Blood pressure control in patients with hypertension: a community-based study

The objective of own study was to investigate the quality of hypertension management in a rural Chinese population. A prospective cross-sectional study was conducted in 922 hypertensive patients in a regional community in southern China. The average systolic (SBP) and diastolic blood pressure (DBP) was 167.8 +/- 22.5 mmHg and 94.3 +/- 14.2 mmHg respectively. A total of 823 patients (89.3%) patients had a SBP of greater than or equal to 140 mmHg, and 596 (64.6%) had a DBP of greater than or equal to 90 mmHg. Fully 568 patients (69.7%) were treated with one or two antihypertensive drugs, mostly with calcium channel blockers. In patients treated with antihypertensive drugs, the average SBP and DBP were 170.3 +/- 23.1 mmHg and 96.2 +/- 14.8 mmHg, respectively. Blood pressure was poorly controlled in these hypertensive patients. Further studies are required to identify the barriers to the effective management of uncontrolled hypertension in a rural setting.     

Studies on abnormalities of adrenal steroidogenesis in essential hypertension, primary aldosteronism and renovascular hypertension: responses of plasma steroids to angiotensin III

In the present study, effects of angiotensin on the adrenal steroidogenesis were studied in essential hypertension, primary aldosteronism and renovascular hypertension (RVH). Angiotensin III(A III), an analogue of angiotensin II, was administered to 17 normal volunteers (9 male and 8 female), 44 patients with essential hypertension (EH) (15 with high renin; HREH, 15 with normal renin; NREH and 14 with low renin; LREH), 8 patients with primary aldosteronism (5 with adrenal adenoma; APA and 3 with bilateral adrenocortical hyperplasia; IHA) and 5 patients with renovascular hypertension. In all the patients with hypertension and normal subjects, blood pressure (BP) and plasma concentrations of progesterone (P), corticosterone (B), aldosterone (Aldo), 17 alpha-hydroxyprogesterone(17-OHP) and cortisol(F) were measured before and after intravenous administration of A III (0.1, 0.5, 1.0, 10, 20 and 40 ng/kg/min, for 15 min, respectively). 1) BP rose from 164 +/- 19/88 +/- 8 to 180 +/- 19/112 +/- 10 mmHg [systolic BP(SBP); P less than 0.01, diastolic BP(DBP); P less than 0.01] in HREH, from 162 +/- 12/96 +/- 7 to 186 +/- 11/118 +/- 8 mmHg in NREH(SBP; P less than 0.01, DBP; P less than 0.01), 165 +/- 12/94 +/- 8 to 202 +/- 12/126 +/- 9 mmHg in LREH(SBP; P less than 0.001, P less than 0.001) and 118 +/- 8/72 +/- 7 mmHg to 136 +/- 11/88 +/- 8 mmHg in controls (SBP; P less than 0.01, DBP; P less than 0.01). The elevation in NREH and LREH was greater than that in HREH and controls. The elevations of BP both in APA and IHA were remarkably greater than that in controls and as similar as LREH(APA; 174 +/- 21/103 +/- 12 to 204 +/- 18/136 +/- 8 mmHg, IHA; 176 +/- 10/104 +/- 4 to 206 +/- 17/138 +/- 10 mmHg). The elevation in RVH was similar to that in NREH(173 +/- 9/108 +/- 8 to 194 +/- 13/132 +/- 10 mmHg). 2) Plasma P increased from 25.5 +/- 7.5 to 39.5 +/- 13.8 ng/100 ml(P less than 0.001) in HREH, from 28.0 +/- 7.7 to 45.3 +/- 12.7 ng/100 ml(P less than 0.001) in NREH, from 23.8 +/- 8.2 to 47.2 +/- 19.4 ng/100 ml(P less than 0.001) in LREH and 26.6 +/- 11.0 to 43.4 +/- 14.6 ng/100 ml in controls. The increment in HREH or NREH was similar to that in controls(P less than 0.1, respectively), whereas greater than controls in LREH(P less than 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)     

Blood pressure is linked to salt intake and modulated by the angiotensinogen gene in normotensive and hypertensive elderly subjects

