Agustin J. Ramirez

Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension.

Clinical Practice Guidelines for the Management of Hypertension in the Community A Statement by the American Society of Hypertension and the International Society of Hypertension

Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.

Michael A. Weber, MD; Ernesto L. Schiffrin, MD; William B. White, MD; Samuel Mann, MD; Lars H. Lindholm, MD; John G. Kenerson, MD; John M. Flack, MD; Barry L. Carter, Pharm D; Barry J. Materson, MD; C. Venkata S. Ram, MD; Debbie L. Cohen, MD; Jean-Claude Cadet, MD; Roger R. Jean-Charles, MD; Sandra Taler, MD; David Kountz, MD; Raymond R. Townsend, MD; John Chalmers, MD; Agustin J. Ramirez, MD; George L. Bakris, MD; Jiguang Wang, MD; Aletta E. Schutte, MD; John D. Bisognano, MD; Rhian M. Touyz, MD; Dominic Sica, MD; Stephen B. Harrap, MD

Clinical Practice Guidelines for the Management of Hypertension in the Community

Michael A. Weber, MD; Ernesto L. Schiffrin, MD; William B. White, MD; Samuel Mann, MD; Lars H. Lindholm, MD; John G. Kenerson, MD; John M. Flack, MD; Barry L. Carter, Pharm D; Barry J. Materson, MD; C. Venkata S. Ram, MD; Debbie L. Cohen, MD; Jean-Claude Cadet, MD; Roger R. Jean-Charles, MD; Sandra Taler, MD; David Kountz, MD; Raymond R. Townsend, MD; John Chalmers, MD; Agustin J. Ramirez, MD; George L. Bakris, MD; Jiguang Wang, MD; Aletta E. Schutte, MD; John D. Bisognano, MD; Rhian M. Touyz, MD; Dominic Sica, MD; Stephen B. Harrap, MD

Latin American guidelines on hypertension. Latin American Expert Group.

Hypertension is a highly prevalent cardiovascular risk factor in the world and particularly overwhelming in low and middle-income countries. Recent reports from the WHO and the World Bank highlight the importance of chronic diseases such as hypertension as an obstacle to the achievement of good health status. It must be added that for most low and middle-income countries, deficient strategies of primary healthcare are the major obstacles for blood pressure control. Furthermore, the epidemiology of hypertension and related diseases, healthcare resources and priorities, the socioeconomic status of the population vary considerably in different countries and in different regions of individual countries. Considering the low rates of blood pressure control achieved in Latin America and the benefits that can be expected from an improved control, it was decided to invite specialists from different Latin American countries to analyze the regional situation and to provide a consensus document on detection, evaluation and treatment of hypertension that may prove to be cost-utility adequate. The recommendations here included are the result of preparatory documents by invited experts and a subsequent very active debate by different discussion panels, held during a 2-day sessions in Asuncion, Paraguay, in May 2008. Finally, in order to improve clinical practice, the publication of the guidelines should be followed by implementation of effective interventions capable of overcoming barriers (cognitive, behavioral and affective) preventing attitude changes in both physicians and patients.

Reflex control of blood pressure and heart rate by arterial baroreceptors and by cardiopulmonary receptors in the unanaesthetized cat.

