J. Carel Bakx

Development of blood pressure and the incidence of hypertension in men and women over an 18-year period: results of the Nijmegen cohort study

The objective of this study was to determine the factors that influence diastolic blood pressure (DBP) and the incidence of hypertension. In 1977, DBP and cardiovascular risk factors were measured in 7092 men and women. In 1995, 2335 subjects participated at a second screening. Those patients already under hypertension treatment in 1977 were excluded. The DBP tracking was studied in subjects not under hypertension treatment during the study. Hypertension was defined on two ways in the analysis: under current hypertension treatment or a DBP > 95 mmHg measured at rescreening in 1995. Forty-seven percent of the subjects with a DBP < 75 mmHg in 1977 remained in the same category of DBP in 1995, and 7% had become hypertensive. Of the 75-84 mmHg group in 1977, 40% stayed in the same category in 1995 and 15% became hypertensive. Of the 85-94 mmHg category, 30% stayed in the same category and 30% became hypertensive in 1995. Of the highest category in 1977 (> 95 mmHg), 64% were still in that category in 1995. Baseline DBP in 1977 had the highest predictive value for future DBP. Weight gain over the years increased the risk for future hypertension: in contrast, there was no risk at a low DBP without weight gain. There is no need for regular check-ups for those patients with a low DBP who experience no weight gain. Borderline DBP (85-95 mmHg), together with weight gain, increases the risk of development of hypertension. The risk was especially high for men in the lower socioeconomic class.

Non-cardiovascular co-morbidity in elderly patients with heart failure outnumbers cardiovascular co-morbidity.

Patients with heart failure often suffer from multiple co‐morbid conditions. However, until now only cardiovascular co‐morbidity has been well described.

A Novel Approach to Office Blood Pressure Measurement: 30-Minute Office Blood Pressure vs Daytime Ambulatory Blood Pressure

PURPOSE Current office blood pressure measurement (OBPM) is often not executed according to guidelines and cannot prevent the white-coat effect. Serial, automated, oscillometric OBPM has the potential to overcome both these problems. We therefore developed a 30-minute OBPM method that we compared with daytime ambulatory blood pressure. METHODS Patients referred to a primary care diagnostic center for 24-hour ambulatory blood pressure monitoring (ABPM) had their blood pressure measured using the same validated ABPM device for both ABPM and 30-minute OBPMs. During 30-minute OBPM, blood pressure was measured automatically every 5 minutes with the patient sitting alone in a quiet room. The mean 30-minute OBPM (based on t = 5 to t = 30 minutes) was compared with mean daytime ABPM using paired t tests and the approach described by Bland and Altman on method comparison. RESULTS We analyzed data from 84 patients (mean age 57 years; 61% female). Systolic and diastolic blood pressures differed from 0 to 2 mm Hg (95% confidence interval, −2 to 2 mm Hg and from 0 to 3 mm Hg) between mean 30-minute OBPM and daytime ABPM, respectively. The limits of agreement were between −19 and 19 mm Hg for systolic and −10 and 13 mm Hg for diastolic blood pressures. Both 30-minute OBPM and daytime ABPM classified normotension, white-coat hypertension, masked hypertension, and sustained hypertension equally. CONCLUSIONS The 30-minute OBPM appears to agree well with daytime ABPM and has the potential to detect white-coat and masked hypertension. This finding makes 30-minute OBPM a promising new method to determine blood pressure during diagnosis and follow-up of patients with elevated blood pressures.

Study Heterogeneity and Estimation of Prevalence of Primary Aldosteronism: A Systematic Review and Meta-Regression Analysis.

