Fernando Pinto

Prevalence, awareness, treatment and control of hypertension and salt intake in Portugal: changes over a decade. The PHYSA study.

Objective: To determine prevalence, awareness, treatment and control of hypertension and the 24-h sodium excretion (24h-UNa) in the Portuguese adult population and to examine their changes from a similar study done in 2003. Design and setting: A population-based cross-sectional survey conducted in 2011–2012. Methods: A multistage-stratified (by age and sex) sampling method was used to select a representative sample of the 18–90-year-old population yielding 3720 participants (52.6% women, 97.1% Caucasians). Hypertension was defined as a SBP of at least 140 mmHg or DBP of at least 90 mmHg [average of 2–3 blood pressure (BP) measurements by trained observers with OMRON M6] or reported knowledge or treatment with antihypertensive drugs at the first visit (V1). A complete clinical information was obtained with a standard questionnaire. This procedure was repeated 10–15 days after visit 2 (V2) and 24-h urinary sample was collected for 24h-UNa, 24-h potassium excretion and creatinine excretion. Results: The overall prevalence of hypertension at V1 was 42.2% (44.4% in men, 40.2% in women) (42.1% in 2003). The age-specific prevalence of hypertension was 6.8, 46.9 and 74.9% in people below 35 years, 35–64 years and above 64 years. Comorbidities were 2.2–6.3 times more common in hypertensive patients vs. normotensive individuals. Overall, among the hypertensive patients, 76.6% were aware of the hypertension condition, 74.9% were treated and 42.5% were controlled (BP <140/90 mmHg), that is, respectively, 1.7, 1.9 and 3.8 times higher vs. data in 2003, with lower values in men vs. women and younger vs. older people. Global mean BP was 127.4/74.6 ± 17.7/10.5 vs. 134.7/80.4 ± 21.2/14.1 mmHg in 2003. From V1 to V2, control of hypertension increased on average by 14.8%. Multivariate analysis showed that age and BMI were independently associated with prevalence of hypertension. 24h-UNa (84% valid urinary samples) was 182.5 ± 64.7 mmol/day (10.7 g salt/day) and 24-h potassium excretion 75.2 ± 26.1 mmol/day. 24h-UNa was higher in patients with hypertension than in normotensive individuals (185.4 ± 64.8 vs. 177.8 ± 64.5 mmol/day; P < 0.02) and correlated with SBP (r = 0.05), age (r = 0.08) and BMI (r = 0.10) (P < 0.01). Conclusion: Hypertension prevalence among Portuguese adults remained stable in the past decade, but proportions of awareness, treatment and control of hypertension improved significantly. Salt intake is still high being almost double the WHO recommendations.

Blood pressure and low-density lipoprotein-cholesterol lowering for prevention of strokes and cognitive decline: a review of available trial evidence.

Background and objectives: It is well established by a large number of randomized controlled trials that lowering blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) by drugs are powerful means to reduce stroke incidence, but the optimal BP and LDL-C levels to be achieved are largely uncertain. Concerning BP targets, two hypotheses are being confronted: first, the lower the BP, the better the treatment outcome, and second, the hypothesis that too low BP values are accompanied by a lower benefit and even higher risk. It is also unknown whether BP lowering and LDL-C lowering have additive beneficial effects for the primary and secondary prevention of stroke, and whether these treatments can prevent cognitive decline after stroke. Results: A review of existing data from randomized controlled trials confirms that solid evidence on optimal BP and LDL-C targets is missing, possible interactions between BP and LDL-C lowering treatments have never been directly investigated, and evidence in favour of a beneficial effect of BP or LDL-C lowering on cognitive decline is, at best, very weak. Conclusion: A new, large randomized controlled trial is needed to determine the optimal level of BP and LDL-C for the prevention of recurrent stroke and cognitive decline.

Continuation of the ESH-CHL-SHOT trial after publication of the SPRINT: rationale for further study on blood pressure targets of antihypertensive treatment after stroke.

