High-risk Hypertensive Patients Research Articles

5943Clinical efficacy of the combination of atorvastatin and perindopril in prevention of cardiovascular outcomes and mortality among high-risk hypertensive patients randomized to the ASCOT-LLA trial

5943Clinical efficacy of the combination of atorvastatin and perindopril in prevention of cardiovascular outcomes and mortality among high-risk hypertensive patients randomized to the ASCOT-LLA trial

Hypertension Survey in Italy: Novel Findings from the Campania Salute Network.

The "Campania Salute" (CS) is a network system aimed at improving the management of essential hypertension by integrating the activity of general practitioners (GPs) with that of the hypertension specialists. It involves 23 outpatient hypertensive clinics distributed in different community hospitals of the Napoli's metropolitan area, 60 randomly selected GPs homogeneously distributed in the same area, and the Hypertension Clinic of the Federico II University in Naples (co-ordinating centre). Through the CS system it is possible to share clinical data collected during each visit at peripheral units (general practitioners and community hospitals hypertensive clinics), which manage low-risk hypertensive patients, and the co-ordinating centre, which mainly manages high-risk hypertensive patients. The co-ordinating centre works in co-operation with the peripheral units in the treatment and follow-up of all hypertensive patients. Since the first reports on the CS network activity, it has been evident the effectiveness of this network in ameliorating the clinical management of the hypertensive disease. CS network is also a large prospective registry that generated several scientific reports based on the longitudinal assessment of hypertensive patients during their treatment. Nowadays, as observed in the Health Search Database, the rate of BP control in Campania was 69.5%, almost reaching the "Objective 70%", a result that could be in part linked to the activity of the CS network.

Relationship between initial therapy and blood pressure control for high-risk hypertension patients in the UK: a retrospective cohort study from the THIN general practice database

ObjectiveTo examine the UK practice patterns in treating newly diagnosed hypertension and to determine whether subgroups of high-risk patients are more or less likely to follow particular therapeutic protocols and...

The effect of circadian blood pressure pattern on presence of fragmented QRS complexes in hypertensive subjects

The association of deteriorated circadian blood pressure (BP) variability with presence of fragmented QRS (fQRS) on electrocardiography (ECG) is not clear. The present study aims to evaluate the relationship of BP patterns with presence of fQRS on ECG. A total of 338 consecutive newly diagnosed and never treated hypertensive patients who are without left ventricular hypertrophy and underwent 24-hour ambulatory BP monitoring were enrolled. Patients were classified as dippers, nondippers, and reverse dippers according to ambulatory BP monitoring results. The groups were compared regarding frequency of fQRS on ECG. The frequency of fQRS was significantly higher in reverse dippers compared with dippers (37.7% vs. 20.6%, P = .013). In multivariate logistic regression analysis, nighttime systolic BP was found to be an independent predictor of fQRS on ECG (P < .001, 95% confidence interval = 0.901–0.955). Other predictors of fQRS were daytime diastolic BP and age. Furthermore, fQRS was found to be an independent predictor of reverse dipping BP pattern in hypertensive patients (P = .004, odds ratio: 2.416, 95% confidence interval = 1.327–4.396). In conclusion, as a marker of fibrosis and higher fibrotic burden within myocardium, fQRS may be useful to determine the high-risk hypertensive patients in the absence of left ventricular hypertrophy.

Altered plasma fibrin clot properties in hypertensive patients with obstructive sleep apnoea are improved by continuous positive airway pressure treatment.

