L. M. Ruilope

Prospective comparison of therapeutical attitudes in hypertensive type 2 diabetic patients uncontrolled on monotherapy. A randomized trial: the EDICTA study.

OBJECTIVE To compare the anti-hypertensive effect of combination therapy versus a single drug regimen schedule (dose-titration or switching to a different drug class) in type 2 diabetic hypertensive patients with inadequate blood pressure (BP) control on monotherapy. DESIGN Prospective, randomized, open-fashion, parallel study of two therapeutic strategies during an 8-week period. SETTING Primary care centers in Spain. PARTICIPANTS A total of 898 men and women with type 2 diabetes mellitus and hypertension, receiving antihypertensive treatment with one single drug and whose BP was > 140 and/or 90 mmHg. INTERVENTION Patients were randomized to a fixed combination therapy (verapamil 180 mg plus trandolapril 2 mg; Knoll AG, Ludwigshafen, Germany) or continued on a single drug regimen, either increasing the dose of the current drug or switching to a different drug class. MAIN OUTCOME MEASURE Absolute BP reduction in the two groups of treatment, and the percentage of normalized patients (< 140/90 mmHg) in each group. RESULTS The diastolic BP (DBP) decrease (5.6 mmHg) was significantly greater in patients treated with combination therapy, compared to patients on monotherapy (2.9 mmHg). The decrease in systolic BP (SBP) was not significantly different (11.1 versus 10.0 mmHg). In addition, a significantly higher number of patients treated with combination therapy (82% versus 74%) reached diastolic BP normalization (< 90 mmHg). CONCLUSIONS In type 2 hypertensive patients with uncontrolled BP despite anti-hypertensive monotherapy, the change to combination therapy was more effective in attaining DBP control than any monotherapy schedule (either increasing the dose or switching to another different drug class).

Resultados de la primera encuesta sobre patrones de uso e interés por las nuevas tecnologías de los pacientes atendidos en Unidades de Hipertensión Arterial en España

El objetivo de este trabajo fue evaluar la accesibilidad a Internet y el interes por las nuevas tecnologias de los pacientes hipertensos asistidos en las Unidades de Hipertension Arterial (HTA) espanolas. Se contacto con 75 Unidades de Hipertension de todo el territorio nacional para solicitar su colaboracion. La recogida de datos se realizo mediante una encuesta de 15 preguntas facilitada por el personal de enfermeria, o el propio medico, previamente instruidos. Las encuestas se cumplimentaron entre el 19 de noviembre y el 21 de diciembre de 2001. Se recogieron un total de 2.367 encuestas procedentes de mas del 50 % de las Unidades de HTA contactadas. El uso de Internet en el colectivo de pacientes hipertensos analizado no difiere de forma sustancial del uso de Internet en la poblacion general. Se observa un elevado interes por el uso de nuevas tecnologias como una nueva herramienta en el control de la hipertension por parte de los pacientes. Este interes se demuestra en que un 56 % de los pacientes visitaria una pagina web dedicada a pacientes hipertensos, un 50 % de los pacientes consultaria con su medico a traves de Internet (si bien unicamente el 29 % de los encuestados ha utilizado alguna vez Internet) y un 43,5 % de los pacientes estaria dispuesto a recibir mensajes de salud en su telefono movil. En los pacientes hipertensos con edades comprendidas entre los 30 y los 60 anos el uso de Internet se cifra en torno al 45 %. Considerando que es en los pacientes mas jovenes donde la implantacion de medidas sanitarias produce un mayor beneficio, parece indicado desarrollar programas informativos y formativos a traves de Internet y las nuevas tecnologias. Por tanto, cabe afirmar que existe una demanda de nuevas herramientas tecnologicas por parte del colectivo de pacientes hipertensos.

Heart rate and heart rate variability in resistant versus controlled hypertension and in true versus white-coat resistance.

