Long-term Control Of Hypertension Research Articles

Impact of RAAS Receptors and Membrane-Bound Transporter System in the Left Ventricle during the Long-Term Control of Hypertension.

The Renin-Angiotensin-Aldosterone System (RAAS) has been implicated in systemic and neurogenic hypertension. The infusion of RAAS inhibitors blunted arterial pressure and efficacy of use-dependent synaptic transmission in sympathetic ganglia. The current investigation aims to elucidate the impact of RAAS-mediated receptors on left ventricular cardiomyocytes and the role of the sarcolemma-bound carrier system in the heart of the hypertensive transgene model. A significant increase in mRNA and the protein expression for angiotensin II (AngII) receptor subtype-1 (AT1R) was observed in (mREN2)27 transgenic compared to the normotensive rodents. Concurrently, there was an upregulation in AT1R and a downregulation in the MAS1 proto-oncogene protein receptor as well as the AngII subtype-2 receptor in hypertensive rodents. There were modifications in the expressions of sarcolemma Na+-K+-ATPase, Na+-Ca2+ exchanger, and Sarcoendoplasmic Reticulum Calcium ATPase in the transgenic hypertensive model. These observations suggest chronic RAAS activation led to a shift in receptor balance favoring augmented cardiac contractility and disruption in calcium handling through modifications of membrane-bound carrier proteins and blood pressure. The study provides insight into mechanisms underlying RAAS-mediated cardiac dysfunction and highlights the potential value of targeting the protective arm of AngII in hypertension.

Hypertension control after intracerebral hemorrhage among varying small vessel disease etiologies.

Intracerebral hemorrhage (ICH) is attributable to cerebral small vessel disease (cSVD), which includes cerebral amyloid angiopathy (CAA) and hypertensive-cSVD (HTN-cSVD). HTN-cSVD includes patients with strictly deep ICH/microbleeds and mixed location ICH/microbleeds, the latter representing a more severe form of HTN-cSVD. We test the hypothesis that more severe forms of HTN-cSVD are related to worse hypertension control in long-term follow-up after ICH. From consecutive non-traumatic ICH patients admitted to a tertiary care center, we classified the ICH as CAA, strictly deep ICH/microbleeds, and mixed-location ICH/microbleeds. CSVD burden was quantified using a validated MRI-based score (range: 0-6 points). We created a multivariable (linear mixed effects) model adjusting for age, sex, race, year of inclusion, hypertension, and antihypertensive medication usage to investigate the association of average systolic blood pressure (SBP) during follow-up with cSVD etiology/severity. 796 ICH survivors were followed for a median of 48.8months (IQR 41.5-60.4). CAA-related ICH survivors (n = 373) displayed a lower median SBP (138mmHg, IQR 133-142mmHg) compared to those of strictly deep ICH (n = 222, 141mmHg, IQR 136-143mmHg, p = 0.04), and mixed location ICH/microbleeds (n = 201, 142mmHg, IQR 135-144mmHg, p = 0.02). In the multivariable analysis, mixed location ICH/microbleeds (effect: + 3.8mmHg, SE: 1.3mmHg, p = 0.01) and increasing cSVD severity (+ 1.8mmHg per score point, SE: 0.8mmHg, p = 0.03) were associated with higher SBP in follow-up. CSVD severity and subtype predicts long-term hypertension control in ICH patients.

Long-Term Effect of Home Blood Pressure Self-Monitoring Plus Medication Self-Titration for Patients With Hypertension

