Non-diabetic Hypertensive Patients Research Articles

Arterial hypertension and prediabetes

Background and objectivesThe aim of this study was to assess the factors related to new diabetes in hypertensive. Patients and methodsThis prospective follow-up study involved 2588 non-diabetic, hypertensive patients. The total follow-up was 15,053 patient-years with a median of 3.4 years (interquartile interval 1.4–6.8). ResultsDuring the follow-up, 333 (13%) patients had new diabetes, with a conversion rate of 2.21 (95% confidence interval [CI], 1.98–2.46) 100/patients/year. In a Cox proportional hazard model including baseline characteristics and modifications during the follow-up the three components of metabolic syndrome (excluding blood pressure and glucose values) HR 1.69 (95% CI, 1.36–2.09), family history of diabetes HR 1.49 (95% CI, 1.20–1.85) and baseline blood glucose ≥110mg/dl HR 7.84 (95% CI, 5.99–10.29) were the most important factors related to new diabetes. Weight variation during the follow-up, and statins, beta-blockers or diuretic treatment did not increase the risk of new diabetes, blood pressure control at the end of study reduce the risk HR 0.74 (95% CI, 0.61–0.91). ConclusionsIn hypertensive non-diabetic patients in primary prevention the factors related to new diabetes can easily identified at the beginning of follow-up. Being obese, with family history of diabetes, and glucose values ≥110mg/dl dramatically increase the risk of developing new diabetes.

Effect of losartan and atenolol on insulin sensitivity in nondiabetic hypertensive patients.

Effect of losartan and atenolol on insulin sensitivity in nondiabetic hypertensive patients.

PP.22.06] PLASMA D-DIMER LEVELS ARE RELATED TO INTRARENAL VASCULAR RESISTANCE IN NON-DIABETIC ESSENTIAL HYPERTENSIVE PATIENTS

Objective: Hypertensive nephroangiosclerosis is characterized by progressive narrowing of preglomerular arterioles that leads to increased intrarenal vascular resistance. This can be estimated by duplex ultrasound evaluation and measurement of the intrarenal resistance index (IR). In addition to high blood pressure, other factors can contribute to development and progression of nephroangiosclerosis. The aim of this study was to investigate the possible relationships between some emergent cardiovascular risk factors, such as a prothrombotic state, and presence and severity of nephroangiosclerosis, as evaluated by measurement of IR, in hypertension. Design and method: In 115 non-diabetic, essential hypertensive patients (age 46 ± 13 years; 63 males, 57 never treated with anti-hypertensive drugs, 58 studied after drug wash-out of at least 2 weeks) we measured anthropometric variables, fasting plasma glucose and insulin, HOMA-index, 24-h creatinine clearance (CrCl) and urinary protein excretion, plasma levels of fibrinogen, D-dimer, prothrombin fragment 1 + 2, plasminogen activator inhibitor-1, tissue-plasminogen activator, lipoproteina (a), and homocysteine. Patients with CrCl < 30 ml/min/1.73 m2 were excluded. In all patients, IR was calculated as the average of 4 to 6 separate measurements that were obtained in the interlobar arteries respectively in the upper, middle, and lower third of both kidneys and patients were subdivided according to tertiles of IR. Results: IR was greater in women than in men, and in patients previously treated with antihypertensive drugs. Patients in the highest tertile of IR were older and had greater body mass index, pulse pressure, D-dimer and fibrinogen levels, and lower CrCl than patients in lowest IR tertile. No differences in the other variables considered in the study were found across IR tertiles. At univariate analysis IR was significantly and directly related to age, systolic and pulse pressure, HOMA-index, urinary protein excretion, D-dimer, and inversely with CrCl. At multivariate analysis, IR was independently associated with pulse pressure, CrCl and D-dimer levels. Conclusions: In non-diabetic hypertensive patients subclinical damage of intrarenal vessels is related with an activation of the hemostatic system that could play a role in the early stages of hypertensive nephropathy.