OBJECTIVES: To evaluate salt sensitivity in elderly subjects with different forms of hypertension and controls and to investigate any modulation by genotype DESIGN: Randomized, double-blinded, placebo-controlled latin-square SETTING: Tertiary referral hospital PARTICIPANTS: Community subjects (n = 46) aged > or = 60 years classified as isolated systolic hypertension [ISH; systolic blood pressure (SBP) > or = 160, diastolic blood pressure (DBP) < 90 mmHg, n = 19], diastolic +/- systolic hypertension (SDH; DBP > or = 90 mmHg, n = 10) and normotension (SBP < 160, DBP < 90 mmHg, n = 17). INTERVENTION: Four 14 day treatments, 50, 100, 200 and 300 mmol/day of sodium chloride supplementation interspersed with 14 day washout periods on a salt-restricted diet. MAIN OUTCOME MEASURES: The 24 h blood pressure, heart rate, weight, urinary sodium and creatinine clearance measured during baseline, treatment and washout periods and angiotensinogen (AGT) and angiotensin converting enzyme (ACE) genotypes. RESULTS: For the entire cohort, the mean +/- standard error (SE) of change from baseline in SBP for 50, 100, 200 and 300 mmol/day salt was 7.7+/-2.4, 12.1+/-2.4, 16.6+/-3.0, 18.5+/-2.6 mmHg, respectively. For DBP, the respective changes were: -0.1+/-1.5, 2.4+/-1.6, 3.0+/-1.5, 5.8+/-1.7 mmHg. The increase in SBP among ISH subjects was significantly higher than among subjects in the SDH and normotensive groups (P < 0.05). AGT genotype influenced the effect of salt dose on the change in DBP (P = 0.006) but not SBP (P = 0.7). CONCLUSIONS: In healthy, older subjects, a linear increase in BP occurred with increasing salt dose, it appeared most pronounced in ISH subjects and could be modulated by AGT genotype.     

Variation in cuff blood pressure in untreated urban outpatients with mild hypertension in Harare, Zimbabwe--implications for the diagnosis of hypertension

Duplicate measurements of BP were recorded at six visits in 32 male urban factory workers found to have raised BP (systolic blood pressure (SBP) greater than or equal to 160 mmHg or diastolic blood pressure (DBP) greater than or equal to 90 mmHg) at the initial visit). A systematic decrease in both SBP and DBP occurred over the first three visits. The BP at visits 4-6 was not significantly different. Most of the decrease in BP occurred between the first and second visit (mean SBP decreased 8.5 mmHg and mean DBP decreased 11.1 mmHg). After 6 visits 66% of subjects could be classified into clear clinical groups (normotensive 53.5%, hypertensive 12.5%) but in 34% the variation in cuff BP precluded classification. In these subjects prolonged observation or home BP monitoring may be required before initiating lifelong treatment.     

Evaluation of the activity of the autonomic nervous system in "dipper" and "non dipper" essential hypertensives. Gender differences]

OBJECTIVES: 1) To compare the autonomic nervous system activity parameters obtained from a photoplethysmographic recording in dipper and non dipper hypertensive. 2) To look for an interaction between dipper/non dipper status and gender. METHODS: Prospective study involving 245 untreated hypertensives (51 +/- 13 years, 146 men, 99 women). All of the patients underwent a 24-hour ambulatory blood pressure measurement (ABPM) as well as an echocardiography for left ventricular mass index determination (LVMI) and a photoplethysmographic recording of blood pressure (BP). Nondippers were defined as those whose nocturnal decrease in systolic BP (SBP) and/or diastolic BP (DBP) was < 10% of daytime BP. Spectral powers were obtained from the photoplethysmographic recording using a fast Fourier transform over the low frequency band (LF) and the high frequency band (HF). Baroreflex sensitivity (BRS) was evaluated by the sequences method. RESULTS: Of the 245 patients, 159 were dippers (98 men, 61 women) and 86 were non dippers (48 men and 38 women). Clinic BP was significantly higher in non dippers than in dippers (168/101 vs 161/98 mmHg; p < 0.01 for SBP and p < 0.05 for DBP) whereas daytime ABPM and LVMI were not different, whatever the gender. LF spectral powers were significantly lower in non dippers than in dippers for SBP (respectively 25 +/- 11% vs 30 +/- 13%; p < 0.01) for DBP (respectively 35 +/- 14% vs 41 +/- 15%; p < 0.01) and for HR (respectively 34 +/- 15% vs 38 +/- 15%; p = 0.03). They showed a positive correlation with the nocturnal SBP fall (r = 0.21, p < 0.001 for SBP and DBP spectral powers, r = 0.19; p < 0.005 for HR spectral power) and with the nocturnal DBP fall, too (r = 0.19; p < 0.005 for SBP spectral power, r = 0.20; p < 0.002 for DBP spectral power, r = 0.19; p < 0.005 for HR spectral power). HF spectral powers tended to be higher in non dippers than in dippers but in a non significative way. BRS was roughly the same in dippers and non dippers (7.5 +/- 2.7 vs 7.0 +/- 3.1 ms/mmHg, NS). The interaction between non dipper/dipper status and sex was non significant whatever the LF spectral power. CONCLUSIONS: 1) The greater the nocturnal BP fall, the higher the sympathetic activity indexes. 2) This relationship was found both in males and females.     

