Initial Diagnosis Of Hypertension Research Articles

Multimodal data-driven, vertical visualization prediction model for early prediction of atherosclerotic cardiovascular disease in patients with new-onset hypertension.

: Hypertension is an important contributing factor to atherosclerotic cardiovascular disease (ASCVD), and multiple risk factors, many of which are implicated in metabolic disorders, contribute to the cause of hypertension. Despite the promise of multimodal data-driven prediction model, no such prediction model was available to predict the risk of ASCVD in Chinese individuals with new-onset hypertension and no history of ASCVD. : A total of 514 patients were randomly allocated to training and verification cohorts (ratio, 7 : 3). We employed Boruta feature selection and conducted multivariate Cox regression analyses to identify variables associated with ASCVD in these patients, which were subsequently utilized for constructing the predictive model. The performance of prediction model was assessed in terms of discriminatory power (C-index), calibration (calibration curves), and clinical utility [decision curve analysis (DCA)]. : This model was derived from four clinical variables: 24-h SBP coefficient of variation, 24-h DBP coefficient of variation, urea nitrogen and the triglyceride-glucose (TyG) index. Bootstrapping with 500 iterations was conducted to adjust the C-indexes were C-index = 0.731, 95% confidence interval (CI) 0.620-0.794 and C-index: 0.799, 95% CI 0.677-0.892 in the training and verification cohorts, respectively. Calibration plots with 500 bootstrapping iterations exhibited a strong correlation between the predicted and observed occurrences of ASCVD in both the training and verification cohorts. DCA analysis confirmed the clinical utility of this prediction model. The constructed nomogram demonstrated significant additional prognostic utility for ASCVD, as evidenced by improvements in the C-index, net reclassification improvement, integrated discrimination improvement, and DCA compared with the overall ASCVD risk assessment. The developed longitudinal prediction model based on multimodal data can effectively predict ASCVD risk in individuals with an initial diagnosis of hypertension. : The trial was registered in the Chinese Clinical Trial Registry (ChiCTR2300074392).

From Admission to Discharge: Predicting National Institutes of Health Stroke Scale Progression in Stroke Patients Using Biomarkers and Explainable Machine Learning.

As a result of social progress and improved living conditions, which have contributed to a prolonged life expectancy, the prevalence of strokes has increased and has become a significant phenomenon. Despite the available stroke treatment options, patients frequently suffer from significant disability after a stroke. Initial stroke severity is a significant predictor of functional dependence and mortality following an acute stroke. The current study aims to collect and analyze data from the hyperacute and acute phases of stroke, as well as from the medical history of the patients, in order to develop an explainable machine learning model for predicting stroke-related neurological deficits at discharge, as measured by the National Institutes of Health Stroke Scale (NIHSS). More specifically, we approached the data as a binary task problem: improvement of NIHSS progression vs. worsening of NIHSS progression at discharge, using baseline data within the first 72 h. For feature selection, a genetic algorithm was applied. Using various classifiers, we found that the best scores were achieved from the Random Forest (RF) classifier at the 15 most informative biomarkers and parameters for the binary task of the prediction of NIHSS score progression. RF achieved 91.13% accuracy, 91.13% recall, 90.89% precision, 91.00% f1-score, 8.87% FNrate and 4.59% FPrate. Those biomarkers are: age, gender, NIHSS upon admission, intubation, history of hypertension and smoking, the initial diagnosis of hypertension, diabetes, dyslipidemia and atrial fibrillation, high-density lipoprotein (HDL) levels, stroke localization, systolic blood pressure levels, as well as erythrocyte sedimentation rate (ESR) levels upon admission and the onset of respiratory infection. The SHapley Additive exPlanations (SHAP) model interpreted the impact of the selected features on the model output. Our findings suggest that the aforementioned variables may play a significant role in determining stroke patients' NIHSS progression from the time of admission until their discharge.