Alberto Zanchetti, Lisheng Liu, Giuseppe Mancia, Gianfranco Parati, Guido Grassi, Marco Stramba-Badiale, Vincenzo Silani, Grzegorz Bilo, Giovanni Corrao, Antonella Zambon, Lorenza Scotti, Xinhua Zhang, Ting Rui Guan, Yuqing Zhang, Xuezhong Zhang, Eivind Berge, Josep Redon, Krzysztof Narkiewicz, Anna Dominiczak, Peter Nilsson, Margus Viigimaa, Stéphane Laurent, Enrico Agabiti-Rosei, Zhaosu Wu, Dingliang Zhu, José Luis Rodicio, Luis Miguel Ruilope, Nieves Martell-Claros, Fernando Pinto Roland E. Schmieder, Michel Burnier, Maciej Banach, Renata Cifkova, Csaba Farsang, Alexandra Konradi, Irina Lazareva, Yuriy Sirenko, Maria Dorobantu, Arman Postadzhiyan, Rok Accetto, Bojan Jelakovic, Dragan Lovic, Athanasios J. Manolis, Philippos Stylianou, Dror Dicker, Gangzhi Wei, Chengbin Xu, Hengge Xie, Antonio Coca, John O’Brien, Gary Ford, on behalf of the ESH-CHL-SHOT trial investigators

Estimation of populational 24-h urinary sodium and potassium excretion from spot urine samples: evaluation of four formulas in a large national representative population.

Objective: The aim of this study was to assess the validity of the estimation of 24-h urinary sodium (UNa) and urinary potassium (UK) excretion obtained through four formulae based on occasional urine samples. Design and methods: We analysed 2399 individuals (51% females) aged 18 to 96 years representatives of Portuguese population. Tanaka, Kawasaki, INTERSALT and NHANES formulae were used to predict 24-h UNa and UK excretions from spot morning urinary samples (OUrS). We compared it with validated real 24-h urine samples (VUrS) (24-h UNa: 4052 ± 1432 mg/day, 24-h UK = 2928 ± 1004 mg/day). We compared observed vs. estimated measurements by examining bias (observed minus predicted UNa and UK), the correlation and intraclass correlation (ICC) coefficients between measurements, and Bland–Altman plots. We analysed the differences between observed and estimated Na and K excretion across subgroups defined by quintiles of observed Na and K excretion and subgroups defined hypertension status and control. The area under the ROC curve was used to assess the discriminatory capacity of formulas between high-intake salt individuals from low-intake individuals, taking the arbitrary values 3000 and 3900 mg/day for, respectively, Na and K intake. Results: Formulas produced significant mean bias for UNa: Kawasaki−1277, INTERSALT−569, NHANES−116 and for UK Tanaka−754, Kawasaki−95 mg/day. Correlation coefficients were less than 0.360 and ICC coefficients were all less than 0.458 for both UNa and UK estimations. Bias varied across quintiles with overestimation of UNa at lower quintiles (by 29–105%) and underestimation at higher quintile (by 7–37%) regardless of formula. The Bland–Altman plots indicated a high dispersion of the estimates biases regardless of the formulae and normotension/hypertension condition particularly at higher levels. All formulas exhibited an area under the receiver operating characteristic curve below 0.67 both in normotensive individuals and hypertensive individuals. Conclusion: We found a poor agreement between estimated and observed measurements of UNa and UK in our large population. All these formulas incur in over- or underestimations of UNa and UK excretion that may be unreliable for clinical evaluation of individuals and mean population daily UNa and UK excretion.

[PP.29.11] ASSOCIATION OF SODIUM-POTASSIUM INTAKE RATIO WITH THE INCIDENCE OF STROKE EVENTS IN A POPULATION UNDER THE AGE OF 65 YEARS IN FIVE DIFFERENT REGIONS OF PORTUGAL