Small artery remodeling is the most prevalent (earliest?) form of target organ damage in mild essential hypertension

BACKGROUND: The heart and blood vessels are exposed to elevated blood pressure (BP) in hypertensive patients, but their changes in response to BP or non-hemodynamic stimuli may be different, and occur with different time-courses. To evaluate this, we studied the prevalence of structural and functional alterations of resistance arteries and cardiac hypertrophy in patients with mild essential hypertension. METHODS: Resistance arteries were dissected from gluteal subcutaneous tissue from 38 hypertensive patients (47 +/- 1 years; 71% male; BP 148 +/- 2/99 +/- mmHg), studied on a pressurized myograph, and compared to those from 10 normotensives (44 +/- 3 years; 40% male; BP 113 +/- 4/76 +/- 2 mmHg). RESULTS: The prevalence of abnormal structure (media-to-lumen ratio, M/L) and impaired endothelial function (maximal acetylcholine response) was 97 and 58% (abnormal was defined as greater than mean + 1 SD of normotensives), or 63 and 34% (abnormal defined as greater than mean +/- 2SD). Thirty four percent of hypertensive patients exhibited left ventricular hypertrophy by echocardiography. When grouped into tertiles according to increasing ambulatory systolic BP (SBP), the highest BP tertile showed increased M/L (P< 0.01) and left ventricular mass index (LVMI, P < 0.05) and marginally decreased endothelial function (P= 0.07). LVMI was greatest in the tertile of patients with highest M/L (P< 0.05). Endothelial function was decreased in the tertile with greatest vascular stiffness (P< 0.01). By multivariate analysis, M/L correlated with ambulatory SBP (beta = 0.40, P= 0.02), and LVMI correlated with ambulatory SBP (beta = 0.41, P = 0.001) and body mass index (beta = 0.30, P< 0.05). Female sex influenced endothelial function negatively (beta = -0.63, P< 0.01). CONCLUSION: Structural alterations of resistance arteries were demonstrated in most hypertensive patients, followed by endothelial dysfunction and cardiac hypertrophy in a smaller number of hypertensives. Small artery structural remodeling may precede most clinically relevant manifestations of target organ damage in mild essential hypertension.     

Usefulness of the alpha1-blocker doxazosin as a third-line antihypertensive drug.

It has been reported that a substantial majority of hypertensives receive insufficient blood pressure (BP) control. As combination therapy for the treatment of hypertension, Ca channel blockers (CCBs), angiotensin II (AII) receptor blockers (ARBs), and/or AII-converting enzyme (ACE) inhibitors are mainly prescribed, while the efficacy of alpha(1)-blockers in such combination therapy remains unknown. The aim of this study was to investigate the efficacy of a low dose of an alpha(1)-blocker added to combination therapy with CCBs and either ARBs or ACE inhibitors for the treatment of hypertension. Subjects were 41 hypertensive patients (23 women and 18 men, mean age 66+/-12 years) who had been followed at the National Kyushu Medical Center. All patients showed poor BP control despite haven taken a combination of CCBs and ARBs or ACE inhibitors for more than 3 months. Doxazosin at a dose of 1 to 2 mg was added to each treatment regimen. The changes in various clinical parameters, including BP and blood chemistry, following the addition of doxazosin were then evaluated. The mean follow-up period was 170 days. BP decreased from 152+/-14/81+/-12 mmHg to 135+/-14/70+/-11 mmHg after the addition of doxazosin at a mean dose of 1.5 mg/day (p<0.001). When good systolic blood pressure (SBP) control was defined as <140 mmHg, the prevalence of patients with good SBP control increased from 24% to 61% (p<0.01). Similarly, the prevalence of patients with good diastolic blood pressure (DBP) control (<90 mmHg) increased from 78% to 98% (p<0.01). Patients whose SBP decreased more than 10 mmHg (n=25) showed significantly higher baseline SBP, serum total cholesterol and low-density lipoprotein (LDL) cholesterol levels compared to those who showed less SBP reduction (<10 mmHg) (n=16, p<0.01). Comparable BP reductions were obtained between obese (body mass index [BMI] > or =25, DeltaBP at 3 months: -15+/-15/-12+/-9 mmHg, n=18) and non-obese (BMI<25, DeltaBP: -14+/-19/-7+/-8 mmHg, n=23) patients. The results suggest that addition of a low dose of the alpha(1)-blocker doxazosin effectively reduces BP in patients taking CCBs and ARBs or ACE inhibitors. Thus, doxazosin seems to be useful as a third-line antihypertensive drug.     