FOLLOW-UP OF VASCULAR LESIONS IN FIBROMUSCULAR DYSPLASIA. NO EVIDENCE FOR PROGRESSION YET

Objective: It is currently unknown whether the vascular lesions in patients with fibromuscular dysplasia (FMD) are progressive in time. Therefore, repeat CT-angiography (CTA) is often necessary to evaluate possible evolution of the abnormalites. It would be unjustified to frequently expose patients to this diagnostic modality with its drawbacks (radiation, contrast material) if the vascular lesions turn out to be stable. The aim of our study was to explore whether vascular FMD lesions (unifocal or multifocal, with or without aneurysms) change in terms of extensiveness or localization over a period of a few years. Design and method: To qualify for the present study, patients had to be diagnosed with FMD in any vascular bed and both the diagnostic and the follow-up CTA had to be performed at the same institution using the same imaging protocol. Patients who had been referred by other hospitals and were followed in our own clinic were excluded from the analysis. On both the basal and the follow-up CTA, we assessed the number of lesions, the site of lesions, and the presence or absence of aneurysms. Results: A total of 161 patients had both a diagnostic and a follow-up CTA at our own clinic. Their mean age at diagnosis was 49 + 11 years (range 19-76) and 63% of the patients had been detected during a work-up for hypertension. On average, FMD was diagnosed nine years after the initial diagnosis of hypertension had been made. In the remainder of the patients, FMD was diagnosed after the patient had experienced a dissection (coronary, carotid). Follow-up CTA after two years was available in 111 patients and after three years in 50 patients. In only three patients we found new vascular lesions after a period of two years. In all the others, the pattern of lesions remained constant. Conclusions: Over a period of two to three years, vascular FMD lesions do not seem to progress in most patients. If repeat CTA scanning is considered, one should respect at least this time period.

HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings.

HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. It is implemented in 24 countries and over 2,000 primary healthcare facilities. This paper describes the results of a multicomponent, stepwise, quality improvement intervention designed by the HEARTS in the Americas to support advances in hypertension treatment protocols and evolution towards the Clinical Pathway. The quality improvement intervention comprised: 1) the use of the appraisal checklist to evaluate the current hypertension treatment protocols, 2) a peer-to-peer review and consensus process to resolve discrepancies, 3) a proposal of a clinical pathway to be considered by the countries, and 4) a process of review, adopt/adapt, consensus and approval of the clinical pathway by the national HEARTS protocol committee. A year later, 16 participants countries (10 and 6 from each cohort, respectively) were included in a second evaluation using the HEARTS appraisal checklist. We used the median and interquartile scores range and the percentages of the maximum possible total score for each domain as a performance measure to compare the results pre and post-intervention. Among the eleven protocols from the ten countries in the first cohort, the baseline assessment achieved a median overall score of 22 points (ICR 18 -23.5; 65% yield). After the intervention, the overall score reached a median of 31.5 (ICR 28.5 -31.5; 93% yield). The second cohort of countries developed seven new clinical pathways with a median score of 31.5 (ICR 31.5 -32.5; 93% yield). The intervention was effective in three domains: 1. implementation (clinical follow-up intervals, frequency of drug refills, routine repeat blood pressure measurement when the first reading is off-target, and a straightforward course of action). 2. treatment (grouping all medications in a single daily intake and using a combination of two antihypertensive medications for all patients in the first treatment step upon the initial diagnosis of hypertension) and 3. management of cardiovascular risk (lower BP thresholds and targets based on CVD risk level, and the use of aspirin and statins in high-risk patients). This study confirms that this intervention was feasible, acceptable, and instrumental in achieving progress in all countries and all three domains of improvement: implementation, blood pressure treatment, and cardiovascular risk management. It also highlights the challenges that prevent a more rapid expansion of HEARTS in the Americas and confirms that the main barriers are in the organization of health services: drug titration by non-physician health workers, the lack of long-acting antihypertensive medications, lack of availability of fixed-doses combination in a single pill and cannot use high-intensity statins in patients with established cardiovascular diseases. Adopting and implementing the HEARTS Clinical Pathway can improve the efficiency and effectiveness of hypertension and cardiovascular disease risk management programs.

Use of lifestyle interventions in primary care for individuals with newly diagnosed hypertension, hyperlipidaemia or obesity: a retrospective cohort study.