Objective: Portugal has one of the highest rate of stoke mortality in Europe along with a high level of salt intake. High sodium intake has been associated with hypertension (HT) and with stroke mortality whereas potassium intake been considered as a protector factor. Our aim was to examine the relationship between sodium/potassium intake ratio (Na/K-R) with the occurrence of hospitalized cerebrovascular events (CE) in five regions of Portugal in subjects under the age of 65 years. Design and method: In 2010–2011 sodium (NaU) and potassium (KU) excretion and Na/K-R were measured in 24 h validated (by urinary creatinine) urinary collections in a representative sample of the adult population of five health regions of the country. In the same period records of CE in subjects under the age of 65 were obtained for each region from a national hospitalisation database from mainland Portuguese public hospitals statistic provided by Authority for Health Services of PMH (ACSS). CE were expressed by 100000 habitants in agreement with national population census 2011. Results: Valid urinary samples were obtained in 2004 subjects < 65yrs. Average NaU was 180 + 65 mmol/d, KU 75 + 26 mmol/d and excretion Na/K-R 2.53 + 0.93 (range within 5 regions 2.46–2.71, ANOVA p = 0.042). Prevalence of HT was 33.2% (range within 5 regions 30.6–44.8%, Chi-square p = 0.009). CE were 86.7/100000 (83% ischemic, range within 5 regions 77.6–98.2). Using the data from all 5 regions, Na/K-R correlated with CE (r = 0.903, p = 0.036) after adjustment for BP. Correlation was similar and still significant for women and men in separate. In average, each increase of Na/K-R by 0.1 corresponded to an increased incidence of 8,9 CE per 100000 inhabitants per year. Prevalence of HT also appear to be associated with CE but such a tendency was not significant. Conclusions: In adult subjects under 65 years, the increase of sodium/potassium ratio is associated with an increased incidence of hospitalized cerebrovascular events. This reinforces the importance of salt restriction and potassium supplementation in middle age subjects for the prevention of cardiovascular events.

[OP.8E.01] HIGH SALT INTAKE POTENTIATES THE RELATION BETWEEN BLOOD PRESSURE AND ALBUMINURIA

Objective: It is still disputable whether high salt intake is associated with cardiovascular/renal damage independently of blood pressure (BP) levels. We evaluated whether high salt intake could potentiate the relation between BP and albuminuria. Design and method: In a representative sample (n = 3720) of the Portuguese adult population (PHYSA Study) we evaluated BP in 2 different occasions, and 24 h sodium excretion (UNa+, mmol/day) and 24 h albuminuria excretion (log of mg/24 h) both in 24 h urinary samples validated by urinary creatinine. We evaluated the relation between BP and albuminuria for all and for each of the 4 quartiles of UNa+ distribution just in subjects NOT treated with modulators of the renin angiotensin system. Results: We evaluate 2004 subjects, 51,5 % female, ageing 47 + 16 yrs. BMI 27 + 15 Kg/m2). Systolic BP (SBP, average 127 + 16 mmHg) correlated with log of albuminuria (average log 0.79 + 0.36 mg/24 h) (r = 1.05 p < 0.02). Quartiles of UNa + did not differ for age, gender distribution and BMI. From the quartil with the lower UNa + values Q1 = 111 + 20 mmol/d to the subsequent quartiles Q2 = 143 + 12; Q3 = 183 + 13 and Q4 = 260 + 49 mmol/d with the highest values, these was a significant increase of SBP in Q1 = 123 + 16; Q2 = 124 + 15; Q3 126 + 14 and Q4 127 + 15 mmHg (p < 0.03, ANOVA) and of Log of albuminuria: Q1 = 0.68 + 0.29; Q2 = 0.72 + 0.28; Q3 = 0.82 + 0.34 and Q4 = 0.95 + 0.42 (p < 0.01, ANOVA). For similar SBP within the range of mean + 1SD (110–140 mmHg, n = 1341) albuminuria significantly (p < 0.001) progressively increased from Q1 (0.67 + 0.28) to Q4 (0.95 + 0.45) with a regression line between SBP and albuminuria becoming progressively steeper. Conclusions: Our data suggest that high salt intake potentiates the effect of pressure on the rise of urinary albumin excretion, suggesting a deleterious effect of high salt on the vascular and renal homeostasis partially independent of blood pressure.