OP.1A.05] NOCTURNAL BLOOD PRESSURE RELATES MORE CLOSELY TO KIDNEY DISEASE IN THE DUBLIN OUTCOME STUDY

Objective: Hypertension is the most common modifiable risk factor for cardiovascular disease. It is also the fastest growing reason for renal replacement therapy. Ambulatory blood pressure (ABP) has consistently been shown to be a superior predictor of cardiovascular risk to that measured in the clinic setting. There is however limited data in its use to risk stratify patients with renal dysfunction We studied the relationship between ABP and renal disease in a in a cohort of non-diabetic hypertensive patients. Design and method: At baseline, when not on antihypertensive medication, 3,760 non-diabetic patients (1,789 male, mean age 51.88 (SD 13.9) years) underwent ABP and baseline assessment including phlebotomy. Using the Cockcroft-Gault Equation we calculated an estimated creatinine clearance. All statistic were performed using SAS 9.0. Results: Nighttime blood pressure was more closely correlated with creatine clearance that daytime blood pressure (- 0.194 vs −0.106, p, 0.0001). A similar pattern was seen for systolic blood pressure (SBP) when compared to diastolic blood pressure. Using multiple logistic regression when those with normal renal function (N = 2,050) were compared to those with significant renal impairment (N = 441) nighttime blood pressure was stronger predictor of renal function Each 10mmHg increase in nighttime SBP was associated with an odd ratio of 1.29 (1.18–1.40; p < 0.0001). This was after adjustment for daytime SBP, age, gender, smoking history, BMI and cardiovascular history. Conclusions: Nighttime SBP has a significant association with renal dysfunction independent of other risk factors including of daytime blood pressure. ABP should be used in the assessment of patients with renal disease. Future research into the benefits of treating elevated nighttime blood pressure is needed to clarify this association.

Hipertensión arterial y prediabetes

Background and objectivesThe aim of this study was to assess the factors related to new diabetes in hypertensive. Patients and methodsThis prospective follow-up study involved 2588 non-diabetic, hypertensive patients. The total follow-up was 15053 patient-years with a median of 3.4 years (interquartile interval 1.4-6.8). ResultsDuring the follow-up 333 (13%) patients had new diabetes, with a conversion rate of 2.21 (95% confidence interval [CI], 1.98-2.46) 100/patients/year. In a Cox proportional hazard model including baseline characteristics and modifications during the follow up the three components of metabolic syndrome (excluding blood pressure and glucose values) HR 1.69 (95% CI, 1.36-2.09), family history of diabetes HR 1,49 (95% CI, 1,20-1,85) and baseline blood glucose ≥110 mg/dl HR 7.84 (95% CI, 5.99-10.29) were the most important factors related to new diabetes. Weight variation during the follow up, and statins, beta-bloquers or diuretic treatment did not increase the risk of new diabetes, blood pressure control at the end of study reduce the risk HR 0,74 (95% CI, 0.61-0.91). ConclusionsIn hypertensive non-diabetic patients in primary prevention the factors related to new diabetes can easily identified at the beginning of follow up. Being obese, with family history of diabetes, and glucose values ≥110 mg/dl dramatically increase the risk of developing new diabetes.

Is It Time to Reappraise Blood Pressure Thresholds and Targets? A Statement From the International Society of Hypertension-A Global Perspective.

