Alex Roca-Cusachs

Urinary albumin excretion is associated with true resistant hypertension

Resistant (or refractory) hypertension (RH) is a clinical diagnosis based on blood pressure (BP) office measurements. About one third of subjects with suspected RH have indeed pseudo-resistant hypertension and 24-h ambulatory-blood pressure-monitoring aids to precisely identify them. Our aim was to determine those clinical, laboratory or echocardiographic variables that may be associated with subjects with sustained hypertension (namely true RH). We carried out a cross-sectional analysis of 143 patients consecutively enrolled with the clinical diagnosis of RH. All patients underwent clinical-demographic, laboratory evaluation, 2D-echocardiography and 24-h ambulatory-blood pressure-monitoring. Pseudo-resistant hypertension or white-coat RH was defined if office BP was ⩾140 and/or 90 mm Hg and 24-h BP <130/80 mm Hg. One-hundred and three (72%) patients had true RH and 40 (28%) patients had white-coat RH. True RH patients had significantly higher diabetes prevalence and higher office-systolic blood pressure (SBP) levels. Regarding target organ damage, left ventricular mass index (LVMI) and 24-h urinary albumin excretion (UAE) were also higher in true RH after adjustment for possible confounders (P=0.031 and P=0.012, respectively). In a logistic regression analysis, only office-SBP (multivariate OR (95%CI): 1.030 (1.003–1.057), P=0.030) and UAE (multivariate OR (95% CI): 2.376 (1.225–4.608), P=0.010) were independently associated with true RH. We conclude that true resistant hypertension is associated with silent target organ damage, especially UAE. In patients with suspected RH, assessment of 24 h ambulatory BP is the most accurate way to detect a population with high risk for target-organ damage.

Discrepancies between Office and Ambulatory Blood Pressure: Clinical Implications

BACKGROUND Recent trials have documented no benefit from small reductions in blood pressure measured in the clinical office. However, ambulatory blood pressure is a better predictor of cardiovascular events than office-based blood pressure. We assessed control of ambulatory blood pressure in treated hypertensive patients at high cardiovascular risk. METHODS We selected 4729 patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Patients were aged >/=55 years and presented with at least one of the following co-morbidities: coronary heart disease, stroke, and diabetes with end-organ damage. An average of 2 measures of blood pressure in the office was used for analyses. Also, 24-hour ambulatory blood pressure was recorded at 20-minute intervals with a SpaceLabs 90207 device. RESULTS Patients had a mean age of 69.6 (+/-8.2) years, and 60.8% of them were male. Average time from the diagnosis of hypertension to recruitment into the Registry was 10.9 (+/-8.4) years. Mean blood pressure in the office was 152.3/82.3 mm Hg, and mean 24-hour ambulatory blood pressure was 133.3/72.4 mm Hg. About 60% of patients with an office-pressure of 130-139/85-89 mm Hg, 42.4% with office-pressure of 140-159/90-99 mm Hg, and 23.3% with office-pressure > or =160/100 mm Hg were actually normotensive, according to 24-hour ambulatory blood pressure criteria (<130/80 mm Hg). CONCLUSION We suggest that the lack of benefit of antihypertensive therapy in some trials may partly be due to some patients having normal pressure at trial baseline. Ambulatory monitoring of blood pressure may allow for a better assessment of trial eligibility.