Optimal control of blood pressure can reverse left ventricular hypertrophy in uremic hypertensive hemodialysis patients

We investigated the effects of antihypertensive treatment on left ventricular hypertrophy (LVH) of long-term hemodialysis patients. In uremic patients, it is still controversial in antihypertensive effect to the regression of LVH. The left ventricular size and function of 39 uremic hypertensive long-term hemodialysis patients (27 men, 12 women, mean age 58.3) was evaluated with M-mode, 2-dimensional and Doppler echocardiography before, and 12 months after, the start of combined antihypertensive therapy. This therapy included angiotensin II converting enzyme inhibitors, beta-blockers and calcium antagonists. Patients were classified as responders or nonresponders, depending upon whether their systolic blood pressure (SBP) decreased by more than 10 mmHg after antihypertensive treatment for 12 months. Before treatment, 36 (92%) patients had LVH and diastolic dysfunction and three (8%) had systolic dysfunction. At the end of 12 months, only 25 (64%) patients had LVH, 30 (77%) had diastolic dysfunction and 2 (5%) had systolic dysfunction. Left ventricular mass index (LVMI) also decreased from 203.63 +/- 70.47 g/m2 to 178.57 +/- 67.31 g/m2. LVMI correlated with systolic blood pressure (SBP) but did not correlate with diastolic blood pressure (DBP). There were 26 responders and 13 non-responders. Among responders, both the SBP (153.91 +/- 13.24 mmHg vs 134.43 +/- 14.21 mmHg, p < 0.01) and DBP (90.39 +/- 7.89 mmHg vs 79.98 +/- 7.35 mmHg, p < 0.01) decreased significantly after antihypertensive therapy. Responders also exhibited progressive regression of LVH (LVMI decreased significantly from 208.52 +/- 72.03 g/m2 to 168.52 +/- 55.53 g/m2, p < 0.05). However, LVH regression was not found in nonresponders (LVMI showed 194.84 +/- 64.36 g/m2 vs 193.66 +/- 77.67 g/m2). We conclude that good control of blood pressure can reverse LVH in hypertensive hemodialysis patients.     

Diltiazem compared with metoprolol as add-on-therapies to diuretics in hypertension. Swedish Diltiazem-Metoprolol Multicentre Study Group

In a randomized, double-blind, parallel group study, diltiazem was compared with metoprolol as add-on therapy to diuretic treatment in 115 patients with hypertension. Following a placebo and diuretic period of four weeks, patients were randomized to either slow release diltiazem 90 mg twice daily or metoprolol 100 mg once daily using a double dummy technique. If after four weeks a target supine diastolic blood pressure (DBP) less than or equal to 90 mmHg pressure was not reached, the doses of diltiazem and metoprolol were doubled. Supine inclusion systolic/diastolic blood pressures (SBP/DBP) at randomization were 158 +/- 13 (mean +/- SD)/102 +/- 5 mmHg in the diltiazem group and 158 +/- 17/101 +/- 6 mmHg in the metoprolol group. Active therapy significantly lowered SBP and DBP in both groups by 7-10%. Heart rate was significantly lowered in both groups, although the effect of metoprolol was more pronounced. Response rates (supine DBP less than or equal to 90 mmHg and/or decreased by greater than or equal to 10%) were 43% on diltiazem 90 mg twice daily and 52% on metoprolol 100 mg once daily, increasing to 82% and 62%, respectively, after dose escalations. No serious side effects were seen, but three patients, two on diltiazem and one on metoprolol, were withdrawn from the study due to severe headache, nausea and bradycardia respectively. of mild to moderate adverse reactions, tiredness was most frequent, occurring in 14.5% and 15.8% on active diltiazem and metoprolol therapy, respectively. We conclude that both diltiazem and metoprolol lower BP when added to diuretics in hypertensive patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

T1198C polymorphism of the angiotensinogen gene and antihypertensive response to angiotensin-converting enzyme inhibitors.

This study examined the association between T1198C polymorphism of the angiotensinogen (AGT) gene and the blood pressure response to ACE inhibitors in a Chinese hypertensive cohort. After a 2-week single-blind placebo run-in period, benazepril (10-20 mg/day) or imidapril (5-10 mg/day) was administered for 6 weeks to 509 patients with mild-to-moderate essential hypertension. Polymerase chain reaction combined with restriction enzyme digestion was used to detect the polymorphism, and the patients were classified as having the TT, TC, or CC genotype. The achieved changes in systolic and diastolic blood pressure (SBP and DBP) were analyzed to determine their association with genotypes at the AGT gene locus. In the total 509 patients, the TT genotype was observed in 44 patients (8.7%), the TC genotype in 214 patients (42.0%), and the CC genotype in 251 patients (49.3%). The SBP reductions in patients with the TT genotype, TC genotype, and CC genotype were -15.3+/-12.7 mmHg, -14.0+/-12.7 mmHg, and -14.4+/-12.4 mmHg, respectively (p=0.809). The DBP reductions in patients with the TT genotype, TC genotype, and CC genotype were -8.5+/-8.1 mmHg, -8.3+/-7.5 mmHg, and -8.9+/-6.6 mmHg, respectively (p=0.638). There were no significant differences in the changes in SBP or DBP after treatment among the three genotype groups. In conclusion, these results suggest that the AGT genotype does not predict the blood pressure-lowering response to antihypertensive treatment with ACE inhibitors in Chinese hypertensive patients.     