Patient empowerment through pharmacologic self-management is a common strategy for some chronic diseases such as diabetes, but it is rarely used for controlling blood pressure (BP). Several trials have shown its potential for reducing BP in the short term, but evidence in the longer term is scarce. To evaluate the longer-term effectiveness of BP self-monitoring plus self-titration of antihypertensive medication vs usual care for patients with poorly controlled hypertension, with passive follow-up and primary-care nursing involvement. The ADAMPA (Impact of Self-Monitoring of Blood Pressure and Self-Titration of Medication in the Control of Hypertension) study was a randomized, unblinded clinical trial with 2 parallel arms conducted in Valencia, Spain. Included participants were patients 40 years or older, with systolic BP (SBP) over 145 mm Hg and/or diastolic BP (DBP) over 90 mm Hg, recruited from July 21, 2017, to June 30, 2018 (study completion, August 25, 2020). Statistical analysis was conducted on an intention-to-treat basis from August 2022 to February 2024. Participants were randomized 1:1 to usual care vs an individualized, prearranged plan based on BP self-monitoring plus medication self-titration. The main outome was the adjusted mean difference (AMD) in SBP between groups at 24 months of follow-up. Secondary outcomes were the AMD in DBP between groups at 24 months of follow-up, proportion of patients reaching the BP target (SBP <140 mm Hg and DBP <90 mm Hg), change in behaviors, quality of life, health service use, and adverse events. Among 312 patients included in main trial, data on BP measurements at 24 months were available for 219 patients (111 in the intervention group and 108 in the control group). The mean (SD) age was 64.3 (10.1) years, and 120 patients (54.8%) were female; the mean (SD) SBP was 155.6 (13.1) mm Hg, and the mean (SD) diastolic BP was 90.8 (7.7) mm Hg. The median follow-up was 23.8 months (IQR, 19.8-24.5 months). The AMD in SBP at the end of follow-up was -3.4 mm Hg (95% CI, -4.7 to -2.1 mm Hg; P < .001), and the AMD in DBP was -2.5 mm Hg (95% CI, -3.5 to -1.6 mm Hg; P < .001). Subgroup analysis for the main outcome showed consistent results. Sensitivity analyses confirmed the robustness of the main findings. No differences were observed between groups in behaviors, quality of life, use of health services, or adverse events. In this secondary analysis of a randomized clinical trial, BP self-monitoring plus self-titration of antihypertensive medication based on an individualized prearranged plan used in primary care reduced BP in the longer term with passive follow-up compared with usual care, without increasing health care use or adverse events. These results suggest that simple, inexpensive, and easy-to-implement self-management interventions have the potential to improve the long-term control of hypertension in routine clinical practice. ClinicalTrials.gov Identifier: NCT03242785.

Approach and intervention in blood pressure abnormalities

Hypertension is when blood pressure (BP) is measured above the limits of what is considered normal. Almost all guidelines define hypertension as a systolic blood pressure (SBP) above 140 mmHg and a diastolic blood pressure (DBP) above 90 mmHg. Blood pressure should not be seen only as a numerical value that should be monitored and lowered when it rises. Blood pressure is an important vital sign that can provide important clues to the clinician about the patient's current condition. Long-term control of hypertension in individuals significantly reduces cardiovascular risk. In the case of hypertensive emergencies or urgent situations, antihypertensive treatment should be initiated after consideration of the approach to the recommendations. Recent observational studies suggest that pharmacologic treatment of acute and asymptomatic in-hospital BP elevations may not be beneficial and may even increase the risk of in-hospital and post-discharge complications. The patient's current clinical status and additional comorbidities should be evaluated, and attention should be paid to contraindications and drug dosage adjustments.

Digital redesign of hypertension management with practice and patient apps for blood pressure control (PIA study): A cluster-randomised controlled trial in general practices.