We investigated plasma fibrin clot properties in high-risk hypertensive patients with obstructive sleep apnoea (OSA) and assessed the impact of continuous positive airway pressure (CPAP) treatment on clot phenotype. We studied 50 hypertensive patients with clinically significant OSA (age 50.0 ± 8.8 years, 39 M, 11 F). In total, 38 hypertensive patients without OSA balanced for age, sex, blood pressure, cardiovascular risk factors, and metabolic status served as controls. Plasma fibrin clot properties, including clot permeability coefficient, clot lysis time (CLT), and turbidimetric parameters of clot formation were determined. Patients underwent transthoracic echocardiography, carotid ultrasonography, evaluation of endothelial function and calcium score index of coronary arteries, and Doppler imaging of renal arteries. Compared with controls, OSA patients were characterized by more compact fibrin structure (lower median clot permeability coefficient, 6.00 vs. 7.25 10 cm; P < 0.001), impaired fibrinolysis (longer median CLT, 108.00 vs. 92.50 min; P < 0.001), and by faster clot formation (shorter median lag phase, 40.50 vs. 42.50 s; P = 0.041), and higher median maximum clot absorbency indicating denser fibrin networks (0.87 vs. 0.81; P = 0.028). Clot permeability coefficient and CLT correlated with apnoea-hypopnoea index (r = -0.46; P < 0.001 and r = 0.44; P < 0.001, respectively) as well with mean (r = 0.31; P = 0.003; r = -0.36; P = 0.001, respectively) and minimal oxygen saturation (r = 0.46; P < 0.001; r = -0.49; P < 0.001, respectively). After 3 months of CPAP treatment we observed an increase in clot permeability coefficient (5.95 vs. 7.60 10 cm; P = 0,001), shortened CLT (107.00 vs. 87.00; P = 0.006), a longer lag phase of fibrin formation (40.00 vs. 43.50 s; P = 0.013), and a trend toward lower maximum clot absorbency (0.86 vs. 0.81; P = 0.058). In hypertensive patients at high cardiovascular risk, OSA was associated with unfavourable prothrombotic fibrin clot characteristics, including hypofibrinolysis, which significantly improve as early as after 3 months of CPAP treatment.

Abstract P278: Potential Value of Long-term Intensive BP Treatment in 40-year Patients: A Computer Simulation Study

Introduction: Intensive blood pressure (BP) goals are considered for high cardiovascular disease (CVD) risk adults ≥50 years old; the long-term value of intensive BP goals in younger high CVD risk patients has not been studied. Objectives: We used individual patient computer simulations to assess the incremental value of intensive BP goals in high CVD risk patients as young as 40 years. Methods: Six age/sex cohorts of 100,000 individuals were assembled by sampling NHANES surveys 1999-2010. BP and other risk factor trajectories were projected from ages 60 to 69, 50 to 69, and 40 to 69 years based on Framingham Offspring Cohort analyses. One BP treatment scenario simulated treating BP &lt;140/90 mmHg in all patients ≥140/90; a second scenario added to the first a goal &lt;BP 130/90 mmHg in patients with systolic BP ≥130 and 10-year CVD risk ≥10%. Costs included added treatment and side-effect costs and avoided CVD costs. Incremental cost-effectiveness ratios (ICERs) assessed changes in costs and quality-adjusted life years due to adding intensive BP goals in each cohort. Results: Intensive goals were generally cost-effective in high-risk CVD risk patients (Table). Treating 40-year old cohorts was the highest value strategy. This was because of large life-year gains when events are prevented early in life and because hypertensive 40 year-olds “age into” much higher BPs and CVD risk over time. To illustrate the latter, mean untreated systolic BPs at age 60 were 152, 148, and 146 mmHg, and mean 10-year CVD risk scores were 17%, 15% and 13% for 40-, 50- and 60-year-old male cohorts, respectively. Conclusion: Intensive BP goals were projected to be cost-effective over a 30-year time horizon in high-risk hypertensive patients as young as 40 years old.

Efficacy of Zofenopril vs. Irbesartan in Combination with a Thiazide Diuretic in Hypertensive Patients with Multiple Risk Factors not Controlled by a Previous Monotherapy: A Review of the Double-Blind, Randomized "Z" Studies.

