Lars Lindholm

Ambulatory blood pressure in normotensive and hypertensive subjects: Results from an international database

Objective To delineate more precisely an operational threshold for making clinical decisions based on ambulatory blood pressure (ABP) measurement by studying the ABP in subjects who were diagnosed as either normotensive or hypertensive by conventional blood pressure (CBP) measurement. Subjects: Twenty-four research groups recruited 7069 subjects. Of these, 4577 were normotensive (CBP 140/90 mmHg), 719 were borderline hypertensive (systolic CBP 141–159 mmHg or diastolic CBP 91–94 mmHg) and 1773 were definitely hypertensive. Of the subjects in the last of these categories, 1324 had systolic hypertension (systolic CBP 21 60 mmHg) and 131 0 had diastolic hypertension (diastolic CBP 295 mmHg). Combined systolic and diastolic hypertension was present in 861 subjects. Hypertension had been diagnosed from the mean of two to nine (median two) CBP measurements obtained at one to three (median two) visits. Results The 95th centiles of the ABP distributions in the normotensive subjects were (systolic and diastolic, respectively) 133 and 82 mmHg for 24-h ABP, 140 and 88mmHg for daytime ABP and 125 and 76mmHg for night-time ABP, respectively. Of the subjects with systolic hypertension, 24% had 24-h systolic ABP 4 33 mmHg. Similarly, 30% of those with diastolic hypertension had 24-h diastolic ABP 432 mmHg. The probability that hypertensive subjects had 24-h ABP below these thresholds tended to increase with age and was two- to fourfold greater if the CBP of the subject had been measured at only one visit and if fewer than three CBP measurements had been averaged for establishing the diagnosis of hypertension. By contrast, for each 1 O-mmHg increment in systolic CBP, this probability decreased by 54% for 24-h systolic ABP and by 26% for 24-h diastolic ABP, and for each 5-mmHg increment in diastolic CBP it decreased by 6 and 9%, respectively. In comparison with 24-h ABP, the overlap in the daytime and night-time ABP between normotensive and hypertensive subjects was of similar magnitude and was influenced by the same factors. Conclusions The ABP distributions of the normotensive subjects included in the present international database were not materially different from those in previous reports in the literature. One-fifth to more than one-third of hypertensive subjects had an ABP which was below the 95th centile of the ABP of normotensive subjects, but this proportion decreased if the hypertensive subjects had shown a higher CBP upon repeated measurement. The prognostic implications of elevated CBP in the presence of normal ABP remain to be determined.

STOP-Hypertension 2: a prospective intervention trial of "newer" versus "older" treatment alternatives in old patients with hypertension. Swedish Trial in Old Patients with Hypertension.

It is well established that hypertensive patients benefit from drug treatment of their disorder. In recent years three major out-come studies of antihypertensive treatment in elderly hypertensives have shown substantial benefits, i.e. a reduction in the risk of stroke and other cardiovascular mortality and morbidity. In all these studies beta-blockers and/or diuretics were used in comparison with placebo. Newer therapeutic alternatives have, however, at least theoretically, many advantages which could result in further improvements in prognosis. The initial Swedish Trial in Old Patients with Hypertension (STOP-Hypertension 1) was conducted in men and women aged 70-84 years. STOP-Hypertension 2 will evaluate the therapy used in STOP-Hypertension 1 against therapy based on either ACE-inhibitors (enalapril and lisinopril) or on calcium antagonists (isradipine and felodipine), using the PROBE design (Prospective, Randomised, Open, Blinded Endpoint evaluation). The primary aim will be to assess the effect on cardiovascular mortality. Statistical calculations indicate that 6,600 patients, followed for four years will be needed (2p < 0.05, power 90%) to obtain significance if there is a 25% difference between the new and the established therapy. Patients in primary health care (300 centres) will be included if their supine blood pressure is > or = 180/105 mmHg (and/or). Recruitment of patients started in September 1992 and so far more than 100 patients/week have been included.

The impact of health care advice given in primary care on cardiovascular risk

Abstract Objective: To evaluate the additional benefit of “intensive” health care advice through six group sessions, compared with the advice usually offered to subjects with multiple risk factors for cardiovascular disease. Design: Prospective, randomised controlled clinical study lasting 18 months. Setting: 681 subjects aged 30-59 years, with at least two cardiovascular risk factors in addition to moderately high lipid concentrations: total cholesterol >/=6.5 mmol/l on three occasions, triglycerides <4.0 mmol/l, and ratio of low density lipoprotein cholesterol to high density lipoprotein cholesterol >4.0. Most (577) of the subjects were men. Main outcome measure: Percentage reduction in total cholesterol concentration (target 15%); quantification of the differences between the two types of health care advice (intensive v usual) for the Framingham cardiovascular risk and for individual risk factors. Results: In the group receiving intensive health care advice total cholesterol concentration decreased by 0.15 mmol/l more (95% confidence interval 0.04 to 0.26) than in the group receiving usual advice. The overall Framingham risk dropped by 0.068 more (0.014 to 0.095) in the group receiving intensive advice, and most of the risk factors showed a greater change in a favourable direction in this group than in the group receiving usual advice, but the differences were seldom significant. The results from questionnaires completed at the group sessions showed that the subjects improved their lifestyle and diet. Conclusion: Limited additional benefit was gained from being in the group receiving the intensive health care advice. It is difficult to make an important impact on cardiovascular risk in primary care by using only the practice staff. Better methods of communicating the messages need to be devised. Key messages Key messages This multicentre study examined the effects of “usual” or “intensive” health care advice on 681 subjects aged 30-59 years with a moderately high cholesterol concentration and two or more other cardiovascular risk factors The intensive advice programme was based mainly on group sessions led by doctors and nurses from health centres The study found that after 18 months of intervention limited additional benefit was derived from the intensive health care advice Messages and the means of delivering them to individuals in need should be customised for each person

