of follow-up. The best hemodynamic and clinical outcomes can be achieved in the patients with a surgical valve size of 25 mm or greater. Valve-in-valve aortic valve implantation could become a viable approach for selected high-risk patients with failed surgical bioprostheses.

Abstract 7: Outcomes at Six Months of a Randomized Trial of Home Blood Pressure Telemonitoring with Pharmacist Case Management

Background: Patients with high blood pressure (BP) visit a physician on average 4 times per year, though fewer than half achieve BP control. Practical, effective, and sustainable models are needed to improve BP management. Aims: Hyperlink is a clinic-randomized trial testing an intervention that combines home BP telemonitoring with pharmacist case management in patients with uncontrolled hypertension. Methods: We enrolled 450 patients with uncontrolled BP from 16 primary care clinics. Eight clinics (222 patients) were randomized to usual care and 8 clinics (228 patients) to intervention. Intervention patients received home telemonitors that transmit BP data to a secure database. Pharmacists consult with patients by phone and adjust antihypertensive therapy based on home BP data. The intervention lasts 12 months with follow-up to 18 months to observe durability. The primary outcome is BP control at 6 and 12 months, defined as BP ≤140/90 mm Hg (or ≤130/80 mm Hg in patients with chronic kidney disease or diabetes). Data on demographics, medication use and adherence, and satisfaction with care were also gathered. Here we report 6-month BP outcomes. General and generalized linear mixed models are used to accommodate the cluster-randomization. Results: Enrollees were 45% female, 83% white, and 13% black, with mean age of 61 years. Mean BP at baseline was 148/85 mm Hg in both treatment groups. Of the 403 attending the 6-month visit (197 usual care, 206 intervention), 45.2% in usual care and 71.8% in intervention achieved BP control (p&lt;0.0001). In usual care, mean systolic BP decreased by 10.3 mm Hg and diastolic decreased by 3.4 mm Hg. In intervention, mean systolic BP decreased by 21.6 mm Hg and diastolic decreased by 9.3 mm Hg. The difference in change between groups was 11.3 mm Hg systolic (p&lt;0.0001) and 5.8 mm Hg diastolic (p=0.003). Self-reported satisfaction with care in the six months following baseline was higher for intervention (mean=4.6) than usual care (mean=4.4, p&lt;0.01), on a 5 point scale (1=worst care possible, 5=best care possible). Between baseline and 6 months mean number of antihypertensive drugs used per participant increased from 1.4 to 1.6 in usual care and from 1.5 to 2.3 in intervention. The difference between treatment groups in increased drug use from a particular class was largest among thiazide diuretics (4.6% increase usual care, 27.6% intervention) and ACE inhibitors (1.6% increase usual care, 13.6% intervention). Calcium channel blocker and beta blocker use also increased more among intervention patients, while loop diuretic use decreased. Self-reported adherence to BP medications indicated better adherence for intervention (mean=0.7) than usual care (0.3, p&lt;0.01) measured on the Morisky scale (0-4, lower scores indicating better adherence) during the 6 months following the baseline visit. Conclusions: Home telemonitoring with pharmacist case management was effective at reducing BP for hypertensive patients over 6 months. This intervention may be cost-effective for managing hypertensive patients with uncontrolled BP, especially if results are sustained during the maintenance and post-intervention phases of follow-up.

Asymptomatic Aortic Stenosis: The Influence of the Systemic Vasculature on Exercise Time

Changes in the peripheral vasculature occur in patients with aortic stenosis (AS). The aims of the present study were to characterize peripheral arterial waveforms and aortic pulsewave velocity (PWV) in patients with AS and to determine their relationship to exercise time. The study included 101 patients with a median age of 68 years (range, 27-84 years) with at least moderate AS. Patients underwent transthoracic echocardiography, an assessment of the radial artery waveform and PWV using a SphygmoCor device, and a treadmill exercise stress test. The mean brachial systolic blood pressure was 143 ± 23 mm Hg in patients with severe AS and 135 ± 15 mm Hg in patients with moderate AS (P = .04). The mean radial augmentation index was 102 ± 20% in patients with severe AS and 89 ± 16% in those with moderate AS (P < .001). The radial augmentation index was related to the effective valve orifice area (R = -0.45, P = .001), the peak transvalvular pressure difference (R = 0.33, P = .001), and the mean transvalvular pressure difference (R = 0.33, P = .001). On univariate analysis, exercise time was related to systemic arterial compliance (R = 0.312, P = .008) and PWV (R = -0.44, P < 0.001). On multivariate analysis, after adjusting for age, AS severity, and PWV, only age was a significant predictor of exercise time (β = -0.46; P = .006; 95% confidence interval, -15 to -3). In patients with asymptomatic moderate to severe AS, exercise capacity is influenced only by age, not by resting measures of aortic valve stenosis or aortic stiffness.