Predictors of controlled ambulatory blood pressure in treated hypertensive patients with uncontrolled office blood pressure.

Although some treated hypertensive patients have controlled 24-h ambulatory blood pressure (ABP) despite their uncontrolled office blood pressure (BP), the factors relating to the control of 24-h ABP remain unknown. We conducted a study to assess 24-h ABP and its association with other cardiovascular risk factors, including echocardiographic left ventricular hypertrophy (LVH), in elderly hypertensive patients (n =41) with uncontrolled office BP (>140/90 mmHg) during long-term medication. Although a majority of the patients had isolated elevation of office systolic BP (SBP), there was no significant relationship between office SBP and 24-h SBP, and about half of the patients had controlled 24-h ABP (125+/-8/69+/-6 mmHg). Patients with controlled 24-h ABP (125+/-8/69+/-6 mmHg) had similar office BP (150+/-6/77+/-5 vs. 150+/-7/79+/-7 mmHg), but lower left ventricular mass index (LVMI) (123+/-34 vs. 156+/-34 g/m(2)) and body mass index (BMI) (24.4+/-2.1 vs. 26.4+/-3.6 kg/m(2)) compared with those with uncontrolled 24-h ABP (149+/-13/78+/-7 mmHg). Multivariate analysis showed that LVMI and BMI were independently associated with controlled 24-h ABP, and the control status of 24-h ABP was highly dependent on the presence of LVH and obesity. Therefore, absence of LVH and obesity may be useful for predicting the level of control of 24-h ABP in treated patients whose office BP is uncontrolled without ABP measurements.     

Freehand three-dimensional echocardiographic evaluation of the effect of telmisartan compared with hydrochlorothiazide on left ventricular mass in hypertensive patients with mild-to-moderate hypertension: a multicentre study

Antihypertensive efficacy, effects on left ventricular mass index (LVMI) and tolerability of telmisartan, an angiotensin II receptor blocker, were compared with those of hydrochlorothiazide (HCTZ). Adult patients with mild-to-moderate hypertension and an optimal acoustic window by two-dimensional echocardiography were randomised at baseline to 12 months' double-blind, once-daily treatment with telmisartan 80 mg or HCTZ 25 mg. Two-dimensional echocardiography and freehand precordial three-dimensional echocardiography and 24-h ambulatory blood pressure monitoring were performed at baseline and after treatment. Of the 41 telmisartan group patients and 28 HCTZ group patients, 40 and 25, respectively, completed the study. Following treatment, 24-h mean SBP (telmisartan 157 +/- 11 vs 133 +/- 7 mmHg, P<0.001; HCTZ 154 +/- 10 vs 144 +/- 11 mmHg, P<0.003) and DBP (telmisartan 96 +/- 6 vs 83 +/- 5 mmHg, P<0.001; HCTZ 95 +/- 7 vs 87 +/- 8 mmHg, P<0.003) were significantly reduced. Telmisartan produced significantly greater 24-h mean SBP and DBP reductions than HCTZ (P<0.001). LVMI was significantly reduced by telmisartan (141 +/- 16 vs 125 +/- 19 g/m2, P<0.001), but not by HCTZ (139 +/- 20 vs 135 +/- 22 g/m(2)). Incidences of adverse events in both the treatment groups were low; two cases of hypokalaemia occurred with HCTZ. In conclusion, telmisartan 80 mg was well tolerated and significantly reduced SBP, DBP and LVMI after 12 months' treatment compared with HCTZ.     

Improvement of blood pressure control in hypertensive patients with renal diseases.