Long-term hypertension control prevents heart attacks and other cardiovascular diseases, yet implementation is insufficient worldwide. The redesign of hypertension management by information and communication technology (ICT) improved hypertension control, e.g., by transmission of blood pressure (BP) measurements to a central webspace. However, an easy-to-use secure patient app connected with a practice management centre is lacking. This study evaluates the effectiveness of the newly developed PIA (PC-supported case management of hypertensive patients to implement guideline-based hypertension therapy using a physician-defined and -supervised, patient-specific therapeutic algorithm) intervention with PIA-ICT and eLearning for general practices. The effectiveness of the PIA intervention was evaluated in a cluster-randomised study. Practices were randomly allocated (1:1) to the intervention or the control group (usual care). Group allocation was unmasked for participants and researchers. The primary outcome was the BP control rate (BP<140/90mmHg) after 6-12months. Secondary outcomes included BP changes and satisfaction with PIA-ICT. The trial is registered in the German Clinical Trials Register (DRKS00012680). Starting from December 1, 2019, 64 general practices were recruited over 1 year during the COVID-19 pandemic. Overall, 848 patients were enrolled between April 15, 2020 and March 31, 2021. The study was completed Sept 30, 2021. At baseline, 636 patients (intervention: 331; control: 305) of 50 general practices met the inclusion criteria. The final dataset for analyses comprised 47 practices and 525 patients (intervention 265; control 260). In the adjusted hierarchical model, the PIA intervention increased the BP control rate significantly by 23.1% points (95% CI: 5.4-40.8%): intervention 59.8% (95% CI: 47.4-71.0%) compared to 36.7% (95% CI: 24.9-50.3%) in the control group. Systolic BP decreased by 21.1mmHg in the intervention and 15.5mmHg in the control group. The PIA redesign of care processes improved BP in an outcome-relevant way. Prospectively, it may constitute an important model for hypertension care in Germany. This study is funded by the German Innovation Fund (Grant number: 01NVF17002).

Blood pressure elevations in hospital.

Long-term hypertension control in the community significantly reduces cardiovascular risk. However, the benefit of controlling acute elevations of blood pressure in hospitalised patients is unclear. In-hospital elevations of blood pressure are relatively common and might not reflect poorly controlled blood pressure before admission. The measurement of blood pressure in hospital patients significantly differs from the best practice recommended for primary care and outpatients. Recent observational studies suggest that the pharmacological treatment of acute, asymptomatic, in-hospital elevations of blood pressure may have no benefit. However, it may increase the risk of in-hospital and post-discharge complications. Pending the development of robust inpatient measurement protocols, acute blood pressure elevations in hospitalised patients should not routinely require antihypertensive treatment in the absence of symptoms or acute end-organ damage. Rather, such elevations should facilitate follow-up of blood pressure and other cardiovascular risk factors after discharge.

Abstract 124: Angiotensin-(1-12) Immunoneutralization: A New Approach To Hypertension Treatment

There is a critical need to identify new therapeutic targets and treatments, given emerging data documenting the limited effectiveness of current antihypertensive drugs to have a marked impact in preventing target organ damage and cardiovascular death. While monoclonal antibodies (mAb) are revolutionizing the treatment of human diseases, including severe hypercholesterolemia, their applicability to long-term hypertension control remains unexplored. Identification of angiotensin-(1-12) [Ang-(1–12)] as a non-renin-dependent substrate for Ang II generation in rodents and humans led us to engineer a mAb directed against the C-terminus of human Ang-(1–12) [h-Ang-(1-12)] sequence. We utilized a model of hypertension expressing the human angiotensinogen (AGT) gene in the rat genome [TGR(hAGT)L1623 rats] to address the effectiveness of endogenous h-Ang-(1–12) immunoneutralization in controlling the elevated blood pressure and reversing hypertension-induced target organ damage. Acute delivery of the h-Ang-(1–12) mAb (30 mg/Kg, i.v.) in anesthetized hypertensive transgenic rats induced a prompt arterial pressure fall (M ± SE: -18 ± 6/-16 ± 3 mm Hg, n=7; p&lt; 0.001) in the absence of corresponding heart rate changes. The antihypertensive effect of the h-Ang-(1-12) mAb triggered a rise in plasma renin concentrations (from 107 ± 24 to 381 ± 260 ng/mL/h) that was inversely correlated with the fall in mean arterial pressure (r= -0.92, p&lt; 0.001). Prior intravenous delivery of aliskiren fumarate (3-5 mg/Kg, i.v.) while inducing a fall in arterial pressure did not mask the antihypertensive action of the h-Ang-(1-12) mAb. Extension of these acute effects of the h-Ang-(1-12) mAb to awake instrumented transgenic hypertensive rats given consecutive daily doses of the mAb (30 mg/Kg, i.m. x 4 -5 days, n=7) documented a trend for significant statistical drops in daytime blood pressure and no changes in heart rate. We conclude that Ang-(1–12) is an endogenous Ang II forming substrate participating in the control of arterial pressure in a humanized model of high blood pressure and that selective immunoneutralization of this alternate substrate is a promising and novel therapeutic approach to treat hypertension and prevent its adverse cardiovascular sequelae.