Editorial What should the optimal blood pressure goal be in patients with diabetes mellitus or chronic kidney disease?

Editorial What should the optimal blood pressure goal be in patients with diabetes mellitus or chronic kidney disease?

The Role of Olmesartan Medoxomil-Based Combination Therapy in the Management of Hypertension: A Review for Nurse Practitioners

Background: Uncontrolled hypertension increases the likelihood of cardiovascular morbidity and mortality and places a great burden on health care systems. Hypertension (defined as a blood pressure [BP] of greater than (>) 140/90 mm Hg or >130/80 mm Hg in patients with diabetes) is amenable to treatment through lifestyle changes or pharmacological intervention. Although prevalence of hypertension has remained stable through recent years, advances in patient education and the availability of effective antihypertensive agents has allowed patients to better control their BP. Angiotensin II receptor blockers (ARBs) are a widely prescribed class of antihypertensive agents, and the ARB olmesartan medoxomil (OM) has been shown in clinical trials to effectively reduce BP with a placebo-like safety and tolerability profile.Purpose: To review the efficacy of OM-based treatment algorithms in patients with uncontrolled hypertension in specific demographic groups and to discuss the role of the nurse practitioner in the management of hypertension. Conclusions: Nurse practitioners hold a distinctive role at the forefront of primary care, which enables them to identify at-risk patients, ensure accurate diagnosis of hypertension through the proper measurement of BP, provide counseling on lifestyle changes, and prescribe effective pharmacotherapy. Safety and efficacy profiles of OM facilitate its inclusion into combination treatment algorithms when additional antihypertensive agents are needed to achieve desirable BP control. Clinical Implications: Clinical practice guidelines have established the paradigm that treating patients to defined BP goals may enable better patient outcomes. However, not all patients are managed to established goals. Issues of adherence, regimen complexity, and recognition of the need to escalate from monotherapy to combination therapy are common barriers to effective patient management.

The predominance of metabolic regulation of cerebral blood flow and the lack of "Classic" autoregulation curves in the viable brain

Background:The influence of cerebral perfusion pressure (CPP) on real-time focal cerebral blood flow (fCBF) is not fully understood, in either intact or injured brain. We wanted to evaluate that relationship, and by implication investigate the relative importance of perfusion pressure versus metabolism in the regulation and control of cerebral blood flow. Our hypothesis was that metabolic needs dominated over a physiologic range of blood pressure.Methods:This was an observational study of 23 patients, most of them with closed head injury, three with subarachnoid hemorrhage, one with a gunshot wound to the brain, and one monitored after craniotomy for unruptured aneurysm. Arterial lines, ventriculostomies, and fCBF monitors were placed. CPP (mean arterial pressure – intracranial pressure) and fCBF were measured and recorded to a computer database every minute. The relationship between CPP and fCBF was graphed and correlation coefficients were compared between survivors and non-survivors.Results:Graphs of CPP versus fCBF did not show any linearity over a range of 50–150 mm Hg in patients who survived. In those who died, four of seven showed some indication of linearity. The difference in the correlation coefficients between survivors and non-survivors was statistically significant (P < 0.05), with survivors having essentially no correlation, as expected with autoregulation intact, and non-survivors having a mean correlation of 0.311.Conclusions:In the functioning and viable brain, metabolic regulation of cerebral blood flow (CBF) predominates, leading to the lack of an obvious relationship between perfusion pressure and flow. This predominance of metabolic regulation is robust and preserved over a wide range of brain injury, with pressure autoregulation necessary but not clinically apparent in the metabolically active brain. This robust and constantly varying relationship of pressure and flow shown by our real-time measurements of fCBF has important implications for interpreting clinical measurements of autoregulation. Perhaps most importantly, the development of a correlation between pressure and flow may indicate and be an early warning of deterioration.