For hypertensive patients with renal diseases (RD), strict blood pressure (BP) control has been recommended in recent hypertension guidelines, such as JNC VI, JNC 7, WHO/ISH 1999 and ESH-ESC 2003. We assessed the current status of BP control and the changes of BP control before and after the publication of these guidelines in 489 hypertensive patients with or without RD (age, 19-89 years, mean 59+/-13 years) who visited the hypertension and kidney outpatient clinic at Kyushu University Hospital. The clinical characteristics of RD and non-RD patients were assessed (RD patients: age, 20-89 years, mean 60+/-13 years, n=311; non-RD patients: age, 19-86 years, mean 58+/-13 years, n=178). In addition, we compared the BP control status in 2003 to that in 1996. In 2003, the BP in RD patients was 134+/-16/78+/-10 mmHg and that in non-RD patients was 138+/-12/83+/-9 mmHg. When strict BP control was defined as <130/80 mmHg, the frequency of strict BP control in RD patients was 28.9% in 2003. In addition, the BP levels of RD patients in 2003 were significantly lower than those in 1996 (134+/-16/78+/-10 mmHg vs. 141+/-17/85+/-10 mmHg, p<0.05 for both systolic blood pressure [SBP] and diastolic blood pressure [DBP]), and the frequency of strict BP control in RD patients was higher in 2003 than in 1996 (28.9% vs. 11.8%, p<0.01). The BP levels of non-RD patients in 2003 tended to be lower than those in 1996 (138+/-12/83+/-9 mmHg vs. 141+/-13/85+/-9 mmHg, n.s.). In 2003, angiotensin II receptor blockers (ARBs) were more frequently prescribed to RD patients than to non-RD patients. Furthermore, the use of ARBs was markedly increased in 2003 compared with 1996. In conclusion, in our outpatient clinic, BP levels in hypertensive patients with RD have improved in recent years, and were lower than those in hypertensive patients without RD, which may in part reflect the physicians' awareness of the importance of strict BP control in RD patients, as suggested by several recent hypertension guidelines.     

Relationship between polymorphism of the angiotensin-converting enzyme gene and the response to angiotensin-converting enzyme inhibition in hypertensive patients.

The aim of this study was to investigate the relationship between polymorphism of the anglotensin-converting enzyme (ACE) gene and the blood pressure response to ACE inhibition in a hypertensive cohort. Imidapril (5-10 mg/day) or benazepril (10-20 mg/day) was administered for 6 weeks to 517 essential hypertensives. ACE gene polymorphism was examined by the polymerase chain reaction (PCR) method and the patients were classified as having the 190-bp deletion homozygous (DD) genotype, the 490-bp insertion homozygous (II) genotype, or the 490-bp insertion, 190-bp deletion heterozygous (ID) genotype. The achieved change in systolic and diastolic blood pressure (SBP and DBP) was analyzed for association with genotypes at the ACE gene locus. The DD genotype was observed in 132 patients (25.5%), the ID genotype in 255 patients (49.3%), and the II genotype in 130 patients (25.2%). The SBP reductions in the patients with the DD genotype, II genotype, and ID genotype were -14.5 +/- 12.7 mmHg, -14.3 +/- 13.1 mmHg and -14.0 +/- 12.2 mmHg, respectively (p = 0.94). The DBP reductions in the patients with the DD genotype, II genotype, and ID genotype were -8.7 +/- 7.4 mmHg, -8.7 +/- 7.7 mmHg and -8.5 +/- 6.7 mmHg, respectively (p = 0.96). There was no significant association between the ACE gene polymorphisms and the response to ACE inhibition. These results suggest that ACE genotype does not predict the blood pressure-lowering response to antihypertensive treatment with ACE inhibition.     

Arm position and blood pressure: a risk factor for hypertension?

The objective of this study was to re-evaluate the effect of arm position on blood pressure (BP) measurement with auscultatory and oscillometric methods including ambulatory blood pressure monitoring (ABPM). The setting was the hospital outpatient department and the subjects chosen were normotensive and hypertensive. The effect of lowering the arm from heart level on indirect systolic BP (SBP) and diastolic BP (DBP) measurement as well as the importance of supporting the horizontal arm were measured. In the sitting position, lowering the supported horizontal arm to the dependent position increased BP measured by a mercury device from 103+/-10/60+/-7 to 111+/-14/67+/-10 mmHg in normotensive subjects, a mean increase of 8/7 mmHg (P<0.01). In hypertensive subjects, a similar manoeuvre increased BP from 143+/-21/78+/-17 to 166+/-29/88+/-20 mmHg, an increase of 23/10 mmHg (P<0.01). Combined results from normotensive and hypertensive subjects demonstrate a direct and proportional association between BP (SBP and DBP) and the increase produced by arm dependency. Similar changes and associations were noted with oscillometric devices in the clinic situation. However, supporting the horizontal arm did not alter BP. Of particular interest, analysis of 13 hypertensive subjects who underwent ABPM on two occasions, once with the arm in the 'usual' position and once with the arm held horizontally for BP measurement during waking hours, demonstrated changes comparable to the other devices. The mean 12-hour BP was 154+/-19/82+/-10 mmHg during the former period and significantly decreased to 141+/-18/74+/-9 mmHg during the latter period (P<0.01). Regression analysis of the change in SBP and DBP with arm position change again demonstrated a close correlation (r(2)=0.8113 and 0.7273; P<0.001) with the artefact being larger with higher systolic and diastolic pressures. In conclusion, arm movements lead to significant artefacts in BP measurement, which are greater, the higher the systolic or diastolic pressure. These systematic errors occur when using both auscultatory and oscillometric (clinic and ABPM) devices and might lead to an erroneous diagnosis of hypertension and unnecessary medication, particularly in individuals with high normal BP levels. Since clinical interpretations of heart level vary, the horizontal arm position should be the unambiguous standard for all sitting and standing BP auscultatory and oscillometric measurements.     