Studies in unanaesthetized animals have reported that section of the carotid sinus and aortic nerves is accompanied by an increased blood pressure variability but not by a sustained blood pressure rise, thus questioning the role of arterial baroreceptors in the long term control of mean blood pressure values. However, sino-aortic denervation (SAD) does not produce denervation of all baroreceptor areas, and it has been suggested that aortic baroreceptor fibres in the vagus and cardiopulmonary vagal afferents that restrain sympathetic vasoconstrictor tone prevent blood pressure from permanently rising. In unanaesthetized cats we recorded blood pressure intra-arterially for 8-12 h when baroreflexes were intact, 7 days after SAD and 1-2 days additional bilateral cervical vagotomy. Blood pressure signals were analysed by computer to provide means and coefficients of variation (CV, variabilities) for each recording period. In intact cats, mean blood pressure was 99 +/- 7 mmHg (average +/- s.e.) and CV 6 +/- 1%. SAD did not alter mean blood pressure but markedly increased CV (12 +/- 2%; P less than 0.01). Additional vagotomy did not alter mean blood pressure (104 +/- 6 mmHg), nor did it alter the increased CV observed after SAD alone. Vagotomy failed to affect mean blood pressure and CV even when performed in cats with intact carotid and aortic nerves. The lack of effect of vagotomy did not depend on simultaneous section of afferent and efferent fibres, because selective blockade of the latter by atropine also failed to affect mean blood pressure and CV.(ABSTRACT TRUNCATED AT 250 WORDS)

Telmisartan improves insulin resistance in high renin nonmodulating salt-sensitive hypertensives.

Background Nonmodulating (NMHT) is a high-renin subtype of salt sensitive hypertension, which additionally develops insulin resistance and oxidative stress. Conversely, modulating hypertensives (MHT) normally regulates renal hemodynamics after high sodium intake without metabolic impairment. We postulate that telmisartan, an angiotensin receptor blocker with partial peroxisome proliferators-activated receptorγ partial agonist, may improve insulin resistance compared with ramipril, an angiotensin-converting enzyme inhibitor (ACEI) in NMHT. Methods We studied 18 NMTH (32 ± 5y nine men, BMI 29 ± 3 kg/m2) and 16 MHT (34 ± 4, 10 men, BMI 28 ± 5 kg/m2) before and after the crossover administration of ramipril 10 mg (3 months) or telmisartan 80 mg (3 months). In each patient studied we measured, before and after each treatment period, office blood pressure, glycemia and insulinemia before and 60 and 120 min after a glucose overload (75 g), total cholesterol, high-density lipoprotein and low-density lipoprotein fractions, triglycerides and highly sensitive C-protein-reactive protein. After that, HOMA-IR Index was calculated. Results Plasma renin activity was higher in NMHT 4.4 ± 0.5 than MHT 2.6 ± 0.9 ng.ml.h; P < 0.01. Blood pressure was similarly reduced either in MHT or NMHT by ramipril (MHT: from 159 ± 10/102 ± 4 to 142 ± 6/93 ± 3 mmHg, P < 0.05; NMHT: from 162 ± 12/97 ± 4 to 139 ± 7/89 ± 2 mmHg, P < 0.05) or telmisartan (MHT: from 154 ± 8/96 ± 5 to 137 ± 6/88 ± 4 mmHg, P < 0.05; NMHT: from 161 ± 9/96 ± 5 to 137 ± 5/86 ± 3 mmHg, P < 0.05). In NMHT, fasting glycemia (99 ± 10 mg%) and insulinemia (16 ± 4 μU%) and 120 min glycemia (110 ± 2 mg%) and insulinemia (57 ± 9 μU%) were higher than in MHT (fasting: 92 ± 8 mg% and 9.2 ± 2 mU%; 120 min: 95 ± 5 and 21 ± 5 μU%, P < 0.05). In MHT, after 3 months treatment with either ramipril or telmisartan no changes were found in fasting and 120 min glycemia and insulinemia. In NMHT, telmisartan, after 3 months treatment, significantly reduced fasting and 120 min insulinemia (fasting: 8.4 ± 2, 120 min: 25 ± 10 μU%; P < 0.01) compared either to basal values or ramipril treatment. Similarly, only in NMHT, compared with basal values and ramipril treatment, telmisartan improved the HOMA-IR index in both MHT (2.76 ± 0.16 to 2.24 ± 0.18, P < 0.05) and NMHT (from: 4.4 ± 1 to 2.3 ± 0.7) and triglyceride plasma levels (MHT: from 139 ± 1.85 to 122 ± 2.4 mg%, P < 0.05; NMHT: from: 223 ± 12 to 146 ± 10 mg%, P < 0.01). Finally, highly sensitive C-protein-reactive protein values were higher in NMHT (0.33 ± 0.07 mg.dl) than in MHT (0.14 ± 0.06 mg.dl; P < 0.01). Both treatments reduced highly sensitive C-protein-reactive protein in NMHT. (ramipril from 0.32 ± 0.05 mg.dl to 0.26 ± 0.06 m.dl (P < 0.05) and telmisartan from 0.34 ± 0.05± to 0.20 ± 0.05 mg.dl (P < 0.01). Conclusion Our data suggest that the improvement of the insulin sensitivity by telmisartan, instead of a similar effect on blood pressure shown by both drugs, could be ascribed to the PPAR agonistic action of telmisartan. This opens an interesting therapeutic approach for patients with hypertension and altered glycemic metabolism.