The SPRINT (Systolic Blood Pressure Intervention Trial) findings,1 together with the publication of other major studies within the last year addressing how low blood pressure should be targeted to prevent cardiovascular events in patients with hypertension,2–4 support what we have known for a long time that: (1) blood pressure >115/75 mm Hg is associated with increased risk of cardiovascular disease and stroke, (2) blood pressure lowering is associated with reduced morbidity and mortality, (3) antihypertensive drugs reduce the incidence of hypertension-associated events, and (4) prevention of cardiovascular morbidity is largely related to blood pressure lowering per se, although other effects of the drugs used contribute to this benefit. The questions that are now posed, particularly in response to an editorial commentary by the Editors of this Journal,5 are the following: What is the threshold at which antihypertensive treatment should be initiated? and what target blood pressure should we strive for to achieve maximum benefit in patients with hypertension? SPRINT and other recent meta-analyses and trials provide new data that allow us to sharpen and refine recommendations for blood pressure targets in people with hypertension.1–4 Here, we will briefly address the questions in the worldwide context of hypertension. In hypertensive patients without diabetes mellitus, previous stroke or polycystic kidney disease, SPRINT has provided strong evidence that targeting systolic blood pressure of <120 mm Hg (as measured by an automated measurement protocol in the office)1 provides significantly stronger protection from cardiovascular events and death than the traditionally accepted target of <140 mm Hg. This study was conducted in a hypertensive patient cohort of intermediate-to-high cardiovascular risk. It should be highlighted that the target of 120 mm Hg in SPRINT was based on blood pressure readings using a defined protocol with an office automated device, where blood pressure …

Lower is better in hypertension, but how low should blood pressure be targeted?

Take home message Aim for a systolic blood pressure lower than the current recommended goal of 140 mm Hg. Optimum systolic blood pressure should be targeted to 120–130 mm Hg, especially in nondiabetic hypertensive patients with significant risk factors. Advantages of aggressive treatment to levels <120 mm Hg are still unclear. Lifestyle modifications rather than initiation of antihypertensive drug treatment should be advocated in individuals with high-normal blood pressure and no history of cardiovascular events.

&lt;b&gt;Factors related to blood pressure control in a prospective cohort of hypertensive outpatients

Previous studies have reported a controversial relationship between inadequate blood pressure control and predictor variables. Current prospective cohort study analyzes the interference of age, gender, diabetes and medication adherence in the control of blood pressure of hypertensive outpatients. Patients were interviewed under blind conditions to determine medication adherence, and clinical variables assessment were standardized. Univariate analysis of variance identified the variables correlated to blood pressure control at the end of the follow-up period. Missing data were excluded from analysis. After adjusting for confounders with univariate analysis, the association between the outcome (BP control rate) with significant factors and the calculated adjusted odds ratios (OR) and their 95% CI was analyzed by logistic regression. No interference by age or medication adherence in blood pressure control was reported. In fact, the higher the number of medications in use, the greater were the chances of having blood pressure control in disorder. Females are associated with a 3.1 increase in odds ratio of poor blood pressure control. Compared with non-diabetic hypertensive patients, hypertensive diabetic ones had a lower chance of poor blood pressure control.

Effect of losartan and atenolol on insulin sensitivity in nondiabetic hypertensive patients.

Objective:To study the effects of losartan and atenolol on glucometabolic parameters in nondiabetic hypertensive patients.Materials and Methods:In a prospective, open-label, parallel group study, nondiabetic patients with mild to moderate hypertension were randomized to either losartan (titrated from 50 to 100 mg/day, n = 20) or atenolol (titrated from 25 mg to 100 mg/day, n = 20) for period of 24 weeks. At baseline, 12 and 24 weeks fasting plasma glucose (FPG), fasting plasma insulin (FPI), homeostasis model assessment for insulin resistance (HOMA-IR) apart from lipid parameters, mean systolic, and diastolic blood pressures levels were determined.Results:At the end of study, losartan significantly (P < 0.05) reduced FPG, FPI, and HOMA-IR compared to atenolol and baseline. While atenolol increased the HOMA-IR levels significantly compared to the baseline.Conclusions:Losartan improved the insulin sensitivity while atenolol worsened it. Losartan is better than atenolol for its effects on the glucose-insulin metabolism.