Combinations between an angiotensin converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) and hydrochlorothiazide (HCTZ) are among the recommended treatments for hypertensive patients uncontrolled by monotherapy. Four randomized, double-blind, parallel group studies with a similar design, including 1469 hypertensive patients uncontrolled by a previous monotherapy and with ≥1 cardiovascular risk factor, compared the efficacy of a combination of a sulfhydryl ACE inhibitor (zofenopril at 30 or 60 mg) or an ARB (irbesartan at 150 or 300 mg) plus HCTZ 12.5 mg. The extent of blood pressure (BP)-lowering was assessed in the office and over 24 h. Pleiotropic features of the treatments were evaluated by studying their effect on systemic inflammation, organ damage, arterial stiffness, and metabolic biochemical parameters. Both treatments similarly reduced office and ambulatory BPs after 18–24 weeks. In the ZODIAC study a larger reduction in high sensitivity C reactive protein (hs-CRP) was observed under zofenopril (−0.52 vs. +0.97 mg/dL under irbesartan, p = 0.001), suggesting a potential protective effect against the development of atherosclerosis. In the ZENITH study the rate of carotid plaque regression was significantly larger under zofenopril (32% vs. 16%; p = 0.047). In the diabetic patients of the ZAMES study, no adverse effects of treatments on blood glucose and lipids as well as an improvement of renal function were observed. In patients with isolated systolic hypertension of the ZEUS study, a slight and similar improvement in renal function and small reductions in pulse wave velocity (PWV), augmentation index (AI), and central systolic BP were documented with both treatments. Thus, the fixed combination of zofenopril and HCTZ may have a relevant place in the treatment of high-risk or monotherapy-treated uncontrolled hypertensive patients requiring a more prompt, intensive, and sustained BP reduction, in line with the recommendations of current guidelines.

On-treatment blood pressures of older hypertensive patients in Canada: implications for Systolic blood PRessure INtervention Trial.

The therapeutic target level for the blood pressure (BP) on antihypertensive drug treatment in older hypertensive patients is still extensively debated. We assessed the achieved BP levels in older treated hypertensive patients in a representative sample of the population. During the 2006 Ontario Survey on the Prevalence and Control of Hypertension, BP (using the SPRINT protocol) and treatment data were collected in 2551 respondents from a random and representative sample of the adult (20-79 years) population. Responses are weighted to the Ontario hypertensive population of 1367 384, of which 684 928 were in the 60-79-year age range. Among 60-79-year-old individuals, using traditional definitions the prevalence of hypertension was 49%. Hypertension treatment rates were high (85%) as were control rates among treated hypertensive patients (85% for 60-69-year-old and 70% for 70-79-year-old patients). A total of 38% of older hypertensive patients were treated with a single antihypertensive drug. A total of 54% of these had a SBP less than 130 mmHg and 23% less than 120 mmHg. Of those treated with combination therapy, 75% had a SBP less than 130 mmHg, and 44% had a SBP less than 120 mmHg. For treated and controlled hypertensive patients, average SBP was 120 mmHg for the 60-69-year age groups, and 119 mmHg in the 70-79-year age groups. These findings suggest that intensive BP control, now being considered for high-risk hypertensive patients based on results from SPRINT, was actually already being achieved ∼10 years ago in a large section of the general hypertensive population of Ontario, Canada.

Combination of high-sensitivity troponin I and N-terminal pro-B-type natriuretic peptide predicts future hospital admission for heart failure in high-risk hypertensive patients with preserved left ventricular ejection fraction.

