J. M. Mallion

Blood pressure levels, risk factors and antihypertensive treatments: lessons from the SHEAF study

Objectives: The SHEAF study (Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-up) is a 3-year prospective cohort study of French elderly (⩾60 years) hypertensive patients designed to assess whether home blood pressure (HBP) measurement provides additional prognostic information over office blood pressure (OBP) in terms of cardiovascular mortality and morbidity. The objective of the present work is to describe the baseline data of the population enrolled in the SHEAF study with special emphasis on blood pressure control in treated hypertensives.Methods:During the 2-week initial inclusion phase, baseline demographics, cardiovascular risk factors, antihypertensive treatments as well as office and home blood pressure were recorded. Baseline OBP was assessed using a mercury sphygmomanometer (three consecutive measurements during two visits performed 2 weeks apart). HBP was performed over a 4-day period (three consecutive measurements in the morning and in the evening).Results:A total of 4939 (95%) of the 5211 patients included in the SHEAF study were treated with at least one antihypertensive drug. Their ages ranged from 60 to 99 years (mean age 70 ± 7 years); 49% were men, 12% had a previous history of coronary artery disease, 14% diabetes and 43% a treated dyslipidaemia. A total of 45% of the treated patients received a single antihypertensive drug, 34% two drugs, 21% three drugs or more. Overall 23% of treated hypertensives were normalised at the doctor’s office (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) and 27% at home (home systolic BP <135 mm Hg and home diastolic BP <85 mm Hg). Poor blood pressure control was associated with age, an increasing presence of diabetes and prescription of several antihypertensives. The proportion of subjects with controlled blood pressure decrease with age from 26% (60–69 years) to 21% (⩾80 years). Blood pressure control of diabetic patients was particularly poor as only 19% had an OBP <140/90 mm Hg and 6% a blood pressure <130/85 mm Hg. The percentage of patients with controlled OBP decreased from 26% when receiving a single antihypertensive drug to 11% when receiving four antihypertensives or more.Conclusion: In the SHEAF study, less than one-third of the patients had an OBP adequately controlled thus confirming previous studies performed in younger populations. Presence of associated cardiovascular risk factors including diabetes did not give rise to a better blood pressure control. When blood pressure control was assessed using HBP measurement similar results were found. As the beneficial effect of antihypertensive treatment has been particularly well established in the elderly, the data of this study underlines the need for a closer and more rigorous management of elderly hypertensives.

Stenting of a renal artery compressed by the diaphragm

A 74-year-old man had a resistant hypertension with an increase in plasma aldosterone and active plasma renin levels, and an irregular appearance of the left kidney outline by ultrasound. The CT scan showed a stenosis of the left renal artery, which was pushed against the aorta by the left crus of the diaphragm. An angioplasty with placement of an autoexpansible stent was carried out with a good result on the arterial pressure level. After 3 years, the patient was re-hospitalised with severe hypertension. The CT scan demonstrated a compression of the stent by the left crus of the diaphragm, with good permeability of the artery downstream from the stent, and radiographic examination showed a fracture of the left renal artery stent. Thus, a reimplantation of the left renal artery in the aorta was carried out. Stenosis of the renal artery by fibres from a crus of the diaphragm is a rare cause of renovascular hypertension. Helicoidal angioscanner imaging is particularly useful to do the diagnosis. In the present case, renal angioplasty with stenting was complicated by a fracture of the stent that led to the surgery. Thus, when renal artery stenosis by a crus of the diaphragm is diagnosed, surgical treatment needs to be considered on a case-by-case basis in relation to the anatomy and the biological and functional data.

Relationship between short-term and long-term blood pressure variabilities in essential hypertensives.

This study was designed to analyse the relationship between the different blood pressure (BP) variabilities obtained in a non-invasive way and to determine the potential contribution of aging, severity of hypertension and increased ventricular mass to these different BP variabilities. Two hundred and six hypertensive patients underwent a 24-h ambulatory BP measurement (ABPM) as well as a photoplethysmographic BP recording and a standard echocardiography. Nocturnal BP fall and standard deviations of hourly mean BP levels as well as post-prandial fall in BP were calculated from the 24-h ABPM and were considered as indexes of long-term variability. Baroreflex sensitivity (BRS) and spectral powers of systolic BP, diastolic BP and heart rate (HR) over the low frequency band (LF: 0.05–0.14 Hz) were obtained from photoplethysmographic recording and were used as indexes of short-term variability. Short-term variability indexes were shown to be significantly related to those of long-term variability. A decrease in LF spectral powers was associated with a particular profile characterised by an attenuation of nocturnal BP fall, an increase of daytime BP standard deviations, an increase in post-prandial BP fall, a decrease in BRS and to a lesser extent, a diminution in night-time HR standard deviation. Moreover, a negative significant relationship was found between standard deviation of daytime systolic BP and both night systolic BP fall and BRS. Age and nocturnal BP level were associated with all BP variability disorders, whereas left ventricular hypertrophy was associated only with a decrease in LF spectral powers and in night BP fall, and an increase in standard deviation of daytime BP. Finally, LF spectral power of SBP was identified as independently predicted by age and night SBP fall.