Lifestyle interventions can be efficacious in reducing cardiovascular disease risk factors and are recommended as first-line interventions in England. However, recent information on the use of these interventions in primary care is lacking. We investigated for how many patients with newly diagnosed hypertension, hyperlipidaemia or obesity, lifestyle interventions were recorded in their primary care electronic health record. A retrospective cohort study. English primary care, using UK Clinical Practice Research Datalink. A total of 770,711 patients who were aged 18 years or older and received a new diagnosis of hypertension, hyperlipidaemia or obesity between 2010 and 2019. Record of lifestyle intervention and/or medication in 12 months before to 12 months after initial diagnosis (2-year timeframe). Analyses show varying results across conditions: While 55.6% (95% CI 54.9-56.4) of individuals with an initial diagnosis of hypertension were recorded as having lifestyle support (lifestyle intervention or signposting) within the 2-year timeframe, this number was reduced to 45.2% (95% CI 43.8-46.6) for hyperlipidaemia and 52.6% (95% CI 51.1-54.1) for obesity. For substantial proportions of individuals neither lifestyle support nor medication (hypertension: 12.2%, 95% CI 11.9-12.5; hyperlipidaemia: 32.2%, 95% CI 31.2-33.3; obesity: 43.9%, 95% CI 42.3-45.4) were recorded. Sensitivity analyses confirm that limited proportions of patients had lifestyle support recorded in their electronic health record before they were first prescribed medication (diagnosed and undiagnosed), ranging from 12.1% for hypertension to 19.7% for hyperlipidaemia, and 19.5% for obesity (23.4% if restricted to Orlistat). Limited evidence of lifestyle support for individuals with cardiovascular risk factors (hypertension, hyperlipidaemia, obesity) recommended by national guidelines in England may stem from poor recording in electronic health records but may also represent missed opportunities. Given the link between progression to cardiovascular disease and modifiable lifestyle factors, early support for patients to manage their conditions through non-pharmaceutical interventions by establishing lifestyle modification as first-line treatment is crucial.

BLOOD PRESSURE INCREASES INDUCED BY IATROGENESIS, OVER THE COUNTER SUBSTANCES, AND HERBALS PRODUCTS

A number of both prescription and over the counter drugs, herbal supplements, and miscellaneous substances can increase blood pressure in subjects by degrees that vary substantially within drug classes and individual patients; such increases often remain within the normal range but may cause overt hypertension (BP>140/90) mmHg and even precipitate hypertensive crises. Blood pressure increases are often potentiated by co-existing cardiovascular conditions, age, renal disease, diabetes, obesity, and interactions with other concomitant medications. The need to scrutinize for drugs or other substances that may be contributing to elevated blood pressures or impairing responses to anti-hypertensive medications is critically important, particularly in the evaluation of resistant and refractory hypertension. Anti-hypertensive effects of diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and β-blockers may be blunted. The drugs most commonly associated with blood pressure elevations are non-steroidal anti-inflammatory agents, sympathomimetic amines, estrogen-containing oral contraceptives, certain antidepressants, angiogenesis inhibitors, and ephedra. Although most drug-induced blood pressure increases do not, in fact, lead to overt hypertension, systolic and diastolic blood pressure elevations of as little as 2 mmHg lead to significant increases in the risk of cardiovascular events. When a medication with the potential to increase blood pressure is added to a patient’s therapeutic regimen, it is most important to monitor for possible changes in blood pressure even within the normal range. An initial diagnosis of hypertension should not be made until a thorough examination of all over the counter products and herbal substances that a patient may be consuming.

Correlation of 24-Hour Average Heart Rate With Early Renal Damage in Patients With Initial Diagnosis of Hypertension