Is masked hypertension an artefact due to the blood pressure measurement method and threshold effects?

From results of office and home measurements of blood pressure (BP), patients can be classified as "hypertensive (HT)", "normotensive (NT)", "office hypertensive (OH)" or "masked hypertensive (MH)" by crossing the classifications obtained from each method. It seems that 9 to 20% of patients could be MH with a prognosis close to HT (SHEAF study). OBJECTIVES: To test the hypothesis that at least one part of the prevalence of MH would be an artefact due to the difference between the methods of measurements (shygmomanometer vs semi-automatic device) and/or due to different definitions of office hypertension (OHT). To determine the impact of different definitions of OHT on the prevalence of MH. METHODS: During the course of a phase IV study, BP was measured with the same semi-automatic device (OMRON 705CP) both at doctor's office (3 measurements at 1-minute intervals) and at home, by the patient himself (3 measurements in the morning and in the evening at 1-minute intervals over the 7 days before the visit). Following definitions were used: Office HT: SBP > or =140 mmHg, DBP > or =90 mmHg, SBP > or =140 mmHg or DBP > or =90 mmHg; Home HT: SBP > or =135 mmHg, DBP> or =85 mmHg, SBP > or =135 mmHg or DBP > or =85 mmHg. Another definition of office HT was used SBP > or =135 mmHg, DBP > or =85 mmHg SBP > or =135 mmHg or DBP > or =85 mmHg. RESULTS: 575 patients were analysed. Results from the two methods of measurements are closed but significantly different (difference for SBP: 3.2 +/- 16.5 mmHg; p < 0.0001; difference for DBP: 1.4 +/- 10.3 mmHg; p = 0.002)     

Arterial stiffness is related to augmented seasonal variation of blood pressure in hypertensive patients

BACKGROUND: Seasonal variation in blood pressure (BP), a usual tendency of both systolic (SBP) and diastolic BP (DBP) to rise during winter in hypertensive patients, may be related to the higher cardiovascular mortality in winter. However, it is not yet clear what factors are relevant to the seasonal BP changes. We hypothesized that arterial stiffness is related to the BP changes between summer and winter. METHODS AND RESULTS: Eighty-five elderly (>55 years) patients with essential hypertension (33 males, 64+/-6.0 years) were enrolled. Seasonal BP profiles over at least 2 years were studied along with arterial stiffness and clinical variables (age, gender, smoking, duration of hypertension, anti-hypertensive medications and body mass index). Both SBP and DBP were significantly higher during winter compared with three other seasons (spring 128+/-10.0/79+/-7.3 mmHg, summer 127+/-9.8/78+/-7.1 mmHg, autumn 127+/-10.3/78+/-8.0 mmHg, winter 136+/-12.5/81+/-7.6 mmHg; SBP changes; p<0.001, DBP changes; p<0.001). There were no significant seasonal differences among spring, summer and autumn. Pulse wave velocity (PWV), a widely used clinical indicator of arterial stiffness was correlated with winter-summer differences in SBP (r = 0.272, p = 0.012), but not in DBP (r = 0.188, p = 0.085). Age, which was correlated with PWV strongly (p<0.001), was not significantly related to the seasonal changes in BP (SBP changes; p = 0.114, DBP changes; p = 0.298). No other clinical variables had significant correlation with seasonal BP changes. Multivariate regression analysis revealed that PWV is the only significant predictor for winter-summer SBP changes. CONCLUSIONS: Our results established a feasible link between arterial stiffness and seasonal BP variation. These findings may partly explain higher cardiovascular risk in patients with increased arterial stiffness.     

Relationship between home blood pressure and longitudinal changes in target organ damage in treated hypertensive patients.