O perfil circadiário de descida noturna da pressão arterial na MAPA é realmente importante na prática clínica diária

Cardiovascular disease is the leading cause of morbidity and mortality worldwide and hypertension is one of its main risk factors. Measurement of blood pressure (BP) is central to the diagnosis, treatment and follow-up of hypertension, and so a reliable and accurate method of measuring BP is vital. The development of the first sphygmomanometers by Riva-Rocci and the standardization of Korotkoff’s auscultatory method in the early 20th century formed the basis of the techniques of office BP measurement, the importance of which in the Framingham studies contributed greatly to the widespread use of this valuable parameter in daily clinical practice. This technique, now over a hundred years old, is by far the most common both in clinical practice and in research, particularly epidemiological studies. The realization that BP is a hemodynamic variable influenced by multiple factors, including exertion, emotional state, food intake, smoking and weather conditions, confirmed by invasive intra-arterial BP measurements, led to a search for ways to monitor this variable non-invasively.

Estimation of the predictive value for hypertension of different indices of obesity in the scope of a national representative survey of hypertension (PHYSA)

reach an optimal BP control and reduce cardiovascular complications. However, to date, it would seem that the results are unsatisfactory in this regard. Purpose of the study: The purpose of this paper is to conduct a meta-analysis of different reports to clarify the compliance of hypertensive pts to therapy. Material and methods: This meta-analysis study was conducted by random sampling of different studies by using Medline, PubMed and EMBASE to determine the compliance of hypertensive pts to antihypertensive therapy. 10 cohort and case-control studies, part of them conducted retrospectively, included a total of 13,653 pts from year 1996 to the year 2010. The degree of compliance of different therapies was recorded and classified as unsatisfactory when it was less than 80% and good or optimal when values 1⁄4> 80% were observed. Results: Compliance to therapy varied from 25% to 85% with a mean of 53% and median value of 50. Higher compliance was seen only in 2 studies, respectively 80% and 85%, concerning, paradoxically, elderly pts who were more compliant than the younger. Mean systolic and diastolic BP were significantly lower in the compliant pts than in the noncompliant group with a mean reduction respectively of 18 mmHg vs 9 mmHg for systolic BP (P<0.01) and of 8.3 mmHg vs 4.1 mmHg for diastolic BP (P<0.01). Both estimates were statistically significant. Conclusions: An unsatisfactory compliance with antihypertensive therapy characterizes a large majority of hypertensive pts. Metaphorically speaking, hypertensive pts should make a tie a knot to keep in mind the proper intake of antihypertensive drugs and, therefore, improve the control of their BP.

Estimation of 24-hour sodium, potassium and albumin excretion from spot urine samples in a national representative survey of hypertension (PHYSA)

reach an optimal BP control and reduce cardiovascular complications. However, to date, it would seem that the results are unsatisfactory in this regard. Purpose of the study: The purpose of this paper is to conduct a meta-analysis of different reports to clarify the compliance of hypertensive pts to therapy. Material and methods: This meta-analysis study was conducted by random sampling of different studies by using Medline, PubMed and EMBASE to determine the compliance of hypertensive pts to antihypertensive therapy. 10 cohort and case-control studies, part of them conducted retrospectively, included a total of 13,653 pts from year 1996 to the year 2010. The degree of compliance of different therapies was recorded and classified as unsatisfactory when it was less than 80% and good or optimal when values 1⁄4> 80% were observed. Results: Compliance to therapy varied from 25% to 85% with a mean of 53% and median value of 50. Higher compliance was seen only in 2 studies, respectively 80% and 85%, concerning, paradoxically, elderly pts who were more compliant than the younger. Mean systolic and diastolic BP were significantly lower in the compliant pts than in the noncompliant group with a mean reduction respectively of 18 mmHg vs 9 mmHg for systolic BP (P<0.01) and of 8.3 mmHg vs 4.1 mmHg for diastolic BP (P<0.01). Both estimates were statistically significant. Conclusions: An unsatisfactory compliance with antihypertensive therapy characterizes a large majority of hypertensive pts. Metaphorically speaking, hypertensive pts should make a tie a knot to keep in mind the proper intake of antihypertensive drugs and, therefore, improve the control of their BP.