Additional risk stratification may provide more aggressive and focalized preventive treatment to high-risk hypertensive patients according to the Japanese hypertension guidelines. We prospectively investigated the predictive value of high-sensitivity troponin I (hsTnI), both independently and in combination with N-terminal pro-B-type natriuretic peptide (NT-proBNP), for incident heart failure (HF) in high-risk hypertensive patients with preserved left ventricular ejection fraction (LVEF). Baseline hsTnI and NT-proBNP levels and echocardiography data were obtained for 493 Japanese hypertensive outpatients (mean age, 68.5 years) with LVEF ≥ 50%, no symptomatic HF, and at least one of the following comorbidities: stage 3-4 chronic kidney disease, diabetes mellitus, and stable coronary artery disease. During a mean follow-up period of 86.1 months, 44 HF admissions occurred, including 31 for HF with preserved ejection fraction (HFpEF) and 13 for HF with reduced ejection fraction (HFrEF; LVEF <50%). Both hsTnI (p < 0.01) and NT-proBNP (p < 0.005) levels were significant independent predictors of HF admission. Furthermore, when the patients were stratified into 4 groups according to increased hsTnI (≥highest tertile value of 10.6pg/ml) and/or increased NT-proBNP (≥highest tertile value of 239.7pg/ml), the adjusted relative risks for patients with increased levels of both biomarkers versus neither biomarker were 13.5 for HF admission (p < 0.0001), 9.45 for HFpEF (p = 0.0009), and 23.2 for HFrEF (p = 0.003). Finally, the combined use of hsTnI and NT-proBNP enhanced the C-index (p < 0.05), net reclassification improvement (p = 0.0001), and integrated discrimination improvement (p < 0.05) to a greater extent than that of any single biomarker. The combination of hsTnI and NT-proBNP, which are individually independently predictive of HF admission, could improve predictions of incident HF in high-risk hypertensive patients but could not predict future HF phenotypes.

GENETIC POLYMORPHISM OF THE INFLAMMATORY CYTOKINE GENES AND ARTERIAL WALL PROPERTIES IN HYPERTENSIVE PATIENTS

Objective. To elucidate the association between polymorphic markers of the genes of C-reactive protein (CRP), interleukin 10 (IL10), interleukin 6 (IL6), lymphotoxin alpha (LTA) and tumor necrosis factor (TNFA) and changes of arterial stiffness in hypertensive patients. Design and methods. The study included 130 patients with hypertension (HTN) (64 (49,3%) men and 66 (50,7%) women), average age 63,7 ± 12,87 years. The intima-media thickness was measured by the method proposed by P. Pignolli. The arterial stiffness was assessed by the carotidfemoral and carotid-radial pulse wave velocity (PWV). Central aortic pulse pressure (PP) was calculated using pulse contour analysis. Results. An association of polymorphic markers of A (-3872)G, G (-2667)C, A (-5237) G CRP gene, G (-1082)A gene IL10, C (-174)G gene IL6, and A (-308)G gene TNFA with pulse wave velocity, PP in the aorta, the presence of atherosclerotic plaques of carotid arteries was found. Among patients with aortic PP &gt; 50 mmHg the frequency of AA genotype carriers of polymorphic marker C804A LTA gene was higher (p = 0,037). Carriers AA genotype had a significantly greater carotid-femoral PWV as compared with native CC genotype (13,4 and 11,9 m/s, p = 0,042) and higher PP in the aorta. Also, higher PP and aortic PWV were found in carriers of GG genotype of A (252)G LTA gene. Among patients with the presence of atherosclerotic plaques of carotid arteries the frequency of AA genotype of the G (-3014)A CRP gene was higher (p = 0,031). Conclusion. Thus, we have shown that CRP gene polymorphism is associated with the development of carotid atherosclerosis and increased central PP, while lymphotoxin alpha gene polymorphism is associated with the increase in arterial stiffness in high risk hypertensive patients. Our data confirm the involvement of pro-inflammatory cytokines in the development of atherosclerosis and endothelial dysfunction.

IS IT POSSIBLE TO IMPROVE THE ADHERENCE TO TREATMENT OF HYPERTENSION AND DYSLIPIDEMIA IN PATIENTS WITHOUT CLINICAL MANIFESTATIONS OF ATHEROSCLEROSIS?