Hipertensión arterial y política de salud en España

José R. Banegas a,b, , Albert Jovell , Benjamı́n Abarca , Manuel Aguilar Diosdado , Luis Aguilera , Pedro Aranda , Vicente Bertoméu , Pedro Capilla , Pedro Conthe , Fernando De Álvaro , Antonio Fernández-Pro , Xavier Formiguera , Jesús Frı́as , Lucı́a Guerrero , José L. Llisterri , José M. Lobos , Juan F. Macı́as , Ángel L. Martı́n De Francisco , Jesús Millán , Juan C. Morales , Vicente Palomo , Alex Roca-Cusachs , Javier Román , Carlos Sanchis , Antonio Sarriá , Julián Segura , Álex De La Sierra , Luis Verde , Julio Zarco n y Luis M. Ruilope a,u a Asociación de la Sociedad Española de Hipertensión y Liga Española para la Lucha contra la Hipertensión Arterial b Universidad Autónoma de Madrid, CIBERESP (CIBER de Epidemiologı́a y Salud Pública), Madrid c Foro Español de Pacientes d Sociedad Española de Medicina General e Sociedad Española de Diabetes f Sociedad Española de Medicina de Familia y Comunitaria g Sociedad Española de Cardiologı́a h Consejo General de Colegios Oficiales de Farmacéuticos i Sociedad Española de Medicina Interna j Sociedad Española de Nefrologı́a en el Comité Español Interdisciplinario para la Prevención Cardiovascular k Sociedad Española para el Estudio de la Obesidad l Departamento de Farmacologı́a y Terapéutica, Universidad Autónoma de Madrid, Madrid m Asociación de Enfermerı́a de Hipertensión y Riesgo Cardiovascular (EHRICA) n Sociedad Española de Médicos de Atención Primaria o Comité Español Interdisciplinar de Prevención Cardiovascular (CEIP) p Sociedad Española de Geriatrı́a y Gerontologı́a q Sociedad Española de Nefrologı́a r Sociedad Española de Arteriosclerosis s Sociedad Española de Farmacéuticos de Atención Primaria t Ibermutuamur-Corporación Mutua-Proyectos Sanitarios u Agencia de Evaluación de Tecnologı́as Sanitarias. Instituto de Salud Carlos III, Madrid v Asociación para la Prevención del Riesgo Cardiovascular (PRECAR) x Sociedad Española de Directivos de Atención Primaria, España

Putative endothelial progenitor cells are associated with flow‐mediated dilation in refractory hypertensives

Background. Hypertension has been related to endothelial dysfunction. Patients with refractory hypertension (RH) have a reduced number of endothelial progenitor cells (EPCs). Aim. To evaluate if blood EPC levels relate to endothelium‐dependent vasodilation (ED‐VD) in RH. Methods. We analyzed 29 RH confirmed by 24‐h ambulatory blood pressure monitoring and assessed complete clinical and laboratory evaluation. EPCs were isolated from peripheral mononuclear cells (MNC) by flow cytometry. ED‐VD was determined measuring flow‐mediated dilation (FMD) by venous occlusion plethysmography. Results. Circulating EPCs/105 MNC (median [Q1–Q3]): 23.0 [4.5–53.8]. FMD (median [Q1–Q3]): 211.7 [79.5–365.8]%. Significant correlations with log‐FMD: EPCs (r = 0.469; p = 0.018) and homocysteine (r = −0.414; p = 0.045). There was no collinearity between EPCs and homocysteine. FMD did not correlate with age, gender, office BP, 24‐h systolic blood pressure or 24‐h diastolic blood pressure, laboratory parameters, C‐reactive‐protein, left ventricular‐mass index, dyslipidaemia, smoking habit and statin or angiotensin system blockers treatment. Multiple linear regression analysis showed that after age‐adjustment, EPC (p = 0.027) and homocysteine (p = 0.004) were the only variables that predicted FMD (R = 0.740). After dividing patients according to EPC number, patients in the lower tertile showed a significantly reduced FMD compared with those in the group of the two upper tertiles of EPC: log‐FMD (mean±SD): 4.7±0.9 vs 5.6±0.8, respectively (p = 0.031). Conclusions. ED‐VD independently correlates with circulating EPCs in RH. Homocysteine is also an independent predictor of lower FMD in such patients.