Sympathetic nervous system has an important role in resistant hypertension. Heart rate (HR) is a marker of sympathetic activity, but its association with resistant hypertension has not been assessed. We aimed to evaluate differences in HR values and variability between resistant and controlled patients and between true and white-coat resistant hypertensives (RHs). We compared office and ambulatory HR, nocturnal dip and s.d. in 14 627 RHs versus 11 951 controlled patients (on ⩽3 drugs) and in 8730 true (24 h blood pressure (BP)⩾130 and/or 80 mm Hg) versus 4825 white-coat (24-h BP<130/80 mm Hg) RHs. After adjusting for age, gender, body mass index, diabetes status and beta blocker use, HR values and variability were significantly elevated in resistant versus controlled patients and in true versus white-coat RHs. In logistic regression models, after adjustment for confounders, office HR (odds ratio for each increase in tertile: 1.337; 95% confidence interval: 1.287–1.388; P<0.001), nocturnal dip (0.958; 0.918–0.999; P=0.035) and night time s.d. (1.115; 1.057–1.177; P=0.013) were all significantly associated with the presence of resistant hypertension. Moreover, night time HR (1.160; 1.065–1.265; P<0.001), nocturnal dip (0.876; 0.830–0.925; P<0.001) and 24-h s.d. (1.148; 1.092–1.207; P<0.001) were all significantly associated with true resistant hypertension. In conclusion, both increased HR and variability are associated with resistant hypertension and with true resistance. These suggest the involvement of the sympathetic nervous system in the development of resistance to antihypertensive treatment.

TRENDS IN ALBUMINURIA UNDER RENIN-ANGIOTENSIN SYSTEM SUPPRESSION: HT.3.05

Introduction: RAS suppression is considered as the therapy of choice, together with a strict BP control, to prevent the development and to impede the progression of albuminuria. Objective: We have reviewed the evolution of albuminuria in a group of 1433 patients (mean age 60.5 yr; 50.3% male), arriving in our unit as a consequence of arterial hypertension with varying degrees of associated cardiovascular risk factors. All had in common the existence of previous therapy with an ACEi or an ARB for a minimum of two years before arrival in the Unit. Results: When first seen 67.7% were normoalbuminuric (albumin-to-creatinine ratio [ACR] <10 mg/g for male, <15 mg/g for female), 11.9% exhibited high-normal values of albuminuria (ACR 10–20 mg/g for male, 15–30 mg/g for female), 16.4% were microalbuminuric (ACR 20–200 mg/g for male, 30–300 mg/g for female) and 4% had macroalbuminuria (ACR >200 mg/g for male, >300 mg/g for female). At that time measured creatinine clearance was 96.8 ± 49.6 and 54.1% had BP values below 140/90 mmHg. All of them were followed for three years during which RAS suppression was maintained, while BP control improved. At the end of follow-up, only 54.9% were normoalbuminuric, 16.1% presented high-normal albuminuria, 21.6% were microalbuminuric and 7.4% macroalbuminuric (p < 0.004). The changes were seen in non-diabetic (p < 0.005) but were more marked in diabetics with only 37.5% of patients being normoalbuminuric. Conclusions: These results indicate that albuminuria develops in the presence of chronic RAS suppression at adequate doses and progresses continuously. Long-term RAS suppression needs to be revisited in order to control this alteration.

Efecto del tratamiento antihipertensivo con irbesartán sobre el riesgo cardiovascular absoluto