Longitudinal evidence on treatment discontinuation, adherence, and loss of hypertension control in four middle-income countries.

Managing hypertension is a highly dynamic process, yet current evidence on hypertension control in middle-income countries (MICs) is largely based on cross-sectional data. Using multiple waves of population-based cohort data from four MICs (China, Indonesia, Mexico, and South Africa), we undertook a longitudinal investigation into how individuals with hypertension move through care over time. We classified adults aged 40 years and over (N = 8527) into care stages at both baseline and follow-up waves and estimated the probability of transitioning between stages using Poisson regression models. Over a 5- to 9-year follow-up period, only around 30% of undiagnosed individuals became diagnosed [Mexico, 27% (95% confidence interval: 23%, 31%); China, 30% (26%, 33%); Indonesia, 30% (28%, 32%); and South Africa, 36% (31%, 41%)], and one in four untreated individuals became treated [Indonesia, 11% (10%, 12%); Mexico, 24% (20%, 28%); China, 26% (23%, 29%); and South Africa, 33% (29%, 38%)]. The probability of reaching blood pressure (BP) control was lower [Indonesia, 2% (1%, 2%); China, 9% (7%, 11%); Mexico, 12% (9%, 14%); and South Africa, 24% (20%, 28%)] regardless of treatment status. A substantial proportion of individuals discontinued treatment [Indonesia, 70% (67%, 73%); China, 36% (32%, 40%); Mexico, 34% (29%, 39%); and South Africa, 20% (15%, 25%)], and most individuals lost BP control by follow-up [Indonesia, 92% (89%, 96%); Mexico, 77% (71%, 83%); China, 76% (69%, 83%); and South Africa 45% (36%, 54%)]. Our results highlight that policies solely aimed at improving diagnosis or initiating treatment may not lead to long-term hypertension control improvements in MICs.

Abstract P878: Racial and Ethnic Disparities in Early Hypertension Control After Intracerebral Hemorrhage

Introduction: Survivors of Intracerebral Hemorrhage (ICH) are at high risk of recurrent stroke. This risk is inversely proportional to average Blood Pressure (BP) after ICH. Racial/ethnic minority ICH survivors in the US demonstrate greater hypertension severity after ICH and are at higher risk of recurrent cerebral bleeding. Since most recurrent strokes occur within 12-18 months of index ICH, rapidly achieving BP control is likely to be crucial. We investigated the frequency, prognostic impact, and racial/ethnic disparities in uncontrolled short-term hypertension (HTN) after ICH. Methods: We analyzed data from prospective ICH cohort studies at Massachusetts General Hospital (MGH-ICH, n=1305) and the University of Hong Kong (HK-ICH, n=523). We classified HTN as controlled, uncontrolled or treatment-resistant and determined: 1) risk factors for uncontrolled and treatment-resistant HTN; and 2) whether HTN control at 3 months is associated with long-term BP control, stroke recurrence and mortality across self-reported race/ethnicity groups. Results: We followed 1828 ICH survivors (1128 White, 565 Asian, 59 Hispanic, 49 Black, 27 other) for a median of 46.2 months. Only 9 of 172 (5%) recurrent strokes occurred before 3 months after ICH. At 3 months, 713 participants (39%) had controlled HTN, 755 (41%) had undertreated HTN, and 360 (20%) had treatment-resistant HTN. BP measurements at 3 months were highly correlated with measurements during follow-up (p&lt;0.001). Black, Hispanic and Asian race/ethnicity were associated with higher prevalence of uncontrolled HTN at 3 months (all p&lt;0.05). Both undertreated and uncontrolled HTN at 3 months were associated with increased risk of recurrent stroke and mortality during follow-up (all p&lt;0.05). Conclusions: Most ICH survivors have inadequate HTN control 3 months after ICH, with under-treatment accounting for the majority of cases. Three-month BP measurements are associated with inadequate long-term HTN control, higher recurrent stroke risk and mortality. ICH survivors self-reporting as Black, Hispanic or Asian appear to be at highest risk for uncontrolled HTN. Optimizing HTN control at 3 months is a unique opportunity to address racial/ethnic disparities in quality of care among survivors of primary ICH.