Relación entre variables clínicas y terapéuticas y calidad de vida relacionada con la salud en pacientes con hipertensión arterial: estudio MINICHAL

Fundamento y objetivo: Evaluar, mediante el cuestionario de calidad de vida relacionada con la salud (CVRS) MINICHAL, la influencia de las variables sociodemograficas, clinicas y terapeuticas en la calidad de vida relacionada con la salud de los pacientes hipertensos. Pacientes y metodo: Estudio observacional, prospectivo y multicentrico en pacientes hipertensos que iniciaban o modificaban tratamiento antihipertensivo. Se realizaron tres visitas, una basal y dos de seguimiento (una al mes y otra a los 6 meses). En ellas se registraron las variables sociodemograficas, clinicas y terapeuticas, y se aplicaron los cuestionarios validados de CVRS MINICHAL, la version espanola del Indice de Bienestar Psicologico y una pregunta sobre el cambio en el estado de salud general con el objetivo de evaluar la influencia sobre la CVRS de dichas variables sociodemograficas, clinicas y terapeuticas. Resultados: Se evaluo a un total de 736 pacientes hipertensos. En el analisis multivariante, el sexo femenino, el numero de enfermedades concomitantes, el grado de hipertension arterial, el grado de afeccion organica y el nivel educativo fueron las variables que se mostraron relacionadas con la CVRS. Se observo una mejoria de la CVRS tras 6 meses de intensificacion del tratamiento, apreciandose una correlacion positiva entre grado de reduccion de presion arterial y de frecuencia cardiaca y mejora en la CVRS, especialmente en la dimension de «Estado de animo». Conclusiones: En los pacientes hipertensos, el mejor control de la presion arterial incide favorablemente sobre la CVRS. Ademas, ciertas caracteristicas de los pacientes se correlacionan negativamente con la CVRS, por lo que la intervencion terapeutica debe estar especialmente dirigida a corregir los factores modificables.

Antihypertensive Effect of Manidipine

Manidipine is a lipophilic, third-generation, highly vasoselective, dihydropyridine (DHP) calcium channel antagonist, which, when given on a once-daily basis, effectively reduces blood pressure (BP) in patients with mild-to-moderate essential hypertension. Manidipine has a gradual onset and a long duration of action, effectively maintaining reduced BP levels throughout the 24-hour dosing period, and is effective in the long term with no evidence of intolerance. The BP-lowering capacity of manidipine is similar to that of other established DHPs and of angiotensin-converting enzyme inhibitors. Diabetic patients and very elderly patients with mild-to-moderate hypertension also respond favourably to treatment with manidipine. Manidipine has neutral effects on glucose and lipid metabolism and is generally well tolerated. Manidipine thus represents a first-line option for lowering BP in patients with mild-to-moderate hypertension.

Blood Pressure Variability in Binswanger’s Disease and Isolated Lacunar Infarction

To determine whether blood pressure (BP) variability is increased in hypertensive patients with Binswanger’s disease (BD), we studied two samples of consecutive treated hypertensive patients: (1) 11 with BD (mean age 71.3 ± 5.2 years); (2) 16 with lacunar infarction (mean age 65.2 ± 8.3 years) without cognitive impairment. An averaged baseline office BP was obtained for 3 consecutive weeks. Ambulatory BP monitoring was then carried out to obtain the averaged mean systolic (SBP) and diastolic BP, and BP variability was defined as the standard deviation of consecutive BP values. Results: Diurnal SBP variability was significantly increased in the BD group (p = 0.04). However, with the analysis of covariance for age and baseline office BP, the difference was no longer significant (p = 0.17 and p = 0.09, respectively). We conclude that increased BP variability in BD patients is probably due to older age and increased baseline office BP. Increased BP variability may be a risk factor for small-vessel disease, but not for cognitive impairment.