The relationship between dietary salt intake and ambulatory blood pressure variability in non-diabetic hypertensive patients

High dietary salt intake was reported to increase blood pressure by numerous studies, but no study has investigated the effect of dietary salt intake on blood pressure variability (BPV). This study aimed to determine if daily salt intake is related to ambulatory BPV. The study included 136 primary hypertensive patients (92 male, 44 female) with a mean age of 50.7±11.1 years. All the patients underwent 24-h ambulatory blood pressure monitoring to determine both the 24-h systolic and 24-h diastolic BPV. 24-h urine sodium was measured. The correlation between BPV and 24-h urinary sodium was investigated. Logarithmic transformation of 24-h urinary sodium [log(24-h urinary sodium)] was positively correlated with the mean 24-h systolic ARV, and nighttime systolic ARV (r=0.371 and p=0.001, r=0.329 and p=0.028, respectively). Similarly, log(24-h urinary sodium) was positively correlated with mean 24-h diastolic ARV and nighttime diastolic ARV (r=0.381 and p=0.001, r=0.320 and p=0.020 respectively). Log(24-h urinary sodium) was an independent predictor of BPV based on multivariate regression analysis. Dietary salt intake might play a role in the pathogenesis of ambulatory BPV.

Intrarenal vascular resistance and prothrombotic state in non-diabetic hypertensive patients

The enzyme dipeptidyl peptidase-IV (DPP-4) inactivates the incretin hormone glucagon-like peptide-1 (GLP-1). GLP-1 has therapeutic effects in patients with type 2 diabetes, but its potential is limited by a short half-life, DPP-4 inhibition is a promising approach to diabetes treatment. This study examined chronic (once-a-day dosing for 8 weeks) effects of the DPP-4 inhibitor PKF-275-055 (1, 3, and 10 mg/kg) on β-cell regeneration and plasma DPP-IV activity, intact GLP-1, glucose, and insulin after an oral glucose load in neonatal wistar rats injected with streptozotocin (STZ) (n2-STZ model), a recognized model of type 2 diabetes. In streptozotocin induced diabetic rats, PKF-275-055 (3, and 10 mg/kg) significantly reduced glucose excursion during the oral glucose tolerance test conducted 2 h and 10 h after administration, with increases in plasma insulin and active glucagon-like peptide-1 (GLP-1) levels and significantly inhibited (> 50% inhibition) plasma DPP-IV activity during both the 1st and 2nd OGTT in diabetic rats. In contrast, PKF-275-055 (1–10 mg/kg) did not cause hypoglycemia in fasted normal rats. Furthermore, PKF-275-055 significantly inhibited advance glycation end product (HbA1c), HOMA-Index, gastric emptying and small intestinal transit rates, with significance at doses of 1 mg/kg or higher. Immunological staining showed PKF-275-055 stimulates β-cell regeneration and reduces pancreatic cell apoptosis in diabetic treated rats. The present preclinical studies indicate that PKF-275-055 is a novel selective DPP-IV inhibitor with long-acting antidiabetic effect that might be a potential agent for type 2 diabetes

Microvascular effects of the inhibition of dipeptidylpeptidase IV by linagliptin in nondiabetic hypertensive patients

Recent studies suggest vascular benefits of dipeptidylpeptidase IV (DPP-IV) inhibition in patients with diabetes mellitus. Only little is known about potential vascular effects of DPP-IV inhibitors in nondiabetic individuals. The aim of this study was to investigate the effect of DPP-IV inhibition in a nondiabetic hypertensive population. This was a double-blinded, randomized, placebo-controlled, mechanistic study, comparing microvascular effects of the DPP-IV inhibitor linagliptin with placebo in nondiabetic individuals with a history of arterial hypertension. Twenty-one patients received 5 mg linagliptin (5 women; age 67.6 ± 6.0 years; mean ± SD), whereas 22 patients were randomized to placebo (5 women; age 64.8 ± 7.1 years). At baseline, after 6 and 12 weeks, retinal microcirculation and arterial blood pressure profiles were assessed. Moreover, blood samples were taken for the measurement of HbA1c, asymmetric dimethylarginine, C-reactive peptide, cyclic guanosinmonophosphate, transforming growth factor beta (TGF-ß1) and cystatin C. Retinal capillary perfusion increased by 23.7 ± 10.3% (mean ± SEM; P < 0.05), retinal arterial flow by 7.6 ± 0.6 (P < 0.05) and the retinal hyperemic response by 290 ± 263% (P < 0.05) during treatment with linagliptin. No change in retinal blood flow was found in the placebo group. Although blood pressure declined in both groups, a significant decline in TGF-ß1 by 9.3 ± 4.5% (P < 0.05) could only be observed in the linagliptin group. No significant change in other laboratory parameters could be observed in both groups. Our study suggests microvascular and antifibrotic effects of linagliptin in a nondiabetic, hypertensive population.