The search for effective ways to improve adherence to medication in patients with hypertension at high risk is critical in reducing morbidity and mortality from cardiovascular diseases. Aim. To assess the possibility of improving adherence to therapy in high-risk hypertensive patients with dyslipidemia by means of electronic version of the SCORE scale in primary care. Material and methods. 300 hypertensive patients with dyslipidemia aged 40 to 65 years without clinical manifestations of atherosclerosis visiting primary care doctor (departmental clinic of Moscow) were examined. The study included only patients (n=150) with high cardiovascular risk and target organ damages (microalbuminuria, left ventricular hypertrophy, subclinical carotid atherosclerosis). The patients were randomized into two groups – main (n=76) and control (n=74). All patients were prescribed antihypertensive and lipid-lowering therapy, recommendations for a healthy lifestyle. In the main group, the positive dynamics of risk was demonstrated with the electronic version of the SCORE scale in the case of achieving target levels of blood pressure (BP) and total cholesterol, smoking cessation and weight loss. No such demonstration was done in the reference group. The duration of study was 12 months. In the groups, evaluation of the achievements of target BP values and lipid variables, risk factors correction, dynamics of SCORE risk and adherence to therapy was done. Adherence to treatment was assessed by Morisky-Green scale. Results. By the end of the study, the average Morisky-Green score in the main group was 2.14 vs 1.27 in the control group (p<0.001). In the main group, adherence to antihypertensive therapy persisted for 8.8 months, to statin therapy – 6.74 months; the same characteristics in the control group were 5.73 and 3.6 months, respectively (p<0.001). Achievement of target levels of BP and total cholesterol in the main group amounted to 55.3% and 35.5% of patients, respectively, in the control group – 18.9% and 10.8%, respectively (p<0.001). The SCORE risk value was significantly lower in the main group than this in control group (4.09 vs 5.25, respectively). Conclusion. Demonstration of electronic version of SCORE scale for high-risk hypertensive patients with dyslipidemia allows increasing the patient's adherence to treatment. This leads to the increase in the effectiveness of therapy, better control of BP and lipid parameters, correction of other modifiable risk factors and as a result to reducing overall cardiovascular risk.

Prevalence of chronic kidney disease in a city of southeast Brazil.

Chronic kidney disease (CKD) is a worldwide public health alarming problem. This study investigated the estimated prevalence of kidney disease in diabetic and high-risk hypertensive patients to cardiovascular disease registered in Hiperdia program of a city of southeast of Brazil. It is a transversal study conducted between May 2014 and August 2015. The study has included randomly 243 diabetic and high-risk hypertensive patients to cardiovascular disease which were originally referred from primary health care to the Hiperdia. CKD was classified based on cause, Glomerular Filtration Rate (GFR), and albumin creatinine ratio (ACR). Were considered abnormalities GFR < 60 mL/min/1.73m2 and/or ACR ≥ 30 mg/g. Of the 243 patients, 89 (36.6%) showed alterations in renal function markers in the first collection. Of these, 60 patients had a GFR < 60 mL/min/1.73 m2 and 25 the GFR was < 45 mL/min/1.73 m2. The ACR was ≥ 30 mg/g in 43 patients and eight of the values were > 1000 mg/g. In 15 patients studied were found both changes. Of the 89 participants with abnormal renal function markers in the first collection 63 held the second test and 42 kept the changes being diagnosed with CKD. None of these patients had prior knowledge of the diagnosis of kidney disease and the need for consultation with the nephrologist. The prevalence of CKD was 17.3% of disease in the population studied.

Omega-3 fatty acids supplementation improves endothelial function and arterial stiffness in hypertensive patients with hypertriglyceridemia and high cardiovascular risk

Association between hypertriglyceridemia and cardiovascular (CV) disease is still controversial. The purpose of this study was to compare omega-3 and ciprofibrate effects on the vascular structure and function in low and high CV risk hypertensive patients with hypertriglyceridemia. Twenty-nine adults with triglycerides 150–499 mg/dL were divided into low (<7.5%) and high (≥7.5%) CV risk, randomized to receive omega-3 fatty acids 1800 mg/d or ciprofibrate 100 mg/d for 12 weeks. Treatment was switched after 8-week washout. Clinical evaluation and vascular tests were assessed at baseline and after intervention. Peripheral (131 ± 3 to 125 ± 3 mm Hg, P < .05) and aortic (124 ± 3 to 118 ± 2 mg/dL, P < .05) systolic blood pressure were decreased by ciprofibrate in low-risk patients. In high-risk patients, pulse wave velocity was reduced (10.4 ± 0.4 to 9.4 ± 0.3 m/s, P < .05) and flow-mediated dilation was increased (11.1 ± 1.6 to 13.5 ± 1.2%, P < .05) by omega-3. In conclusion, omega-3 improved arterial stiffness and endothelial function, pointing out the beneficial effect of this therapy on vascular aging, in high-risk patients.