How Low should the Blood Pressure be reduced in Patients with Hypertension and High Risk for Coronary Artery Disease?

The more aggressive control of blood pressure among patients at high risk for coronary artery disease such as those with coronary artery disease, a 10-year Framingham risk score ≥10%, diabetes mellitus, chronic kidney disease, or other coronary artery risk equivalent with maintenance of the blood pressure below 130/80 mm Hg and below 120/80 mm Hg in patients with left ventricular dysfunction recommended by the American Heart Association (AHA) Task Force scientific statement in 2007 [1] was based upon expert medical opinion at that time, not on prospective, randomized, adequately controlled trial data [2]. The Pravastatin or Atorvastatin Evaluation and Infection TherapyThrombolysis in Myocardial Infarction (PROVE IT-TIMI) 22 trial enrolled 4,162 patients with an acute coronary syndrome (acute myocardial infarction with or without ST-segment elevation or highrisk unstable angina pectoris) [3].The lowest incidence of cardiovascular events occurred with a systolic blood pressure between 130 to 140 mm Hg and a diastolic blood pressure between 80 to 90 mm Hg with a nadir of 136/85 mm. An observational subgroup analysis was performed in 6,400 of the 22, 576 patients in the International Verapamil SR-Trandolapril Study (INVEST) [4]. These patients had diabetes mellitus and coronary artery disease. Patients were considered to have tight control of their blood pressure if they could maintain their systolic blood pressure below 130 mm Hg and their diastolic blood pressure below 85 mm Hg, usual control if they could maintain their systolic blood pressure between 130 to 139 mm Hg, and uncontrolled if their systolic blood pressure was 140 mm Hg or higher. During 16,893 patient-years of follow-up, the incidence of cardiovascular events was 12.6% in patients with usual control of blood pressure versus 19.8% in patients with uncontrolled hypertension, p <0.001 [4]. The incidence of cardiovascular events was 12.6% in patients with usual control of blood pressure versus 12.7% in patients with tight control of blood pressure (p not significant). The all-cause mortality rate was 11.0% with tight control of blood pressure versus 10.2% with usual control of blood pressure (p = 0.06). When extended follow-up was included, the all-cause mortality rate was 22.8% with tight control of blood pressure versus 21.8% with usual control of blood pressure, p = 0.04.

Refractory Hypertension: Definition, Prevalence, and Patient Characteristics

Among patients with resistant hypertension (RHTN), there are those whose blood pressure (BP) remains uncontrolled in spite of maximal medical therapy. This retrospective analysis aims to characterize these patients with refractory hypertension. Refractory hypertension was defined as BP that remained uncontrolled after ≥3 visits to a hypertension clinic within a minimum 6-month follow-up period. Of the 304 patients referred for RHTN, 29 (9.5%) remained refractory to treatment. Patients with refractory hypertension and those with controlled RHTN had similar aldosterone levels and plasma renin activity (PRA). Patients with refractory hypertension had higher baseline BP (175±23/97±15 mm Hg vs 158±25/89±15 mm Hg; P=.001/.005) and heart rate, and higher rates of prior stroke and congestive heart failure. During follow-up, the BP of patients with refractory hypertension remained uncontrolled (168.4±14.8/93.8±17.7 mm Hg) in spite of use of an average of 6 antihypertensive medications, while those of patients with controlled RHTN decreased to 129.3±11.2/77.6±10.8 mm Hg. Spironolactone reduced the BP by 12.9±17.8/6.6±13.7 mm Hg in patients with refractory hypertension and by 24.1±16.7/9.2±12.0 mm Hg in patients with controlled RHTN. In patients with RHTN, approximately 10% remain refractory to treatment. Similar aldosterone and PRA levels and a diminished response to spironolactone suggest that aldosterone excess does not explain the treatment failure.