Predictors of cardiac morbidity in diabetic, new-onset diabetic and non-diabetic high-risk hypertensive patients: The Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial

Diabetic and new-onset diabetic patients with hypertension have higher cardiac morbidity than patients without diabetes. We aimed to investigate whether baseline predictors of cardiac morbidity, the major constituent of the primary endpoint in the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial, were different in patients with diabetes and new-onset diabetes compared to patients without diabetes. In total, 15,245 high-risk hypertensive patients in the VALUE trial were followed for an average of 4.2 years. At baseline, 5250 patients were diabetic by the 1999 World Health Organization criteria, 1298 patients developed new-onset diabetes and 8697 patients stayed non-diabetic during follow-up. Cardiac morbidity was defined as a composite of myocardial infarction and heart failure requiring hospitalization, and baseline predictors were identified by univariate and multivariate stepwise Cox regression analyses. History of coronary heart disease (CHD) and age were the most important predictors of cardiac morbidity in both diabetic and non-diabetic patients. History of CHD, history of stroke and age were the only significant predictors of cardiac morbidity in patients with new-onset diabetes. Predictors of cardiac morbidity, in particular history of CHD and age, were essentially the same in high-risk hypertensive patients with diabetes, new-onset diabetes and without diabetes who participated in the VALUE trial.

0062: Impact of diabetes and hypertension on the longitudinal systolic function of the left ventricle

Hypertension is responsible for many structural changes with myocardial fibrosis leading to left ventricular hypertrophy and progressive deterioration over time of systolic left ventricular and diastolic function. Hypertension and type 2 diabetes are major causes of ventricular dysfunction and heart failure risk factors. Current data suggest that the longitudinal LV systolic dysfunction was found in the early stages of hypertensive cardiomyopathy. Recently, the development of the imaging (2D) strain has facilitated simple and independent measurement of LV strain parameters in the longitudinal, circumferential and radial. This work is to achieve in a series of 30 hypertensive patients with diabetes and 30 non diabetic hypertensive patients (aged 25-75 years) a complete echo cardiographic study, including LVEF biplane Simpson method, calculation of left ventricular mass indexed and the relative thickness parietal to differentiate the eccentric and concentric left ventricular hypertrophy(LVH), analysis of diastolic function and finally the study of the longitudinal strain of LV by speckle tracking technique (calculation GLS).Were excluded from the study patients with secondary hypertension, valvular stenosis or fleeting, arrhythmia, coronary artery disease history. 60 diabetic patients and non-diabetic hypertensive had an LVEF greater than 55% as measured by biplane Simpson method and the conventional method. LVH was present in 85% of diabetic hypertensive against 45% in non-diabetics.The calculation of LV mass according to the ASE method was used to select 20 diabetic patients with concentric LVH against 5 with eccentric LVH. The LV mass index was higher with an average of 120g/m 2 in diabetic patients with LVH compared with non-diabetic patients with LVH. The evaluation of filling pressures by the E/E ’showed high pressures in 8 diabetic hypertensive patients against only 3 non-diabetic hypertensive patients. Analysis of longitudinal function by calculating the GLS showed lower rates to 18% in 18 diabetic hypertensive patients against 9 nondiabetic hyper-tensive patients. GLS was lower than –18% in eight diabetic patients with filling pressures high. We note in this modest work that LVH was clearly predominant in the HTA arm + diabetes with a consequent decrease in longitudinal contraction index. In diabetic hypertensive patients, LVH was generally concentric. Elevated filling pressures was found in 8 diabetic hypertensive patients against only 3 non-diabetic hypertensive patients, with good correlation with the decrease in the GLS. In conclusion, the evaluation of longitudinal systolic function by 2D strain has an important role in the early detection of subclinical heart disease in diabetic hypertensive patients, and could thus identify patients at high risk of heart failure may benefit from preventive strategies

The relation between serum cathepsin D level and carotid intima-media thickness in nondiabetic hypertensive patients.