Blood pressure variability and leukoaraiosis amount in cerebral small-vessel disease

Objectives – To analyze the correlation between blood pressure (BP) variability and leukoaraiosis (LA) amount in patients with symptomatic cerebral small‐vessel disease. Materials and methods– We included 25 hypertensive patients: 13 with Binswangers disease (BD) and 12 with a first‐ever lacunar infarction (LI). Baseline office BP was obtained for 3 consecutive weeks. From a 24‐h ambulatory BP monitoring performed 1 week later we obtained average systolic (SBP) and diastolic (DBP) BP for daytime, nighttime and 24‐h periods. SBP and DBP variability was defined as the within‐subject standard deviation of all readings. A standardized cerebral MR was performed in each patient and an LA score was calculated. Results– No statistically significant correlation was obtained between the LA score and any of the following BP values: 1) Baseline SBP and DBP; 2) 24‐h, daytime or nighttime SBP and DBP, and 3) 24‐h, daytime or nighttime SBP and DBP variability. Conclusion– Increased BP variability is not associated with greater amounts of leukoaraiosis.

Riesgo vascular en las consultas de Medicina Interna. Estudio MICARE

BACKGROUND AND OBJECTIVES The population attended in the Spanish Internal Medicine departments is of increasing age, but the prevalence of vascular risk factors and its degree of control are unknown, as well as the differences by type of hospital or consulting room. PATIENTS AND METHODS Epidemiologic, transversal and metacentric study in patients ≥ 18 years treated in outpatient Internal Medicine hospital. Two-hundred and ninety physicians from 17 Autonomic Communities participated in the study. The type of hospital or consulting room was also recorded. Blood pressure control was defined as <140/90 mm Hg (<130/80 mm Hg in diabetics or patients with vascular disease), LDL-cholesterol control when<130 mg/dl (<100mg/dl in diabetic or vascular disease) and diabetes control if glycated hemoglobin was<7%. RESULTS Data from 2,704 patients was collected (54% men) mean age (SD) 64,1 (14,5) years. Ninety-three percent of them had at least one cardiovascular risk factor: hypertension 73.9%, dyslipidemia 59.5%, abdominal obesity 43.4%, diabetes 39.5%. Fifty percent had some target organ damaged, 46.7% showed vascular disease and 71.2% a high or very high vascular risk. Control over risk factors was: hypertension 33.8%, cholesterol-LDL 40.8% and diabetes 50.7%. There were no differences between type of hospital or type of outpatient consultancy. CONCLUSIONS Over 90% of patients treated in outpatient consultancies of Internal Medicine departments present vascular risk factors, regardless of the type of hospital or type of consulting room. Risk factors control was poor.

Clinical Effects of Torasemide Prolonged Release in Mild-to-Moderate Hypertension: A Randomized Noninferiority Trial Versus Torasemide Immediate Release

The efficacy of a new torasemide prolonged release (PR) formulation to torasemide immediate release (IR) was compared in a randomized noninferiority double-blind trial. Patients with newly diagnosed mild-to-moderate hypertension or unresponsive or poor tolerability to previous antihypertensive monotherapy received 5 mg/day of torasemide-PR (n = 219) or torasemide-IR (n = 223) for 12 weeks (uptitration to 10 mg/day if no response at 4 or 8 weeks). Mean diastolic blood pressure (DBP) reduction in the torasemide-PR group (11.6 +/- 7.1 mmHg, 95% confidence interval [CI] 10.6-12.5) versus torasemide-IR (11.3 +/- 7.5 mmHg, 95% CI 10.2-12.3) met the noninferiority criterion of a nonsided 97.5% CI lower than the preestablished margin of 2 mmHg. A significantly higher percentage of patients in the torasemide-PR group achieved adequate BP control after 8 and 12 weeks. Ambulatory 24-h BP monitoring (ABPM) measurements in a subset of 100 patients showed greater daytime SBP reductions in the torasemide-PR group (128.4 +/- 9.9 mmHg vs. 133.5 +/- 10.4 mmHg, P < 0.05). Safety and tolerability of both formulations were similar.