PP.21.04] INTERLEUKIN-17 RELATED TO RISK FACTORS IN HYPERTENSIVE PATIENTS

Objective: Recently Interleukin 17 (IL-17) had been shown implicated in the pathogenesis of numerous autoimmune diseases, obesity, and cardiovascular diseases. The purpose of the study was to investigate the serum concentration of IL-17 and its association with cardiovascular risk factors in hypertensive patients. Design and method: Ninety hypertensive patients (47 men, 43 women) aged 56 ± 4.1 years were prospectively enrolled for this study. Serum IL-17 had been measured by ELISA method in all participants after wash-out period. All patients were evaluated for anthropometry, cardiovascular risk factors and 24-hour blood pressure monitoring. The results were analysed using two-sided Fisher's exact test and the respective odds ratio (OR) was calculated. Results: Mean serum level of IL-17 was significantly higher (6.7 pg/ml) in high-risk hypertensive patients compared with moderate (on 33%, p = 0,03) and low-risk (on 46%, p = 0,01) patients. In high-risk hypertensive patients increased serum IL-17 above 5.5 pg/ml had been significantly associated with history of previous stroke (OR = 2.43; 95% confidence interval [CI], 1.15 to 3.84), high night-time systolic blood pressure level (OR = 1.87; 95% CI, 1.18 to 2.78) and c-reactive protein (OR = 3.42; 95% CI, 1.65 to 5.62). No relationship between IL-17 and body mass index as well as patient's age had been revealed. Conclusions: High-risk hypertensive patients had elevated level of interleukin-17, which is related to cerebrovascular lesion, high night-time systolic blood pressure level and marker of inflammation. These associations could indicate on potential role of autoimmune cytokines in hypertension progression.

PP.16.14] OBSTRUCTIVE SLEEP APNEA BUT NOT RESISTANT HYPERTENSION INFLUENCES PLASMA FIBRIN CLOT PROPERTIES IN PATIENTS WITH HYPERTENSION AT HIGH CARDIOVASCULAR RISK

Objective: Both obstructive sleep apnea (OSA) and resistant hypertension (RHT) are related with high cardiovascular (CV) risk. Formation of dense and poorly lysable plasma fibrin clots is observed in clinical settings characterized by high CV risk. We investigated plasma fibrin clot properties in high-risk hypertensive patients with and without OSA or RHT but without clinically overt CV disease Design and method: We studied 88 hypertensive patients (64 M, 24F, mean age 48.6 ± 8.9years) at high CV risk (2007 ESH/ESC criteria) suspected of OSA. Patients with diagnosed atherosclerotic CV disease were excluded. Fibrin clot properties including clot permeability (Ks), clot lysis time (CLT), and turbidimetric parameters of clot formation (the lag phase of fibrin formation and maximum absorbency (δAbsmax) at 405 nm) were determined. All patients underwent PSG - the apnea/hypopnea index (AHI) > 15 events/h defined clinically important moderate-to-severe OSA. RHT was defined as uncontrolled HT despite using 3 antihypertensive drugs including diuretic. Patients were divided into 4 groups based on the presence of OSA or RHT: OSA-RHT-, OSA-RHT+, OSA+RHT−, OSA + RHT+ Results: There were no significant differences in gender, age and BMI between the groups. Patients in the OSA+ groups were characterized by lower Ks (5.88 ± 0.86 and 6.09 ± 0.96 vs 7.11 ± 0.90 and 7.58 ± 1.27 10 - 9 cm2; p < 0.001) and by longer CLT (108.85 ± 13.88 and 102.12 ± 11.34 vs 96.46 ± 12.20 and 89.48 ± 15.67 min; p < 0.001 for OSA + RHT+ and OSA + RHT− vs OSA-RHT+ and OSA-RHT- groups respectively) as compared with the groups without OSA. In both OSA groups clots formed faster (lag phase, 41.39 ± 3.82 and 40.71 ± 4.81 vs 41.15 ± 4.20 and 44.60 ± 5.31 s; p = 0.018) and tended to had higher δAbsmax (0.86 ± 0,05 and 0.86 ± 0.05 vs 0.85 ± 0.08 and 0.83 ± 0.07 min; p = 0.12 for OSA + RHT+ and OSA + RHT− vs OSA-RHT+ and OSA-RHT- groups respectively). Ks and CLT correlated with AHI but now with office BP and ambulatory BP levels Conclusions: In hypertensive patients at high CV risk, the presence of OSA but not of RHT was associated with unfavorable, prothrombotic changes in the structure and function of fibrin clots. The study may indicate the involvement of prothrombothic mechanism in which OSA may has an impact on CV risk