Interventionelle renale Sympathikusdenervation zur Behandlung der therapieresistenten Hypertonie

This commentary summarizes the expert consensus and recommendations of the working group 'Herz und Niere' of the German Society of Cardiology (DGK), the German Society of Nephrology (DGfN) and the German Hypertension League (DHL) on renal denervation for antihypertensive treatment. Renal denervation is a new, interventional approach to selectively denervate renal afferent and efferent sympathetic fibers. Renal denervation has been demonstrated to reduce office systolic and diastolic blood pressure in patients with resistant hypertension, defined as systolic office blood pressure ≥ 160 mm Hg and ≥ 150 mm Hg in patients with diabetes type 2, which should currently be used as blood pressure thresholds for undergoing the procedure. Exclusion of secondary hypertension causes and optimized antihypertensive drug treatment is mandatory in every patient with resistant hypertension. In order to exclude pseudoresistance, 24-hour blood pressure measurements should be performed. Preserved renal function was an inclusion criterion in the Symplicity studies, therefore, renal denervation should be only considered in patients with a glomerular filtration rate > 45 ml/min. Adequate centre qualification in both, treatment of hypertension and interventional expertise are essential to ensure correct patient selection and procedural safety. Long-term follow-up after renal denervation and participation in the German Renal Denervation (GREAT) Registry are recommended to assess safety and efficacy after renal denervation over time.

A Comparison of the Ex-PRESS ™ Mini Glaucoma Shunt With Standard Trabeculectomy in the Surgical Treatment of Glaucoma

To compare the success and complication rates of patients with glaucoma who had an Ex-PRESS mini glaucoma shunt device implantation (Optonol, Ltd., Neve Ilan, Israel) to those who had conventional trabeculectomy. The records of 76 eyes of 69 consecutive subjects who had Ex-PRESS implants and 77 eyes of 65 consecutive controls who had trabeculectomy procedures were reviewed. All surgeries were performed by one of the authors (LWH). Success was defined as an intraocular pressure (IOP) between 5 and 21 mm Hg in patients who did not require further glaucoma surgery in the eye of note. The difference in the percentage of cases of postoperative hypotony between the standard trabeculectomy group (16%) and the Ex-PRESS group (4%) was statistically significant (P = .023). The Ex-PRESS device is at least as effective as the standard trabeculectomy in lowering the IOP of patients with glaucoma, with a significantly lower risk of postoperative hypotony. The data further suggest that the Ex-PRESS device results in an overall greater percentage reduction in IOP than with trabeculectomy, although this did not reach statistical significance.

Expanded polytetrafluoroethylene conduits and patches with bulging sinuses and fan-shaped valves in right ventricular outflow tract reconstruction: Multicenter study in Japan

There is no optimal substitute for right ventricular outflow tract (RVOT) reconstruction in congenital heart defects. Expanded polytetrafluoroethylene (ePTFE) valved conduits and patches may be a good alternative to homografts and bovine jugular veins. We have developed a fan-shaped ePTFE valve and an ePTFE valved conduit and patch with bulging sinuses with the aim of enhancing the long-term valve function. Bulging sinuses were constructed on ePTFE conduits and patches as described previously (J Thorac Cardiovasc Surg. 2007;134:327-32). Between February 2001 and January 2011, 794 patients (aged 14 days to 56.8 years old; median, 2.0 years old) had ePTFE valves implanted for RVOT reconstruction at 52 Japanese institutes. Conduits with a fan-shaped ePTFE valve were implanted in 325 patients and a patch with a fan-shaped ePTFE valve was implanted in 469 patients. Valve function was assessed by a series of echocardiograms postoperatively. The mean follow-up was 3.6 years (1.1 months to 10.0 years). Freedom from reoperation at 10 years was 95.4% in patients with conduits and 92.3% in those with patches. Pulmonary insufficiency was mild or nonexistent in 95.0% of patients with conduits and 79.6% of patients with patches. The pressure gradient between the right ventricle and the pulmonary artery was 14.0 ± 13.2 mm Hg in patients with conduits and 11.6 ± 11.6 mm Hg in patients with patches. Fan-shaped ePTFE valved conduits and patches with bulging sinuses have a high freedom from reoperation and prevent pulmonary insufficiency. They represent a promising material for RVOT reconstruction.