CONTEXT For health care planning and allocation of resources, realistic estimation of the prevalence of primary aldosteronism is necessary. Reported prevalences of primary aldosteronism are highly variable, possibly due to study heterogeneity. OBJECTIVE Our objective was to identify and explain heterogeneity in studies that aimed to establish the prevalence of primary aldosteronism in hypertensive patients. DATA SOURCES PubMed, EMBASE, Web of Science, Cochrane Library, and reference lists from January 1, 1990, to January 31, 2015, were used as data sources. STUDY SELECTION Description of an adult hypertensive patient population with confirmed diagnosis of primary aldosteronism was included in this study. DATA EXTRACTION Dual extraction and quality assessment were the forms of data extraction. DATA SYNTHESIS Thirty-nine studies provided data on 42 510 patients (nine studies, 5896 patients from primary care). Prevalence estimates varied from 3.2% to 12.7% in primary care and from 1% to 29.8% in referral centers. Heterogeneity was too high to establish point estimates (I(2) = 57.6% in primary care; 97.1% in referral centers). Meta-regression analysis showed higher prevalences in studies 1) published after 2000, 2) from Australia, 3) aimed at assessing prevalence of secondary hypertension, 4) that were retrospective, 5) that selected consecutive patients, and 6) not using a screening test. All studies had minor or major flaws. CONCLUSIONS This study demonstrates that it is pointless to claim low or high prevalence of primary aldosteronism based on published reports. Because of the significant impact of a diagnosis of primary aldosteronism on health care resources and the necessary facilities, our findings urge for a prevalence study whose design takes into account the factors identified in the meta-regression analysis.

Stage-Matched Nutrition Guidance: Stages of Change and Fat Consumption in Dutch Patients at Elevated Cardiovascular Risk

OBJECTIVE To assess the effects of stage-matched nutrition counseling on stages of change and fat intake. DESIGN Controlled clinical trial. SETTING 9 family practices in a family medicine practice network. PARTICIPANTS 143 patients at elevated cardiovascular risk, aged 40 to 70 years. INTERVENTION Intervention patients received stage-matched counseling from their family physician and a dietitian. Control patients received usual care. MAIN OUTCOME MEASURES Stages of change and fat intake were measured at baseline and after 6 and 12 months. ANALYSIS Chi-squared tests, t tests, and regression analyses (alpha = .05) were conducted. RESULTS More patients in the intervention group than in the control group were in the postpreparation stage after 6 months (70% vs 35%; P < .01) but not after 12 months (70% vs 55%; P = .10). Between 0 and 12 months, the reduction in total fat intake (-5.6% kcal vs -2.4% kcal) was largest in the intervention group. CONCLUSIONS AND IMPLICATIONS Stage-matched nutrition counseling promotes movement through stages of change, resulting in a reduced fat intake. Our results partly support stages of change as a tool for behavior change. Movement across stages of change was not an intermediating factor in the intervention effects. Research should focus on feasible ways to keep patients in the postpreparation stage.

Current treatment of chronic heart failure in primary care; still room for improvement

UNLABELLED RATIONAL AND AIMS: In recent years, guidelines for treatment of patients with chronic heart failure (CHF) have been updated. Insight in current pharmacological and non-pharmacological treatment of CHF in primary care, which was non-optimal in earlier studies, is limited. We aim to describe current pharmacological and non-pharmacological treatment of CHF in primary care. METHODS In this cross-sectional observational study, we included a representative sample of 357 patients diagnosed with CHF from 42 primary care practices in the Netherlands. We combined medical record data with data from patient and doctor questionnaires. RESULTS Mean age of patients was 75.7 years (SD 10.2), 53% were male, and 73% of patients had mild heart failure (New York Heart Association class I or II). 76.5% of patients received diuretics. Angiotensin-converting enzyme inhibitors were prescribed in 40.6% and angiotensin-II receptor blockers in 20.7%; beta-blockers were prescribed to 54.6%, while 24.9% received spironolactone. Patients with more severe heart failure had a lower probability of being treated according to guideline recommendations. Relevant lifestyle advice was given to 40-60% of the patients, depending on the specific lifestyle advice. CONCLUSIONS Implementation of evidence-based pharmacotherapy for heart failure in primary care has improved since clinical guidelines have been updated; especially with respect to prescription of beta-blockers. However, there still seems ample room for improvement, as in the case for providing lifestyle advice.

Self monitoring of high blood pressure

Doing it in the practices waiting room may be better than doing it at home

Body Position and Quality of Sleep Interfere With Day-Night Blood Pressure Dip

We read with interest the study of Verdecchia et al1 on the prognostic significance of the day-night blood pressure (BP) dip and the early morning BP surge. The authors rightfully question the contradicting results of previous reports, suggesting that the early morning BP surge is a risk factor for cardiovascular events, whereas other studies demonstrate that nondipping (and, as such, a lack of surge) is a relevant cardiovascular risk factor.2 The current findings add to the controversy but put more weight on the scale against the …