El bloqueo del sistema renina-angiotensina con inhibidores de la enzima convertidora o con antagonistas de los receptores de angiotensina confiere a los pacientes con hipertension arterial (HTA), que presentan factores de riesgo asociados, lesion de organo diana o enfermedad cardiovascular, una mayor proteccion en terminos de morbimortalidad. El presente estudio tiene como objetivo evaluar el efecto de irbesartan, antagonista de los receptores de angiotensina II, sobre el riesgo cardiovascular absoluto en una cohorte de pacientes hipertensos con riesgo cardiovascular medio, alto o muy alto. Se trata de un estudio multicentrico, prospectivo, observacional en una cohorte de 1.974 pacientes (63±11 anos; 47% varones) con HTA esencial de nuevo diagnostico o no controlada con monoterapia antihipertensiva y riesgo cardiovascular entre medio y muy alto. El tratamiento con irbesartan a dosis entre 150 y 300 mg se utilizo en monoterapia o asociado a hidroclorotiazida 12,5 mg. El seguimiento clinico fue de 6 meses. Las variables evaluadas fueron el riesgo cardiovascular absoluto, medido de forma cuantitativa (algoritmo de Framingham) o cualitativa (grupos de bajo, medio, alto y muy alto riesgo segun las directrices de la OMS/Sociedad Internacional de Hipertension). El tratamiento con irbesartan promovio un descenso significativo (p = 0,0001) de la PAS (de 170,9 ± 18,4 a 138,5 ± 16,5 mmHg) y PAD (de 96,6 ± 11 a 82 ±9 mmHg). El riesgo cardiovascular absoluto medido de forma cuantitativa se redujo un 29,8% (de 12,14 ± 8 a 8,65 ± 6,2; p En conclusion, irbesartan en monoterapia o asociado a hidroclorotiazida se ha mostrado eficaz para la reduccion del riesgo cardiovascular absoluto, que se produce mediante un descenso sustancial de la presion arterial y un buen perfil de seguridad sobre los parametros bioquimicos. La capacidad de tolerancia ha sido excelente, con una tasa muy baja de reacciones adversas.

Modification over time of pulse wave velocity parallel to changes in aortic BP, as well as in 24-h ambulatory brachial BP

Arterial stiffness as assessed by carotid–femoral pulse wave velocity (cfPWV) is a marker of preclinical organ damage and a predictor of cardiovascular outcomes, independently of blood pressure (BP). However, limited evidence exists on the association between long-term variation (Δ) on aortic BP (aoBP) and ΔcfPWV. We aimed to evaluate the relationship of ΔBP with ΔcfPWV over time, as assessed by office and 24-h ambulatory peripheral BP, and aoBP. AoBP and cfPWV were evaluated in 209 hypertensive patients with either diabetes or metabolic syndrome by applanation tonometry (Sphygmocor) at baseline(b) and at 12 months of follow-up(fu). Peripheral BP was also determined by using validated oscillometric devices (office(o)-BP) and on an outpatient basis by using a validated (Spacelabs-90207) device (24-h ambulatory BP). ΔcfPWV over time was calculated as follows: ΔcfPWV=[(cfPWVfu–cfPWVb)/cfPWVb] × 100. ΔBP over time resulted from the same formula applied to BP values obtained with the three different measurement techniques. Correlations (Spearman ‘Rho’) between ΔBP and ΔcfPWV were calculated. Mean age was 62 years, 39% were female and 80% had type 2 diabetes. Baseline office brachial BP (mm Hg) was 143±20/82±12. Follow-up (12 months later) office brachial BP (mm Hg) was 136±20/79±12. ΔcfPWV correlated with ΔoSBP (Rho=0.212; P=0.002), Δ24-h SBP (Rho=0.254; P<0.001), Δdaytime SBP (Rho=0.232; P=0.001), Δnighttime SBP (Rho=0.320; P<0.001) and ΔaoSBP (Rho=0.320; P<0.001). A multiple linear regression analysis included the following independent variables: ΔoSBP, Δ24-h SBP, Δdaytime SBP, Δnighttime SBP and ΔaoSBP. ΔcfPWV was independently associated with Δ24-h SBP (β-coefficient=0.195; P=0.012) and ΔaoSBP (β-coefficient= 0.185; P=0.018). We conclude that changes in both 24-h SBP and aoSBP more accurately reflect changes in arterial stiffness than do office BP measurements.