Abstract Background To investigate the correlation of 24-hour average heart rate (HR) with early renal damage in patients with initial diagnosis of hypertension. Methods A total of 456 outpatients with initial diagnosis of hypertension were recruited between November 2015 and May 2017. Ambulatory electrocardiogram and blood pressure (BP) were monitored in all patients. According to the 24-hour average HR, patients were divided into fast HR group (24-hour average HR >75 beats/minute, n = 203) and nonfast HR group (24-hour average HR ≤75 beats/minute, n = 253). HR, renal function, and urinary microalbumin were analyzed. Results Albumin-to-creatinine ratio, eGFR, body mass index, total cholesterol, low-density lipoprotein cholesterol, 24-hour average HR, night and day average HR, diastolic BP, and daytime systolic BP were higher, while nocturnal BP drop rate was lower in patients with fast HR group than those in nonfast HR group (all P < 0.05). Twenty-four-hour HR and albumin-to-creatinine ratio increased significantly with increases of office BP (P < 0.05). albumin-to-creatinine ratio and eGFR in high-risk group and extremely high-risk group were significantly higher, while eGFR was lower than those in low- and middle-risk group (all P < 0.05). The 24-hour average HR and resting HR were positively correlated with the level of microalbuminuria (r = 0.169, 0.265, respectively, both P < 0.01). Multivariate linear regression analysis showed that the level of BP (B = 17.798), nocturnal BP drop rate (B = −1.766), and 24-hour average HR (B = 0.564) were correlated with microalbuminuria (all P < 0.01). Conclusions The 24-hour average HR is associated with the early renal damage in patients with initial diagnosis of hypertension.

Serum interleukin-18 levels are associated with non-dipping pattern in newly diagnosed hypertensive patients.

Interleukin-18 (IL-18), a pro-inflammatory cytokine, increases inflammation in the endothelium. Increased inflammation plays an important role in the development of hypertension (HT). IL-18 level is higher in hypertensives than normotensives. To investigate the relationship between IL-18 level and diurnal blood pressure (BP) variations in newly diagnosed HT patients. This prospective study included 130 subjects referred to outpatient cardiology clinic with an initial diagnosis of HT. The patients were classified as dipper HT (n = 40), non-dipper HT (n = 50), and normotensive (control, n = 40) according to 24-hour ambulatory BP monitoring. All subjects underwent blood sampling after 12 hours of fasting and transthoracic echocardiography. The serum IL-18 level was significantly higher in the patient group compared with the controls (195.17 ± 93.00 mg/dl vs. 140.75 ± 71.11 mg/dl, P < 0.01) and also in the non-dipper group than in the dipper group (217.3 ± 96.90 mg/dl, 167.5 ± 80.79 mg/dl, P = 0.011). IL-18 level was positively correlated both the night-time SBP and DBP levels (r = 0.29, P = 0.02 and r = 0.34, P < 0.01, respectively). On multivariate linear regression analysis, left atrium diameter, left ventricular mass index, and serum IL-18 level were independent predictors of non-dipping pattern in newly diagnosed HT patients. Higher IL-18 level was particularly associated with an increase in the night-time BP levels. IL-18 can be used as a predictor for non-dipper HT in newly diagnosed HT patients.

Prevalence of sleep apnea in patients with first diagnosis of hypertension

The risk of obstructive sleep apnea (OSA) is significantly increased in patients with hypertension. In addition, OSA appears to be an independent cardiovascular risk factor. So far, sleep apnea screening is only recommended for patients with refractory hypertension and history of OSA. Therefore, OSA often remains undiagnosed in hypertensive patients. The underlying prevalence data are mainly from outpatient hypertension clinics. Data on the prevalence of OSA in patients with hypertension in primary care are not yet available. Due to the cardiovascular risk, some experts recommend screening for OSA when high blood pressure is diagnosed. The study presented here describes for the first time the prevalence of OSA in GP patients immediately after the initial diagnosis of hypertension. 6 family practices participated in the study between December 2012 and April 2014. Cardiorespiratory polygraphy was performed on all patients diagnosed with hypertension during this period using a 24-hour blood pressure monitor (ABPM). A sleep physician evaluated the polygraphy data online. 50 patients were recruited, 6 patients did not meet the inclusion criteria. Thus, the data of 44 patients (19 women) were analyzed. An obstructive sleep apnea was diagnosed in 34% (n = 15) of the patients. 16% (n = 7) had a mild OSA, 16% (n = 7) a moderate OSA and 2% (n = 1) a severe OSA. In a relevant proportion of patients with newly diagnosed hypertension, an undiagnosed OSA was found. In order to estimate the possible effects of sleep apnea screening on hypertension patients, representative studies in the primary medical field are required.