Reference Values of Pulse Wave Velocity in Healthy People from an Urban and Rural Argentinean Population

In medical practice the reference values of arterial stiffness came from multicenter registries obtained in Asia, USA, Australia and Europe. Pulse wave velocity (PWV) is the gold standard method for arterial stiffness quantification; however, in South America, there are few population-based studies. In this research PWV was measured in healthy asymptomatic and normotensive subjects without history of hypertension in first-degree relatives. Normal PWV and the 95% confidence intervals values were obtained in 780 subjects (39.8 ± 18.5 years) divided into 7 age groups (10–98 years). The mean PWV found was 6.84 m/s ± 1.65. PWV increases linearly with aging with a high degree of correlation (r 2 = 0.61; P < 0.05) with low dispersion in younger subjects. PWV progressively increases 6–8% with each decade of life; this tendency is more pronounced after 50 years. A significant increase of PWV over 50 years was demonstrated. This is the first population-based study from urban and rural people of Argentina that provides normal values of the PWV in healthy, normotensive subjects without family history of hypertension. Moreover, the age dependence of PWV values was confirmed.

Guías Latinoamericanas de Hipertensión Arterial

Ramiro A. Sanchez, Miryam Ayala, Hugo Baglivo, Carlos Velazquez, Guillermo Burlando, Oswaldo Kohlmann, Jorge Jimenez, Patricio Lopez Jaramillo, Ayrton Brandao, Gloria Valdes, Luis Alcocer, Mario Bendersky, Agustin Jose Ramirez, Alberto Zanchetti, de parte del Grupo Latinoamericano de Expertos.

Differential control of blood pressure and heart rate by carotid and aortic baroreceptors in unanaesthetized cats

In unanaesthetized cats the most striking effects of sino-aortic denervation (SAD) consist of a marked increase in blood pressure variability and a concomitant marked reduction in heart rate variability. Because the relative contribution of carotid and aortic baroreceptors to these phenomena has never been assessed, blood pressure (intra-arterial catheter) and heart rate were measured in unanaesthetized, unrestrained cats for 8-10 h under three conditions: intact animals, 1 week after section of the carotid sinus or the aortic nerves and 1 week after SAD. Blood pressure and heart rate signals were analysed by a computer to provide mean values and variation coefficients of variation i.e. blood pressure and heart rate variabilities, for each recording period. In the intact cats the coefficient of variation was 6.6 +/- 0.6% (mean +/- s.e.) for mean blood pressure and 11.2 +/- 1.7% for heart rate. The coefficient of variation for mean blood pressure was not altered by either the aortic or the carotid sinus nerve section, a marked increase being observed only after SAD (11.5 +/- 1.3%, P less than 0.01). On the other hand, the coefficient of variation for heart rate was reduced either by the carotid or by the aortic nerve section. The reduction observed following the carotid baroreceptor denervation accounted for the greater fraction of the overall reduction (74 versus 26%) in coefficient of variation for heart rate observed after SAD (4.8 +/- 0.9%, P less than 0.01). These data show that the carotid sinus and aortic nerves are similarly involved in control of blood pressure variability.(ABSTRACT TRUNCATED AT 250 WORDS)

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 …