CONCORDANCE OF BP CONTROL ASSESSED BY OFFICE BP AND BY ABPM IN A LARGE COHORT OF TREATED HYPERTENSIVES: PP.14.06

Objective: To examine the concordance of blood pressure (BP) control by means of both office measurements and ambulatory BP monitoring (ABPM), in a large cohort of treated hypertensives from the Spanish Society of Hypertension ABPM Registry. Methods: A total of 43,499 hypertensives were analyzed. Office BP control was defined when BP <140/90 mmHg. Ambulatory BP control was considered by means of 3 different criteria: daytime BP <135/85 mmHg, 24-h BP <130/80 mmHg, and nightime BP <120/70 mmHg. Clinical characteristics were compared between patients with daytime BP below or above 135/85 mmHg. Results: Office BP control was 22.7%, daytime BP control was 52.0%, 24-h BP control was 44.8%, and nighttime BP control was 39.7%. Concordant control of BP was present in 17.4%, 15.7%, and 12.9%, by the 3 different criteria. The main source of difference between office and ABPM was the proportion of patients with isolated office resistance, the proportion of which, using the 3 aforementioned criteria was 34.5%, 29.1%, and 26.8%, respectively. When compared to patients with normal ABPM values, the presence of elevated daytime BP (higher than 135/85 mmHg) was associated (p < 0.001 for all comparisons) with male gender (57.5% vs 47.7%), diabetes (25.1% vs 20.9%), smoking (17.5% vs 12.5%), left ventricular hypertrophy on EKG (11.1 vs 9.1), and chronic kidney disease (3.0% vs 2.0%). Conclusions: BP control in the treated hypertensive population by using ABPM is twice as observed by office measurements. The proportion of patients with isolated office resistance (white coat) is relatively large. Normal values of ABPM in treated patients are more frequent in women, nondiabetic, and nonsmokers subjects, as well as in those without organ damage.

IMPROVEMENT IN HYPERTENSION CONTROL AFTER A 2-YEAR PARTICIPATION IN A WEB-BASED PROGRAM ON HIGH BP MANAGEMENT: 6C.01

Objective: To examine changes in hypertension control reported by physicians participating in a web-based project for management of patients with high BP. Methods: We selected physicians participating in the Spanish Society of Hypertension ABPM Registry, each one recruiting >20 subjects both in 2005 (group 1 or G1) and 2007 (group 2 or G2) (n = 71). Data between both groups were compared. Cases with repeated ABPM were discarded. Office BP was considered as controlled when <140/90 mmHg and ambulatory BP was considered as controlled when 24-h BP <130/80 mmHg. Results: G1 and G2 included 4,158 and 3,253 patients respectively. Age (62.3 vs 62.7 years), duration of hypertension (8.3 vs 8.1 years), body mass index (29.5 vs 29.3 kg/m2), presence of at least one additional cardiovascular risk factor (91.1% vs 90.3%), prevalence of diabetes (21.9% vs 20.7%), and prevalence of established cardiovascular disease (16.8 vs 15.6%) were similar in both groups. Male sex was 49.0% in G1 and 51.6% in G2, p = 0.03. Office BP was 151.2/86.6 mmHg in G1 and 146.8/84.2 mmHg in G2 (p < 0.001), and control rates were 22.8% and 27.9% respectively (p < 0.001). Mean 24-h BP was 130.4/75.4 mmHg in G1 and 129.2/74.7 mmHg in G2 (p < 0.01), and ambulatory control rates 45.1% and 48.0% respectively (p = 0.022). Combination antihypertensive therapy was more frequently used in 2007 (68.5%) than in 2005 (63.3%), p < 0.001. Conclusions: A modest improvement in 2-year hypertension control rate was observed in patients attended by participant physicians in this web-based ABPM registry. Programs designed to help physicians in daily management of hypertensive patients may be useful for ameliorating hypertension control.