We aimed to investigate the relation between carotid intima-media thickness (CIMT) and serum cathepsin D level in hypertensive patients. This was a cross-sectional study of 74 hypertensive patients (22 males and 52 females, with a mean age of 51.86 ± 11.75 years). Serum levels of cathepsin D were measured with an enzyme-linked immunosorbent assay. CIMT measurements were taken from 3 different points: right and left common carotid arteries, bifurcation, and the first 2 cm of the internal carotid artery. Mean CIMT was calculated by averaging the measurements taken 3 times from each carotid artery. Mean CIMT value was 0.76 ± 0.15 mm, and median cathepsin D level was 190.3 (12.8-2681.3) ng/mL. A marked positive correlation was found between cathepsin D levels and CIMT (r = 0.331, P = 0.04). In multivariate linear regression analysis, cathepsin D, albumin levels, and the duration of hypertension were significant predictors of CIMT (P = 0.017, P = 0.008, and P = 0.043, respectively). Increased serum cathepsin D level was found to be associated with CIMT in nondiabetic hypertensive patients.

Intrarenal Vascular Resistance is Associated With a Prothrombotic State in Hypertensive Patients

Background/Aims: Hypertensive nephroangiosclerosis is associated with progressive increase of intrarenal vascular resistance. In addition to blood pressure, other factors can contribute to hypertensive renal damage including a prothrombotic state. We investigated the relationship between hemostatic markers and intrarenal vascular resistance in hypertension. Methods: In 115 untreated, nondiabetic, hypertensive subjects free of cardiovascular complications and advanced renal function impairment, we measured 24-hour creatinine clearance (GFR) and urinary albumin excretion (UAE), fasting plasma glucose, HOMA-index, and plasma levels of fibrinogen, D-dimer, prothrombin fragment 1+2, plasminogen activator inhibitor-1, homocysteine, and lipoprotein(a). In all patients, measurement of intrarenal resistance was obtained by renal Doppler ultrasound with calculation of the renal resistance index (RI). Results: Patients in the highest tertile of RI were older and had greater body mass index, pulse pressure, fibrinogen, and D-dimer levels and lower GFR than patients in the lowest RI tertile. RI was directly correlated with age, pulse pressure, HOMA-index, UAE, D-dimer, and inversely with GFR. On multivariate analysis, RRI was independently associated with age, GFR, and plasma D-dimer. Conclusions: A prothrombotic state is associated with increased intrarenal vascular resistance in nondiabetic hypertensive patients and might contribute to the early stages of hypertensive renal disease.

Effect of losartan and amlodipine on insulin sensitivity in non-diabetic hypertensive patients

Background: Hypertensive patients show higher insulin levels than normotensive controls. Hypertension is linked to impaired glucose tolerance and resistance to the action of insulin. Untreated hypertensive patients are at risk of developing new onset diabetes mellitus. Different antihypertensive drugs affect the insulin sensitivity distinctly. Few studies have demonstrated the beneficial effects of losartan, an angiotensin receptor blocker on the glucose insulin metabolism, but other studies have failed to demonstrate the insulin resistance lowering effect of losartan. Amlodipine, a long acting calcium channel blocker is considered to have neutral effects on the glucose-insulin metabolism. Methods: In a prospective, open-label, parallel group study, non-diabetic patients with mild to moderate hypertension were randomized to either losartan (titrated from 50 to 100 mg /day, n=20) or amlodipine (titrated from 5 to 10 mg/ day, n=20) for period of 24 weeks. At baseline, 12 weeks and 24 weeks fasting plasma glucose, fasting plasma insulin, homeostasis model assessment for insulin resistance (HOMA-IR) apart from lipid parameters, mean systolic and diastolic blood pressures levels were determined. Results: Intragroup comparison shows that both losartan and amlodipine significantly reduced the HOMA-IR index (P < 0.05, 24 weeks vs. baseline). Losartan reduced HOMA-IR more than amlodipine but this reduction was not statistically significant. Conclusions: Losartan and amlodipine lowered insulin resistance in patients of mild to moderate hypertension.