Recommendations for home blood pressure monitoring in Latin American countries: A Latin American Society of Hypertension position paper.

Out-of-office blood pressure (BP) monitoring appears to be a very useful approach to hypertension management insofar it allows to obtain multiple measurements in the usual environment of each individual, allows the detection of hypertension phenotypes, such as white-coat and masked hypertension, and appears to have superior prognostic value than the conventional office BP measurements. Out-of-office BP can be obtained through either home or ambulatory monitoring, which provide complementary and not identical information. Home BP monitoring yields BP values self-measured in subjects' usual living environment; it is an essential method for the evaluation of almost all untreated and treated subjects with suspected or diagnosed hypertension, best if combined with telemonitoring facilities, also allowing long-term monitoring. There is also increasing evidence that home BP monitoring improves long-term hypertension control rates by improving patients' adherence to prescribed treatment. In Latin American Countries, it is widely available, being relatively inexpensive, and well accepted by patients. Current US, Canadian, Japanese, and European guidelines recommend out-of-office BP monitoring to confirm and refine the diagnosis of hypertension.

Abstract 015: Maternal High Blood Pressure Control Persistently Alters Gut-Brain Communication and Attenuates Hypertension of Offspring

Objective: Evidence suggests involvement of a dysfunctional gut-brain axis in hypertension. Maternal-fetal cross-talk is implicated in the long-term control of hypertension of offspring. Therefore, we tested the hypothesis that maternal factors influence gut-brain axis impacting hypertension in offspring. Methods: Pregnant female spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto (WKY) rats, were treated with captopril (CAP) water (100 mg/kg/day) or sterile water throughout pregnancy and lactation. At weaning, the pups from dams drinking sterile water were continued until age 12 weeks. The pups from dams drinking CAP water were divided into two groups: offspring continuously drinking CAP and offspring withdrawn from CAP, then drinking sterile water until age 12 weeks (N=8-11/group). Results: Compared with SHR, maternal exposure of SHR to CAP lowered systolic BP in offspring at weaning (Δ=24mmHg, P&lt;0.05). This was associated with amelioration of gut inflammation (decreased Cd3 by 2.8-fold, P&lt;0.01) and permeability (increased Tjp1 by 4.3-fold, P&lt;0.01; Ocln increased by 2.8-fold, P&lt;0.01). At 12 week-old, SHR offspring exposed to maternal CAP demonstrated persistent decreased systolic BP (Δ=25mmHg, P&lt;0.01), increased microbial Shannon diversity (Δ=1.25, P&lt;0.001), altered β diversity, and growth of beneficial bacterial genera, compared with SHR (increased Coprococcus by 41-fold, P&lt;0.001; Oscillospira by 4.9-fold, P&lt;0.01; Roseburia by 83-fold, P&lt;0.001; Mucispirillum by 26-fold, P&lt;0.01). Decreases in activated microglia numbers per area (Δ=2.8, P&lt;0.05) and neuroinflammation (decreased Tnf by 2.4-fold, P&lt;0.001; Il1b by 2.7-fold, P&lt;0.05) and improvement of gut inflammation ( Cd3 decreased by 1.8-fold, P&lt;0.01) and permeability (increased Tjp1 by 2.2-fold, P&lt;0.1; Ocln by 1.8-fold, P&lt;0.1) were also observed in these SHR offspring with maternal CAP, compared with SHR. These improvements were also found in the SHR with continuous CAP. Conclusion: Maternal decrease of BP by CAP improves dysregulated gut-brain axis in SHR offspring and long-term lowering of BP. Thus, it provides conceptual support that targeting of the gut-brain axis via the mother may be a relevant strategy for the control of hypertension in the offspring.