Cross-sectional studies have shown that home blood pressure (BP) correlates with hypertensive target organ damage better than clinic BP. However, there have been few longitudinal studies regarding the predictive value of home BP on the changes in organ damage in treated hypertensive patients. Clinic and home BP over a 12-month period, antihypertensive medication use, echocardiographic and electrocardiographic results, and serum creatinine and urinary protein levels were examined in 209 treated hypertensive patients in 1993. These patients were prospectively followed for 5 years. The patients were divided into 4 subgroups according to hypertension control as follows: good control (<140/90 mmHg for clinic BP, <135/85 mmHg for home BP), improved, worsened, and poor control. The average clinic BP was 147.0+/-14.9/87.0+/-7.6 mmHg (mean+/-SD) in 1993 and 146.0+/-13.7/84.1+/-7.5 mmHg in 1998. The average home BP was 136.8+/-10.4/84.3+/-7.6 mmHg in 1993 and 136.1+/-9.7/81.2+/-7.7 mmHg in 1998. The left ventricular mass index (LVMI) positively correlated with both home systolic BP and clinic systolic BP in 1998 but not in 1993. The correlation tended to be closer for home BP than for clinic BP. LVMI did not change in patients with good or improved home systolic BP, while it increased in those with poor or worsened home systolic BP. The relationship between changes in LVMI and clinic BP was not significant. In conclusion, Home BP was more effective than clinic BP as a predictor of changes in left ventricular hypertrophy in treated hypertensive patients. Home BP should be controlled to below 135/85 mmHg to prevent cardiac hypertrophy.     

Value of nocturnal blood pressure in treated non-insulin-dependent hypertensive patients]

The purpose of the study was to evaluate the loss of nocturnal (N) decline in blood pressure (BP) in type II treated hypertensive diabetics. The study concerned 36 hypertensive diabetics 59 +/- 10 years old, 20 men and 16 women, with poor metabolic control (HbA1C: 9.6 +/- 3%), without dysautonomia; 14 had macroproteinuria and/or microalbuminuria (mu alb) (< 30 micrograms/min). An ambulatory BP monitoring (Spacelabs 90207) was performed in all patients. Left ventricular mass index (LVMI) and E/A were determined by Doppler-echocardiography. Two groups (G) were individualized: G1 (n = 17), with a normal circadian rhythm (diurnal and N.BP significantly different); G2 (n = 19) with a loss of N decline in systolic (S) and diastolic (D) BP or both; and compared to non diabetic treated hypertensive controls (G3). There was no difference neither in LVMI (125 +/- 43 g/m2), E/A (0.7), 24 h-mean (M) BP in the three groups, nor in HbA1C levels and mu alb occurrence in G1 and G2. Mean N.SBP and mean N.DBP were more closely related to LVMI in G2 than in G1 and G3. [table: see text] Half of these hypertensive diabetics, with bad metabolic control, have an altered circadian BP pattern; the prognostic value of nocturnal BP, related to LVMI despite the antihypertensive treatment, is suggested.     

Effect of ingesting sour milk fermented using Lactobacillus helveticus bacteria producing tripeptides on blood pressure in subjects with mild hypertension

Angiotensin-converting enzyme (ACE) is important in the regulation of blood pressure (BP). Two tripeptides that inhibit ACE, isoleucyl-prolyl-proline (Ile-Pro-Pro) and valyl-prolyl-proline (Val-Pro-Pro), have been isolated from certain sour milks. The aim of the study reported was to evaluate the effect on BP in subjects with mild hypertension of a new sour milk containing tripeptides. The initial number of subjects was 60 (36 men, 24 women). Among the criteria for inclusion in the study were systolic BP (SBP) between 140 and 180 mmHg and/or diastolic BP (DPB) between 90 and 110 mmHg, without antihypertensive drug therapy. There were two study periods with a washout period between. All subjects were given 1.5 dl per day of a placebo (regular sour milk) or of the active product, a milk that had been fermented with Lactobacillus helveticus bacteria and contained 2.4-2.7 mg of Ile-Pro-Pro and 2.4-2.7 mg of Val-Pro-Pro per 1.5 dl. In the first phase, SBP fell 16 mmHg from baseline in the active group, 2 mmHg more than in the placebo group (P=0.0668) and no difference in DBP (P=0.92). There was a statistically significant downward trend both in SBP and DBP (P=0.0001). During the second phase, SBP fell 11 mmHg in the active group (P=0.008). The reduction in SBP was significantly larger in active than placebo group (P=0.012). In the crossover analysis combining both phases, SBP fell on average 2.6+/-15.9 mmHg more on the active product compared with the placebo product, but this difference was not statistically significant (P=0.3111). The difference in DBP, 1.0+/-8.3 mmHg between the two test products was not significant either (P=0.4431). In conclusion, the ingestion of sour milk fermented by L. helveticus bacteria and that containing ACE inhibitory tripeptides seems to lower BP modestly.