The relationship between hypertension ethology in children and ambulatory blood pressure monitoring

Objective: The aim of this study is to verify the diagnosis of hypertension in children who are described as hypertensive via auscultatory/oscillometric measurements, to determine the pattern of hypertension, and to construct a relationship between the etiology of hypertension and the values determined by the measurement of ambulatory blood pressure monitoring. Material and Method: Between 2006 and 2018, files of 349 patients who were evaluated with initial diagnosis of hypertension via auscultatory/oscillometric measurements and underwent ambulatory blood pressure monitoring were retrospectively analyzed. Results: The incidence of isolated systolic hypertension was significantly higher in patients with hypertension secondary to hormonal disorders than in patients with renal parenchymal disease The BMI values of the patients with isolated systolic hypertension were significantly higher than those without. Conclusion: Overweight or obese children tend to have isolated systolic hypertension.

Office blood pressure measurement alone often misclassifies treatment status in children with primary hypertension.

Clinicians frequently rely on office blood pressure (BP) measurements alone to assess hypertension control, despite widespread acceptance of 24-h ambulatory blood pressure monitoring (ABPM) as the reference standard in the initial diagnosis of hypertension. This study was designed to investigate how often the hypertensive status differed between concurrent office BP versus ABPM measurements, and whether any patient-specific characteristics predict the risk for misclassification by office BP. This study evaluated 42 children with primary hypertension who underwent repeated ambulatory monitoring (190 total recordings) with concurrent office BP measurement as part of their participation in n-of-1 trials. In nearly 40% of the visits, the treatment status by office measurement was opposite to the status by ambulatory monitoring. Office BP underestimated the ambulatory hypertensive status (masked uncontrolled hypertension) in 25% of visits and overestimated ambulatory BP (white coat effect) in 14% of visits. The difference between office BP and ambulatory monitoring was consistent within patients across repeated visits. Patients whose office measurement underestimated or overestimated the ambulatory BP at the first visit were more likely to show persistent discrepancy at subsequent visits. The underuse of ambulatory monitoring in management decisions of children treated for primary hypertension may result in systematic misclassification of hypertension control.

Diagnosis and treatment of incident hypertension among patients with diabetes: a U.S. multi-disciplinary group practice observational study.

Early hypertension control reduces the risk of cardiovascular complications among patients with diabetes mellitus. There is a need to improve hypertension management among patients with diabetes mellitus. We aimed to evaluate rates and associations of hypertension diagnosis and treatment among patients with diabetes mellitus and incident hypertension. This was a 4-year retrospective analysis of electronic health records. Adults ≥ 18 years old (n = 771) with diabetes mellitus, who met criteria for incident hypertension and received primary care at a large, Midwestern academic group practice from 2008 to 2011 were included Cut-points of 130/80 and 140/90 mmHg were used to identify incident cases of hypertension. Kaplan-Meier analysis estimated the probability of receiving: 1) an initial hypertension diagnosis and 2) antihypertensive medication at specific time points. Cox proportional-hazard frailty models (HR; 95 % CI) were fit to identify associations of time to hypertension diagnosis and treatment. Among patients with diabetes mellitus who met clinical criteria for hypertension, 41 % received a diagnosis and 37 % received medication using the 130/80 mmHg cut-point. At the 140/90 mmHg cut-point, 52 % received a diagnosis and 49 % received medication. Atrial fibrillation (HR 2.18; 1.21-4.67) was associated with faster diagnosis rates; peripheral vascular disease (HR 0.18; 0.04-0.74) and fewer primary care visits (HR 0.93; 0.88-0.98) were associated with slower diagnosis rates. Atrial fibrillation (HR 3.07; 1.39-6.74) and ischemic heart disease/congestive heart failure (HR 2.16; 1.24-3.76) were associated with faster treatment rates; peripheral vascular disease (HR 0.16; 0.04-0.64) and fewer visits (HR 0.93; 0.88-0.98) predicted slower medication initiation. Diagnosis and treatment of incident hypertension were similar using cut-points of 130/80 and 140/90 mmHg. Among patients with diabetes mellitus, even using a cut-point of 140/90 mmHg, approximately 50 % remained undiagnosed and untreated for hypertension. Future interventions should target patients with multiple comorbidities to improve hypertension and diabetes clinical care.