Ambulatory blood pressure monitoring in the 21st century.

In clinical practice, ambulatory blood pressure monitoring (ABPM) tends to be used solely for diagnosing hypertension, especially to identify white-coat and masked hypertension. However, ABPM can provide additional information to guide the management and drug treatment of hypertension. In this brief review, the general principles governing the use of ABPM in clinical practice, such as the devices and software, recording requirements, the thresholds for the day, night and 24-hour periods and how often to repeat ABPM are summarized. The use of ABPM for diagnosing, determining the efficacy of treatment, and assessing the long-term control of hypertension are discussed.

Bariatric Surgery and Hypertension.

Obesity continues to increase in prevalence worldwide. Hypertension has long been associated with obesity, and weight loss continues to be a first-line therapy in the treatment of hypertension. Lifestyle modification and pharmacologic therapy, however, often meet with treatment failure. Bariatric surgery continues to be the most successful approach to sustained weight loss. This review focuses on the underlying physiologic mechanisms of obesity-hypertension, and the impact of bariatric surgery on the treatment of hypertension. Current available literature on the physiologic mechanisms of obesity-hypertension, and the major trials, meta-analyses and systematic reviews of the impact of bariatric surgery procedures on hypertension are reviewed. Evidence suggests significant improvement in obesity-hypertension in patients who undergo surgical weight-reduction procedures. Malabsorptive techniques such as the Roux-en-Y gastric bypass or surgical resection techniques such as laparoscopic sleeve gastrectomy appear to offer superior results in regards to hypertension control over restrictive techniques such as Gastric Banding. Though long-term control of hypertension following surgery remains a concern, available follow-up post-operative data of up to 10 years suggests a sustained, if lessened, effect on hypertension control over time.

Association between health literacy and hypertension management in a Chinese community: a retrospective cohort study.

Low health literacy is associated with poor clinical outcomes. The relationship between literacy and blood pressure (BP) has been inconsistent. We investigated the determinants of health literacy and the potential relationship between health literacy and hypertension management. We conducted a retrospective cohort trial of 360 hypertensive patients. Scale measurements, physical examination, and laboratory tests were performed based on a standard protocol. To determine factors associated with health literacy, multiple logistic regression analysis was performed and the discriminatory power of the scale score for hypertension control was assessed by the area under the receiver operating curve. After adjusting for potential confounders, our findings show that the level of education, home blood pressure measurement, regular medication, and systolic blood pressure are significantly associated with health literacy. Moreover, patients with high health literacy have better hypertension control, a lower risk of ischemic cardiovascular disease (ICVD), lower brachialanklepulsewavevelocity values, and better health-related quality of life. In addition, our study also demonstrates that we can identify the health literacy level of hypertensive patients using the Chinese Health Literacy Scale for Hypertension. At a cut-off value of 13.5, we predict that patients will achieve long-term hypertension control. Adequate health literacy is a contributing factor to better blood pressure (BP) control and better perceived quality of life in hypertensive patients. Low health literacy increases the 10-year risk of ICVD and incidence of artery stiffness in hypertensive patients. Improving health literacy should be considered an important part of the management of hypertension.