OP.4A.01] SYSTOLIC VISIT-TO-VISIT BLOOD PRESSURE VARIABILITY INCREASES RISK OF MYOCARDIAL INFARCTION AND CONGESTIVE HEART FAILURE IN PATIENTS GIVEN VALSARTAN OR AMLODIPINE IN THE VALUE TRIAL

Objective: High systolic blood pressure variability has been associated with an increased risk of cardiovascular events, and has been shown to be associated with an increased risk of cardiac events in the VALUE trial. In this analysis we aimed to assess if increased visit-to-visit variability in systolic blood pressure increased the risk of myocardial infarction or heart failure in the VALUE trial patient population. Design and method: The VALUE trial was a randomised-controlled, double-masked investigation of valsartan versus amlodipine in patients 50 years or older with hypertension and high risk of cardiovascular events. Mean follow-up time was 4.2 years. We calculated the standard deviation (SD) of mean systolic blood pressure from visits 6 months onward, excluding patients with less than 3 visits, or patients with stroke or cardiac events during the first 6 months. In the pooled treatment arms, we grouped SD in quintiles and compared the risk of myocardial infarction and congestive heart failure (fatal/non-fatal events) in the highest and the lowest quintile, using a Cox regression model, adjusting for a number of prognostic variables, including randomised treatment and mean systolic blood pressure from 6 months onwards. Results: Of 13.803 patients included, 503 (3.6%) experienced myocardial infarction and 489 (3.5%) experienced congestive heart failure. Compared to patients with the lowest variability, those in the highest quintile had an increased risk of myocardial infarction and congestive heart failure (HR 3.2, 95% CI 2.3–4.3, p < 0.0001 and HR 3.1, 95% CI 2.2–4.3, p < 0.0001, respectively, Figure). Conclusions: Visit-to-visit systolic blood pressure variability predicts myocardial infarction and congestive heart failure in high-risk hypertensive patients receiving valsartan or amlodipine, independent of mean systolic blood pressure.

The major arteries and skin microcirculatory vessels status and antihypertensive therapy effect on them in hypertensive patients with high and very high cardiovascular risk