PREVALENCE OF MASKED HYPERTENSION IN SUBJECTS WITH HIGH NORMAL BLOOD PRESSURE: PP.3.98

Objective: To estimate the prevalence of masked hypertension in subjects with high normal blood pressure (BP). Methods: We analyzed data from untreated individuals included in the Spanish Society of Hypertension ABPM Registry (whole sample number 68,045). High normal BP was defined following current guidelines when office systolic BP was 130–139 mmHg and diastolic BP was 85–89 mmHg. A series of demographic and clinical variables were collected. Definitions and risk stratification followed 2007 ESH-ESC guidelines. ABPM was performed under standardized conditions. Masked hypertension was diagnosed when mean 24-h systolic BP = or > 130 mmHg and/or 24-h diastolic BP = or >80 mmHg. Results: We identified 3,199 untreated subjects with high normal BP. Mean (SD) age was 51.2 (15.1) years, 53.6% were men, and 26.4% were obese (body mass index ≥30 kg/m2). Mean (SD) office BP was 132.5 (5.2)/81.5 (6.3) mmHg and mean (SD) 24-h ambulatory BP was 123.9 (10,4)/75.8 (8,2) mmHg. Prevalence (95%CI) of masked hypertension was 39.5% (37.8–41.2). Subjects with masked hypertension showed a 24.5 % prevalence of high cardiovascular risk. With respect to individuals with ambulatory normotension, subjects with masked hypertension were overweighted, more frequently smokers, and showed a higher prevalence of a riser profile of nocturnal BP (p < 0.05 for all comparisons). Prevalence of documented target organ damage and established cardiovascular disease was similar in patients with masked hypertension and subjects with ambulatory normotension. Conclusions: Masked hypertension was present in 4 of 10 subjects with high-normal BP. This proportion and the potential high-risk profile of these individuals should encourage the detection of masked hypertension in subjects with high-normal BP.

HOW HYPERCHOLESTEROLEMIA INFLUENCES ON BLOOD PRESSURE AND VASCULAR RISK PROFILE IN TREATED HYPERTENSIVE PATIENTS: PP.23.449

Objective: To assess the influence of hypercholesterolemia on 24-h blood pressure (BP) and vascular risk in hypertensive patients. Methods: We analyzed data from the Spanish Society of Hypertension ABPM Registry. Hypercholesterolemia was defined as a serum LDL-cholesterol ≥165 mg/dl or current treatment with statins. Definitions for other variables and risk stratification followed 2007 ESH-ESC guidelines. ABPM was performed under standardized conditions and conventional thresholds for ambulatory BP and definition of a non dipping BP were applied. Results: We identified 9,805 subjects with hypercholesterolemia. Mean age (SD) was 64.1 (11.0) and 53.7% were men. Control rates of ambulatory BP were 49.6% (24-h), 57.3% (daytime), and 41.7% (nighttime) despite a widespread use (71.3%) of antihypertensive combinations. A non-dipper pattern of BP was present in 61.5% of subjects. Among those treated with statins, the proportion of patients showing a serum LDL-cholesterol <100 mg/dl was 11.8%. Prevalences of concomitant risk factors and organ damage were smoking 13.2%, diabetes 35.2%, obesity 40.7%, left ventricular hypertrophy 14.0%, radiological evidence of atherosclerosis 9.1%, microalbuminuria 11.8%, coronary heart disease 16.0%, cerebrovascular disease 9.3%, congestive heart failure 3.1%, and chronic kidney disease 4.5%. Consequently, prevalence of patients stratified as having high or very high added risk was 74.4%. Conclusions: Hypercholesterolemia identified hypertensive patients with a 75% likelihood of being at high or very high added cardiovascular risk. More than 50% of hypercholesterolemic hypertensives had their ambulatory BP undercontrolled. Only 53.6% of these patients were receiving statins, being very low (11.8%) the control rate of LDL-cholesterol. Additional efforts should be done for control of global cardiovascular risk in hypertensive patients with hypercholesterolemia.