Isolated systolic hypertension: data on a cohort of young subjects from a French working population (IHPAF).

Elderly patients with isolated systolic hypertension (ISH)—systolic blood pressure (SBP) ⩾140 mmHg and diastolic blood pressure (DBP) <90 mmHg—have increased mortality and morbidity. The aim was to study the incidence of ISH in a younger population of between 15 and 60 years of age, and to measure pulse pressure (PP), mean arterial pressure (MAP) and heart rate (HR) in these subjects. The study population consisted of 27 783 subjects, aged 15–60 years, untreated for hypertension (HT) from a cohort of employees formed to study the incidence of HT in the French working population (AIHFP). BP and HR were measured with a validated, automatic device after 5, 6 and 7 min at rest. The prevalence of ISH was 6.9% in men, 2.3% in women. This prevalence was over 5% in young men and increased at 40–44 years; it was negligible in young women, but increased at 50–54 years to about 10% (ie to the same level as in men of the same age): PP in subjects with ISH (46.9 mmHg) was significantly higher than in the normotensive group (NT—40.9 mmHg); it was comparable in both young men (65.5 mmHg) and older men (66 mmHg); it was higher in men (63.1 mmHg) than in women (61.5 mmHg). HR was higher in ISH than in NT and it was higher in women (≈5 bpm) in whom it decreased with age. The prevalence of ISH is not negligible in HT (30% men, 25% women), with a high prevalence in young subjects and elevated PP, MAP and HR values. These data should be taken into account as elevated ISH, PP and HR are considered as cardio-vascular risk factors.

Conséquences cardiovasculaires du syndrome d’apnées obstructives du sommeil

Resume Propos. – Cet article fait le point sur les donnees passees et actuelles des relations existantes entre syndrome d’apnees obstructives du sommeil et maladies cardiovasculaires. Actualites et points forts. – Le syndrome d’apnees obstructives du sommeil est une pathologie frequente mais sous-estimee qui ne se resume pas a l’association ronflements et obesite. Il est evoque par l’interrogatoire mais son diagnostic de certitude est obtenu par la polysomnographie. De nombreuses etudes ont retrouve des relations significatives entre la presence d’un syndrome d’apnees obstructives du sommeil et la survenue d’evenements cardiovasculaires. Cependant, le lien de causalite n’est etabli de facon formelle que pour l’hypertension arterielle. Les stimuli a l’origine de la reponse cardiovasculaire, aigue et chronique, sont multiples. Les mecanismes physiopathologiques pouvant expliquer l’association morbide entre syndrome d’apnees obstructives du sommeil et maladies cardiovasculaires sont egalement nombreux, en premier lieu l’hyperactivite sympathique. Le pronostic vital de cette pathologie est etroitement lie a la survenue d’accidents cardiovasculaires. Perspectives et projets. – L’existence d’une relation independante entre syndrome d’apnees obstructives du sommeil et atherosclerose n’est pas demontree. L’effet benefique de la pression positive continue nocturne, traitement de reference du syndrome d’apnees obstructives du sommeil, sur l’incidence des maladies cardiovasculaires reste egalement a etablir malgre les resultats des etudes recentes qui suggerent que la prise en charge du syndrome d’apnees obstructives du sommeil par cette therapeutique est a meme de reduire le risque cardiovasculaire, en particulier d’hypertension arterielle.

Metastatic phaeochromocytoma: risks of diagnostic needle puncture and treatment by arterial embolisation.