Hypotensive effects of renal denervation in spontaneously hypertensive rat based on ultrasonic contrast imaging

BackgroundSympathetic nerves-fire rate is generally enhanced in some types of hypertension models. Renal sympathetic denervation(RSD) by the radiofrequency ablation was used to treat the hypertension has achieved curative effect.HTN-1 and HTN-2 trial reported catheter-based renal denervation may cause substantial and sustained blood-pressure reduction in patients with resistant hypertension. However, recent controlled HTN-3 trial questioned the BP lowering effect of Renal denervation treatment. The controversial results maybe arised from the incompleted RSD which implemented inside the renal artery. Now renal denervation therapy for resistant hypertension is in attractive and controversial status. Our aim is to define the hyotensive value of complete renal denervation in adult spontaneous hypertensive rats. MethodsMale spontaneous hypertensive rats(SHR) aged 12 weeks were randomly selected for either unilateral renal artery sympathetic nerves ablation (URSNA), or conventional technique of renal denervation (CRD), or bilateral renal artery sympathetic nerves ablation (BRSNA) and sham operation. Blood pressure, sodium and water balance,serum reninangiotensin II and Norepinephrine concentration were measured during 20 weeks after renal denervation operation. Internal diameters of renal arteries and renal blood flow rate was tested by ultrasonic contrast imaging. ResultsThe continued increased blood pressure in SHR was delayed and significantly reduced by conventional renal denervation over a period of 8 weeks. Both the bilateral and unilateral renal sympathetic nerve ablation procedure did not prevent the development of hypertension in SHR. The attenuation of hypertension was accompanied with the increase of urinary sodium excretion and depression of rennin angiotensin system (RAS). ConclusionsWe concluded that renal denervation may not be an effective therapeutic method in the long-term control of hypertension in adult SHR.

The Role of Nonpharmacologic Device Interventions in the Management of Drug-Resistant Hypertension

Resistant systemic hypertension in patients is defined as the inability to control blood pressure despite taking at least three antihypertensive drugs, one of which is a diuretic. Two nonpharmacologic approaches are being evaluated in resistant hypertensive patients. First, the Rheos® Baroreflex Hypertension Therapy system is an implantable device that activates the carotid baroreflex through electrical stimulation of the carotid sinus wall. Sustained and clinically lower blood pressure has been observed in patient clinical trials. The second approach is a catheter-based strategy which denervates the renal afferent and efferent autonomic nervous system. This strategy has also been shown to be effective in drug-resistant patients, and has also been shown to decrease renin production, preserve renal function, improve glucose tolerance, and reduce left ventricular hypertrophy. Both carotid sinus stimulation and renal denervation are now being evaluated in clinical trials for the long-term control of hypertension.

Effectiveness of Adrenalectomy and Aldosterone Antagonists for Long-Term Treatment of Primary Aldosteronism

The data published by Rossi et al1 provide additional evidence for the well-established efficacy of mineralocorticoid receptor (MR) blockers for the treatment of autonomous hyperaldosteronism whether caused by an aldosterone-producing adenoma or bilateral adrenal hyperplasia.2 The data are interpreted as showing a better outcome for adrenalectomy for patients with an aldosterone-producing adenoma than for MR blocker therapy for those with bilateral adrenal hyperplasia in the provision of a cure (42% versus 0) and the number of antihypertensive drugs needed for the long-term control of hypertension (1.76 versus …

Long-Term Control of Ambulatory Hypertension in Children: Improving With Time But Still Not Achieving New Blood Pressure Goals