A New Blood Pressure Target for High-Risk Patients?

In the 2010 ACCORD blood pressure trial, treating hypertensive diabetic patients intensively to reach a systolic blood pressure (BP) target of <120 mm Hg did not improve outcomes compared with treatment to a standard target of 140 mm Hg (NEJM JW Gen Med Apr 15 2010 and N Engl J Med 2010; 362:1575). Now, in the randomized Systolic Blood Pressure Intervention Trial (SPRINT), researchers compared the same targets in 9361 high-risk nondiabetic hypertensive patients. To enroll in SPRINT, patients were …

Snapshot Hemodynamics and Clinical Outcomes in Hypertension: Precision in the Measurements Is Key.

The recent publication of the Systolic Blood Pressure Intervention Trial (SPRINT) inks the latest chapter in the evolving history of blood pressure management.1 The trial randomized 9361 nondiabetic hypertensive patients aged >50 years with at least one cardiovascular risk factor (not including stroke) to intensive or standard control (systolic blood pressure <120 or <140 mm Hg, respectively). The main conclusion from this large trial was that targeting a systolic blood pressure of <120 mm Hg when compared with <140 mm Hg resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive treatment group.1 It is also informative to focus on the blood pressure difference achieved between the groups and not just the absolute blood pressure targets. What was accomplished in terms of the independent variable, systolic blood pressure, was a difference of 13.1 mm Hg between the 2 groups, which was sustained after the first year of treatment. Importantly, the observed difference in systolic blood pressure was accomplished, whereas the intensive group and the standard group took on average <3 and 2 antihypertensive medications, respectively. This supports the argument that lowering blood pressure can be achieved without an excessive pill burden. This is a relevant practical point, particularly when dealing with people whose systolic blood pressure at study baseline was only moderately elevated on average, 139.7 and 139.7 mm Hg in each group. It should be noted, however, that people with difficult-to-control blood pressure were excluded in SPRINT. This important clinical trial, therefore, raises the critical question of whether we need to be more aggressive than ever before in our blood pressure treatment goals. There is increasing evidence in favor of lower is better from the recent meta-analysis of …

Microalbuminuria in subjects with hypertension attending specialist blood pressure clinics.

Albuminuria is associated with increased risk of cardiovascular disease and target organ damage in patients with diabetes mellitus. In nondiabetic hypertensive patients, the threshold at which microalbuminuria (MAU) increases risk is unclear and there is evidence that cardiovascular risk may be increased in individuals with MAU levels lower than the usual recommended screening thresholds. We compared two definitions of MAU (on the basis of three early morning urine samples) in a cohort of hypertensive patients attending two specialist clinics in Scotland: conventional (MAU(C)) albumin-to-creatinine ratio (ACR) >2.5-25 mg mmol(-1) in males or >3.5-25 mg mmol(-1) in females; and low-grade (MAU(L)) ACR 1.2-2.5 in males or 1.7-3.5 mg mmol(-1) in females. Of the 1059 subjects screened, 786 (74%) were nondiabetic, with estimated glomerular filtration rate ⩾30 ml min(-1) per 1.73 m(2) and without gross proteinuria (low-risk subset). The average age was 58±15 years, body mass index 30±6 kg m(-2) and 46% were males. The prevalence of MAU(C) was 11% and 9.5% in the overall and low-risk subset, respectively, whereas MAU(L) prevalence was 11.1% and 10% respectively. The prevalence of cardiovascular disease was higher (24%) with albuminuria (both MAU(C) and MAU(L)) compared with 14% among those without albuminuria. The use of MAU(L) doubled the number of hypertensive subjects with increased cardiovascular risk who can be targeted for more rigorous risk reduction strategies. Consideration should be given to reducing the current threshold for MAU.