A 62-year-old man had an acute episode of hypertension 72 h after fine needle aspiration biopsy of an intra- hepatic nodule. The patient had been operated 3 years previously for a right adrenal phaeochromocytoma with no evidence of metastases at that time. Thus, a relapse of the tumour was postulated and confirmed by raised levels of urinary metanephrines. The extent of the metastases precluded surgical intervention and thus localised embolisation was proposed and permitted a clinical stabilisation over 8 months. This case indicates the necessity of long-term post-operative follow-up of phaeochromocytoma as well as the dangers of fine needle aspiration biopsy of metastases from this kind of tumour. Treatment of malignant phaeochromocytoma is difficult and embolisation was a useful therapeutic alternative in this case where the metastases were well defined.

Diagnostic and prognostic value of exercise testing.

Summary: Measuring blood pressure during exercise under a standard protocol could be a useful diagnostic method in high‐risk patients and in borderline hypertensive subjects. It may also serve as an adapted test for hypertensive subjects undergoing physical activity at work or at leisure time with a particular cardiovascular work load. It can be used as a method of assessment to confirm the efficacy of an antihypertensive drug, and for prognostic evaluation of cardiovascular risk in terms of morbidity and mortality. An exercise blood pressure profile does not provide information about blood pressure during activities of daily living. For this purpose, ambulatory blood pressure measurement appears to be more relevant. Résumé: La mesure de la pression artérielle à l’effort dans le cadre d’un protocole standardisé apparait être un examen complémentaire important lors de l’étude de certains sujets: sur le plan diagnostique chez les sujets à “haut risque” et les hypertendus limites; sur un plan d’aptitude et d’orientation, chez les sujets hypertendus dont les activités professionnelles ou extra‐professionnelles impliquent une contrainte cardiovasculaire importante; sur un plan thérapeutique pour affirmer l’efficacité d’un médicament; et sur un plan pronostique, pour anticiper les facteurs de risque en terme de morbidité et de mortalité. Encore faut‐il bien réaliser que ces tests d’effort ne permettent pas d’apprécier les contraintes de la vie quotidienne, leur type, leur intensité et leur durée. C’est dans ce cadre que des mesures en ambulatoire paraissent se justifier.

Second-generation calcium antagonists and ambulatory blood pressure monitoring.

Ambulatory blood pressure monitoring (ABPM) is a particularly useful method for evaluating the effects of antihypertensive drugs. ABPM allows the therapeutic effect of an agent to be assessed continually by a large number of measurements, and the greater number of readings contributes to the higher degree of reproducibility associated with ABPM compared to other methods for measuring blood pressure. ABPM also enable measurements to be taken in “real-life” situations and removes the problem of observer bias. The number of patients required for clinical studies can be significantly reduced by using ABPM. It is still essential, however, to identify “white coat” subjects, placebo responders, and patients who do not respond to the treatment. ABPM studies have demonstrated that the novel dihydropyridine calcium antagonist, lacidipine, significantly reduces both systolic and diastolic blood pressures over a 24-h period, both during the day and at night. Furthermore, although the trough-to-peak ratios of many calcium antagonists have been shown to fall below the recommended level of 50%, lacidipine has a ratio above 60%. Other ABPM studies have also shown that lacidipine can correct the ‘early morning increase’ in blood pressure without effecting the 24-h nyethemeral profile.

Non-invasive assessment of cardiac anatomy and blood pressure in patients with borderline hypertension

Extensive non-invasive evaluation of cardiac function and blood pressure was performed in 26 subjects with borderline hypertension. The degree of cardiac hypertrophy was assessed in these subjects using echocardiographic techniques. Blood pressure and its variability were measured using a 24-hour ambulatory monitoring technique and blood pressure measurements obtained during exercise testing.

Cardiac and vascular remodelling: effect of antihypertensive agents.

The 1996 World Health Organization (WHO) recommendations for mild hypertension stressed the need to evaluate target-organ lesions as treatment criteria. The effects of both vascular and heart remodelling on hypertension must to be taken into account, as they adversely influence the prognosis of patients with hypertension. It was previously demonstrated that at least three classes of antihypertensive agents were able to decrease morbidity and mortality in patients with hypertension. Meta-analyses have shown that angiotensin-converting enzyme inhibitors seem to have a marked effect on regression of left ventricular hypertrophy (LVH). However, the relationship between drug-induced LVH regression and reduced morbidity and mortality remains to be confirmed. The effect of antihypertensive agents on vascular hypertrophy, as assessed by intima-media thickness, and their involvement in reducing morbid events, also have to be determined at the vascular level. As experimental data have highlighted the involvement of angiotensin II in animal models of LVH and vascular hypertrophy development, the role of angiotensin II AT1 receptor blockers should also be assessed in this indication.