Impact of Untreated High Blood Pressure on Renal Function Tests at Initial Diagnosis of Hypertension

Background: Pakistani population is at higher risk of developing hypertensive complications at a younger age, resulting from undiagnosed and untreated hypertension (HTN). High cost of medical care is a barrier to early detection and assessment of end organ damage as well as physicians are disinclined to adopt more aggressive therapeutic management to improve blood pressure control. A cross sectional study was planned to determine the effect of high blood pressure on renal function tests in a random population aged 25-50 year, at initial diagnosis of hypertension. Methods: The study was conducted on total 276 subjects; 201selected from five general practitioners clinics in Karachi and were classified into pre hypertensive, and hypertensive stages I and II on the basis of 7th JNC report. Two BP readings were taken half an hour apart. A blood sample was drawn for measurement of serum urea, creatinine and a dipstick test was done to check protein in urine. The results were compared with 75 control, normotensive subjects. The percentage, mean and Standard deviation were computed. ANOVA was performed to compare four study groups and LSD test was applied to compare pair-wise group. Pearson’s correlation was applied to find out association of renal function with stages of hypertension. Results: The mean urea and creatinine levels were on higher normal side in HTN stages-I and II (39.91±8.51 and 1.72±0.54 in stage-I and 44.51±9.93 and 1.91±0.88 in stage-II respectively). The frequency of proteinuria was also more in these groups, indicating declining renal function in these patients as compared to control and prehypertension groups. Conclusion: Subjects diagnosed with stage I and II HTN showed evidence of subclinical renal damage, along with the presence of proteinuria at the time of diagnosis.

Differences in diagnosis and treatment rates between systolic and diastolic hypertension among young adults

Background: Less than 50% of young adults with hypertension have achieved control. Understanding hypertension diagnosis and treatment patterns in primary care will help tailor young adult hypertension interventions. The objective was to compare the rates of receiving an initial hypertension diagnosis and antihypertensive prescription between young adults with 1) isolated systolic, 2) isolated diastolic, and 3) combined systolic/diastolic hypertension. Methods: This retrospective analysis examined 18-39 year-olds with incident hypertension receiving regular primary care in a large academic group practice from 2008-2011. Eligible patients met JNC7 criteria for a hypertension diagnosis and antihypertensive prescription. The average of the last two blood pressures prior to study entry defined the hypertension type. Patients with a previous hypertension diagnosis or antihypertensive prescription were excluded. Kaplan-Meier survival curves were computed for systolic, diastolic, and combined systolic/diastolic hypertension to evaluate the probability of receiving: 1) a hypertension diagnosis and 2) an antihypertensive prescription, as a function of time since meeting hypertension criteria. Cox proportional hazards regression analysis was used to obtain adjusted hazard ratios and 95% confidence intervals (HR; 95% CI). Results: Among 3,525 young adults, 37% had isolated systolic hypertension, 32% isolated diastolic, and 31% combined systolic/diastolic. At 48 months, 69% with combined systolic/diastolic received an initial diagnosis, compared to 55% (isolated diastolic) and 52% (isolated systolic). At 48 months, 59% with combined systolic/diastolic received an initial antihypertensive prescription, compared to 44% (isolated diastolic) and 30% (isolated systolic). After adjusting for patient and provider factors, young adults with combined systolic/diastolic were 70% more likely (HR: 1.7; 1.5-2.1) to receive a diagnosis compared to isolated systolic. Isolated diastolic (HR: 1.3; 1.1-1.6) and combined systolic/diastolic (HR: 2.4; 2.0-2.9) patients were more likely to receive an antihypertensive prescription compared to isolated systolic patients. Conclusions: Hypertension diagnosis and treatment in young adults was less likely with isolated systolic hypertension. Primary care interventions aimed at diagnosis and treatment variation may improve hypertension control in young adults.

Is It Possible to Manage Hypertension and Evaluate Therapy Without Ambulatory Blood Pressure Monitoring?