Short-term therapy can decrease blood pressure (BP) to less than the 95th percentile in only about 50% of children. The aim of our study was to investigate the long-term control of hypertension (HT) in children using ambulatory BP monitoring (ABPM). We analyzed data from all children who started ramipril monotherapy in our center. Controlled HT was defined according to the most current guidelines as systolic and diastolic BP at daytime and nighttime <90th percentile in primary HT and <75th percentile in renoparenchymal HT. Thirty-eight children who were on therapy ≥1 year were included. Thirty-two children had renoparenchymal, and 6 had primary HT. The median age at the beginning of therapy was 13.6 years (range = 4.1-18.0 years), and the median time of antihypertensive therapy was 2.6 years (range = 1.0-11.8 years). Thirty-four percent of children received combination therapy; the median number of antihypertensive drugs was 1.5 drugs/patient (range = 1-4). Sixty-eight percent of children had BP <95th percentile, but only 34% of the children had controlled HT. Children with uncontrolled HT had a tendency to have a higher daytime diastolic BP index before the start of therapy than children with controlled HT (0.99±0.11 vs. 0.94±0.11; P = 0.09). There was a significant decrease in prevalence of nondipping (from 47% to 16%; P = 0.006) with therapy. This first pediatric study focusing on long-term control of HT using ABPM showed that long-term control of HT is better than short-term control, but still only one-third of children achieve the new BP goals. The low control of HT might be improved by more intensive therapy.

524 ACHIEVING THE BETTER BLOOD PRESSURE CONTROL TROUGH THE HOME BLOOD PRESSURE MEASUREMENT OF NURSE MONITORING

Objective: To assess whether home blood pressure measurement which conducted by nurses can improve the hypertension control rates. Methods: Hypertensive patients from the out-patient section were evaluated initially byphysicians and conducted home blood pressure measurement by nurses. A treatment plan was designed and monitored by nurses. Patients were trained to use automated digital home BP monitor and requested to provide 42 BP readingsduring 12-month period. These values were reviewed by the physician-nurse team, and the treatment regimen was adjusted to achieve a goal BP of less than 135/85 mm Hg. Results: One hundred and six consecutively referred patients were enrolled in the study (mean ± SD age, 64 ± 14 years; 58% female; baseline BP, 156 ± 16/85 ± 11 mm Hg). Ninety-four patientssubmitted BP data after 1 month, and 78 patients completed the entire 12-month study period. Overall, mean BP decreased to 138 ± 17/78 ± 8 mm Hg at 1 month and 131 ± 9/75 ± 7 mm Hg at 12 months (P < .01 vs baseline). The percentage of patients who achieved BP control to less than 135/85 mm Hg increased from 0% at baseline to 63% at 12 months. Intensification of antihypertensive drug therapy was required, on average, in 24% of patients at each study interval. Conclusion: Home BP measurement managed by a physician-nurse team has the potential to improve long-term hypertension control rates in a geographically dispersed population. It could reduce both cost and inconvenience associated with the treatment of hypertension. Funding: The present study is supported by the Key Project of Science and Technology of TCM in Gansu Province, China(GZK-2010-Z1).

Nitric-Oxide Supplementation for Treatment of Long-Term Complications in Argininosuccinic Aciduria

Argininosuccinate lyase (ASL) is required for the synthesis and channeling of L-arginine to nitric oxide synthase (NOS) for nitric oxide (NO) production. Congenital ASL deficiency causes argininosuccinic aciduria (ASA), the second most common urea-cycle disorder, and leads to deficiency of both ureagenesis and NO production. Subjects with ASA have been reported to develop long-term complications such as hypertension and neurocognitive deficits despite early initiation of therapy and the absence of documented hyperammonemia. In order to distinguish the relative contributions of the hepatic urea-cycle defect from those of the NO deficiency to the phenotype, we performed liver-directed gene therapy in a mouse model of ASA. Whereas the gene therapy corrected the ureagenesis defect, the systemic hypertension in mice could be corrected by treatment with an exogenous NO source. In an ASA subject with severe hypertension refractory to antihypertensive medications, monotherapy with NO supplements resulted in the long-term control of hypertension and a decrease in cardiac hypertrophy. In addition, the NO therapy was associated with an improvement in some neuropsychological parameters pertaining to verbal memory and nonverbal problem solving. Our data show that ASA, in addition to being a classical urea-cycle disorder, is also a model of congenital human NO deficiency and that ASA subjects could potentially benefit from NO supplementation. Hence, NO supplementation should be investigated for the long-term treatment of this condition.