Aim: to assess the state of the large blood vessels and skin microcirculatory vessels and the effects of angiotensin II receptor blockers (ARB) on them in hypertensive patients with high and very high cardiovascular risk (CVR). Subjects and methods. We examined 59 hypertensive patients aged 35-60 years, of which 29 high CVR subjects and 30 very high CVR (without antihypertensive therapy within 2 weeks prior to the study). In all subjects the evaluation of target organ damage, laser Doppler flowmetry (LDF) with initial perfusion parameters registration and amplitude-frequency spectrum of LDF-grams analysis, registration of central blood pressure, local stiffness parameters and photoplethysmography (PTMG) were performed. The second study was carried out after 2 weeks of antihypertensive treatment with ARB. Results. A significant increase in endothelial rhythm amplitude and coefficient of variation in very high risk hypertensive patients in comparison with a group of high-risk patients was found. In the group of very high-risk hypertensive patients central arterial pressure, augmentation index and local stiffness values were higher (n/a), the rate of carotid arteries extensibility was significantly reduced. There was a significant large vessels impairment in very high risk group according PTMG data. Target blood pressure level achieved in up to 80% of patients after 2 weeks treatment. During the re-examination a statistically significant improvement in the large arteries was found, LDF parameters also improved, but significant values was not reached. Conclusion. The findings suggest that with increasing degree of CVR in patients with hypertension there is a progressive deterioration of both large vessels and microcirculation state. After short-term antihypertensive therapy the function of large vessels improve in very high risk hypertensive patients, but the state of the microvasculature not changes significantly.

Treatment of hypertensive patients with diabetes: beyond blood pressure control and focus on manidipine.

Renin-angiotensin system inhibitors should be considered as the first-line therapy in the treatment of patients with hypertension and diabetes. However, most of the diabetic subjects with hypertension require at least two drugs to achieve blood pressure targets. The ACCOMPLISH trial suggested that the best combination in the treatment of high-risk hypertensive patients should include a renin-angiotensin system inhibitor and a dihydropyridine. However, not all dihydropyridines block the same receptors. Those dihydropyridines that block T-type calcium channel blockers may provide additional advantages. A number of studies suggest that compared with amlodipine, manidipine have the same antihypertensive efficacy, but with a lesser risk of ankle edema. In addition, manidipine, but not amlodipine, significantly reduces urinary albumin excretion rates.

Recommendations for Intensive Blood Pressure Lowering in High-Risk Patients, the Canadian Viewpoint.

Recent publication of the Systolic Blood Pressure Intervention Trial (SPRINT) in close temporal proximity to 2 meta-analyses affirming the benefits of intensive blood pressure (BP) control collectively signify the need to reevaluate BP targets in hypertensive patients at high risk for cardiovascular events.1–3 This commentary discusses how this recent evidence has affected Canadian clinical practice guidelines, describes the process used to update these guidelines in light of this evidence, and outlines the major issues deliberated by Canadian Hypertension Education Program (CHEP) Task Force members during this process. In the SPRINT trial, which studied 9361 subjects aged ≥50 years at increased risk for cardiovascular events, intensive systolic BP control (to <120 mm Hg) reduced the incidence of cardiovascular events and mortality by 25% (5.2% versus 6.8%; hazard ratio 0.75; 95% confidence interval 0.64–0.89) compared with standard systolic BP control (135–139 mm Hg).1 Furthermore, a meta-analysis of 55 randomized controlled trials (265 576 subjects) demonstrated that the reduction in cardiovascular events realized from a 10-mm Hg systolic BP reduction is similar across different quintiles of baseline systolic BP (<130, 130–139, 140–149, 150–159, ≥160 mm Hg).2 In a second meta-analysis of 14 treat-to-target trials (44 989 subjects), a 7-mm Hg mean systolic BP reduction (from 140 to 133 mm Hg) led to a 14% (95% confidence interval 0.78–0.96) reduction in major cardiovascular events.3 In aggregate, these data support the implementation of intensive BP control in high-risk patients. Canadian hypertension clinical practice guidelines are crafted and disseminated by the multidisciplinary 75-member CHEP Recommendations Task Force, a process that is funded by Hypertension Canada.4 CHEP has produced annually updated recommendations for the diagnosis and management of high BP since 1999.5 The CHEP process consists of the following: 1. A Cochrane librarian conducts literature searches in collaboration with Task Force members. These searches are designed to inform …

General practitioners’ justifications for therapeutic inertia in cardiovascular prevention: an empirically grounded typology

ObjectiveTo construct a typology of general practitioners’ (GPs) responses regarding their justification of therapeutic inertia in cardiovascular primary prevention for high-risk patients with hypertension.DesignEmpirically grounded construction of typology. Types were...