In the management of patients with hypertension, blood pressure (BP) has been traditionally measured in the physician's office. The contribution of ambulatory BP monitoring (ABPM) to the management of hypertensive patients has been increasingly recognized through clinical and epidemiological research. Ambulatory BP monitoring can enhance the ability to detect white-coat or masked hypertension, determine the absence of nocturnal dipping status, and evaluate BP control in patients on antihypertensive therapy. Recently, the United Kingdom National Clinical Guideline Centre published guidelines for the clinical management of primary hypertension in adults, recommending the routine use of ABPM to make the initial diagnosis of hypertension. While the advantages of ABPM are apparent from a clinical perspective, its use should be considered in relation to the cost of the equipment, data evaluation, and staff training as well as the possible inconvenience to the patient. In this review, we summarize the clinical importance of ABPM and discuss the current guidelines for establishing the diagnosis of hypertension.

Midaortic Syndrome in Neurofibromatosis Type 1 Resulting in Bilateral Renal Artery Stenosis

We describe the case of a 23-year-old white woman with a long history of hypertension. She was referred to us 7 years after her initial diagnosis of hypertension when her blood pressure control worsened during pregnancy. Clinical examination showed an abdominal bruit and weak femoral pulses. Imaging showed midaortic syndrome with bilateral renal artery stenosis as the cause of her hypertension, and further investigations showed neurofibromatosis type 1 as the underlying disorder. Midaortic syndrome, a rare disorder of the abdominal aorta that is different from classic coarctation, typically is associated with neurofibromatosis. Renal artery stenosis is common, as are weak femoral pulses and impaired development of the lower limbs. Because of the rarity of this syndrome, only anectodal evidence exists with regard to treatment. Surgery and interventional treatment with stent placement in the abdominal aorta have been reported, as well as good outcomes with long-term medical management. Our patient continues to be healthy without intervention, with reasonable blood pressure control and normal kidney function on a 4-drug antihypertensive regimen. We discuss midaortic syndrome with a focus on diagnosis, differential diagnosis, associated conditions, and management. Nephrologists, radiologists, and ultrasonographers should be aware of this rare cause of renovascular hypertension.

Prevalence and Predictors of Poor Antihypertensive Medication Adherence in an Urban Health Clinic Setting

Poor medication adherence may contribute to low hypertension control rates. In 2005, 295 hypertensive patients who reported taking antihypertensive medication were administered a telephone questionnaire including an 8-item scale assessing medication adherence. Overall, 35.6%, 36.0%, and 28.4% of patients were determined to have good, medium, and poor medication adherence, respectively. After multivariable adjustment, adults younger than 50 years and 51 to 60 years were 1.39 (95% confidence interval [CI], 0.56-3.42) and 1.53 (95% CI, 0.64-3.66), respectively, times more likely to be less adherent when compared with their counterparts who were older than 60 years. Black adults and men were 4.30 (95% CI, 1.06-17.5) and 2.45 (95% CI, 1.04-5.78) times more likely to be less adherent, respectively. Additionally, caring for dependents, an initial diagnosis of hypertension within 10 years, being uncomfortable about asking the doctor questions, and wanting to spend more time with the doctor if possible were associated with poor medication adherence. The current study identified a set of risk factors for poor antihypertensive medication adherence in the urban setting.

Sleep quality among relatively younger patients with initial diagnosis of hypertension: Dippers versus non‐dippers

Background. Sleep is a basic physiological process. Normal sleep yields decrease in sympathetic activity, blood pressure (BP) and heart rate. Those, who do not have expected decrease in their BP are considered “non‐dippers”. We aimed to determine if there was any association between the non‐dipping status and sleep quality, designed a cross‐sectional study, and enrolled and evaluated the sleep quality of relatively young patients with an initial diagnosis of hypertension. Methods. Seventy‐five consecutive patients, diagnosed to have stage 1 hypertension by their primary physicians, were referred to our study. Patients had newly diagnosed with stage 1 hypertension. Patients with a prior use of any anti‐hypertensive medication were not included. Eligible patients underwent the Pittsburgh Sleep Quality Index (PSQI), which has an established role in evaluating sleep disturbances. All patients underwent ambulatory BP monitoring. Results. There were 42 non‐dipper patients (mean age = 47.5±11.9 years, 24 male/18 female), as a definition, 31 dipper hypertensive patients (mean age = 48.5±12.8 years, 21 male/10 female) and two with white coat hypertension. Daytime systolic and diastolic mean BPs were not significantly different between the two groups. Night‐time mean systolic and diastolic BPs were significantly higher in non‐dippers compared with dippers. PSQI scores, globally, were significantly higher in non‐dippers compared with dippers. Total PSQI score was not correlated with body mass index. It was noticed that, individually, sleep quality, sleep efficiency and sleep disturbance scores were significantly higher in non‐dippers. Being a poor sleeper in terms of high PSQI score (total score>5) was associated with 2.955‐fold increased risk of being a non‐dipper (95% confidence interval 1.127–7.747). Conclusion. We showed that the risk of having non‐dipping hypertension, a risk factor for poor cardiovascular outcomes among hypertensive individuals, was tripled (odds ratios) among poor sleepers. We think that evaluating sleeping status and sleep quality among the hypertensive population may help unmask non‐dipper hypertension, enabling physicians to treat appropriately.

Spontaneous Feline Hypertension: Clinical and Echocardiographic Abnormalities, and Survival Rate

Systemic hypertension was diagnosed in 58 of 188 untreated cats referred for evaluation of suspected hypertension‐associated ocular, neurologic, cardiorespiratory, and urinary disease, or diseases frequently associated with hypertension (hyperthyroidism and chronic renal failure). Hypertensive cats were significantly older than normotensive subjects (13.0 ± 3.5 years versus 9.6 ± 5.0 years;P &lt;.01), and had a greater prevalence of retinal lesions (48 versus 3%;P &lt;.001), gallop rhythm (16 versus 0%;P &lt;.001), and polyuria‐polydipsia (53 versus 29%;P &lt;.01). Blood pressure was significantly higher(P &lt;.001) in cats with retinopathies (262 ± 34 mm Hg) than in other hypertensive animals (221 ± 34 mm Hg). Hypertensive cats had a thicker interventricular septum (5.8 ± 1.7 versus 3.7 ± 0.64 mm;P &lt;.001) and left ventricular free wall (6.2 ± 1.6 versus 4.1 ± 0.51 mm;P &lt;.001) and a reduced diastolic left ventricular internal diameter (13.5 ± 3.2 versus 15.8 ± 0.72 mm;P &lt;.001) than control cats. Left ventricular geometry was abnormal in 33 of 39 hypertensive subjects. No significant difference was found in age or blood pressure at the initial visit between cats that died or survived over a 9‐month period after initial diagnosis of hypertension. Mean survival times were not significantly different between hypertensive cats with normal and abnormal left ventricular patterns. Further prospective studies are needed to clearly identify the factors involved in survival time in hypertensive cats.

Spontaneous feline hypertension: clinical and echocardiographic abnormalities, and survival rate.

Systemic hypertension was diagnosed in 58 of 188 untreated cats referred for evaluation of suspected hypertension-associated ocular, neurologic. cardiorespiratory, and urinary disease, or diseases frequently associated with hypertension (hyperthyroidism and chronic renal failure). Hypertensive cats were significantly older than normotensive subjects (13.0 +/- 3.5 years versus 9.6 +/- 5.0 years; P < .01), and had a greater prevalence of retinal lesions (48 versus 3%; P < .001), gallop rhythm (16 versus 0%; P < .001), and polyuria-polydipsia (53 versus 29%: P < .01). Blood pressure was significantly higher (P < .001) in cats with retinopathies (262 +/- 34 mm Hg) than in other hypertensive animals (221 +/- 34 mm Hg). Hypertensive cats had a thicker interventricular septum (5.8 +/- 1.7 versus 3.7 +/- 0.64 mm; P < .001) and left ventricular free wall (6.2 +/- 1.6 versus 4.1 +/- 0.51 mm; P < .001) and a reduced diastolic left ventricular internal diameter (13.5 +/- 3.2 versus 15.8 +/- 0.72 mm; P < .001) than control cats. Left ventricular geometry was abnormal in 33 of 39 hypertensive subjects. No significant difference was found in age or blood pressure at the initial visit between cats that died or survived over a 9-month period after initial diagnosis of hypertension. Mean survival times were not significantly different between hypertensive cats with normal and abnormal left ventricular patterns. Further prospective studies are needed to clearly identify the factors involved in survival time in hypertensive cats.