The cost‐effectiveness of treating hypertension in elderly people—an analysis of the Swedish Trial in Old Patients with Hypertension (STOP Hypertension)

Abstract. Objectives. The aim of this study was to estimate the cost‐effectiveness of antihypertensive treatment in elderly people based on the results of the Swedish Trial in Old Patients with Hypertension (STOP Hypertension).

Combined Seropositivity for H. Pylori and C. Pneumoniae is Associated with Age, Obesity and Social Factors

Background Manifestations of cardiovascular disease (CVD) have been associated with chronic infection by Helicobacter pylori and Chlamydia pneumoniae both in cross-sectional and in prospective follow-up cohort studies. This association may be partly due to an increase in metabolic risk factors for CVD, secondary to low-grade inflammation caused by infections. Objective To investigate for subjects classified according to serology titres for infection with C. pneumoniae and H. pylori associations between seropositivity and the degree of obesity and fasting insulin levels, as well as social factors. Methods Using methods based on those in earlier investigations of hypertensive patients in the Dalby primary-health-care district, southern Sweden, we investigated frozen samples from serum of 310 middle-aged treated hypertensives and 288 age-matched and sex-matched normotensive controls from a defined population. The baseline examination included the measurement of weight, height and blood pressure as a mean of two office readings with the subject supine. The body mass index (BMI) was calculated as kg/m2. Fasting blood samples were drawn for measurements of levels of serum lipids, blood glucose, plasma insulin and serum lipids, including total cholesterol and triglycerides. The serology titres for H. pylori were determined by an enzyme-linked immunosorbent assay. The titres for C. pneumoniae were determined by a micro-immunofluorescence method. Self-reported factors concerning social and lifestyle backgrounds were recorded. Results The group (n = 245) of subjects with combined positive serology for H. pylori and C. pneumoniae differed from the group without any positive serology (n = 57) in age (61.6 versus 57.4 years, P < 0.05) and BMI (27.3 versus 25.8 kg/m2, P <0.05). The seropositive group also differed in terms of fasting levels of insulin (12.7 versus 11.6 pmol/l, P < 0.05), but this difference did not remain significant after adjustment for age and BMI. We detected no intergroup difference in blood pressure and levels of glucose and lipids. Members of the group with combined seropositivity reported having a lower social-class position (educational level) than that of members of the seronegative group. Conclusion Subjects with combined positive serology for H. pylori and C. pneumoniae are characterized by greater age, lower social class and higher BMI, as well as higher fasting levels of insulin than those of seronegative subjects. Obesity might be a marker not only for lower social class but also for greater than normal susceptibility to such infections.

A 5-year prospective, observational study of the withdrawal of antihypertensive treatment in elderly people

Abstract. Objectives. To observe blood pressure, cardiovascular events, and total mortality after withdrawing antihypertensive treatment for elderly patients.

Cost-minimisation analysis of three conservative treatment programmes in 180 patients sick-listed for acute low-back pain.

Objective - To perform a cost-minimization analysis of three conservative treatment regimes for acute low-back pain (LBP). Design - A prospective randomized clinical trial. Patients were assigned at random to one of three treatment programmes: General Practitioner Programme (GPP-) controls, Manual Therapy Programme (MTP) or Intensive Training Programme (ITP). Setting - Primary care and physiotherapists in Stockholm, Sweden. Patients - 180 patients sick-listed for acute LBP. Main outcome measures - Direct, indirect and total costs for three treatment programmes. Results - The direct costs for treatment were lowest in the GPP group - 2744 Swedish crowns (SEK) per patient. More patients in the MTP and ITP underwent operations for disk hernia and radiological investigations than in the GPP. Indirect costs, defined as sick-leave for LBP represent about 90% of the total cost. Conclusions - With respect to total costs, the findings were similar between the three treatment programmes. The GPP had the lowest direct costs. It is not possible to conclude which treatment programme is to be recommended as a least cost alternative. The strong effect of indirect costs on the total cost stresses that further studies should focus on methods of shortening sick-leave.OBJECTIVE To perform a cost-minimization analysis of three conservative treatment regimes for acute low-back pain (LBP). DESIGN A prospective randomized clinical trial. Patients were assigned at random to one of three treatment programmes: General Practitioner Programme (GPP-) controls, Manual Therapy Programme (MTP) or Intensive Training Programme (ITP). SETTING Primary care and physiotherapists in Stockholm, Sweden. PATIENTS 180 patients sick-listed for acute LBP. MAIN OUTCOME MEASURES Direct, indirect and total costs for three treatment programmes. RESULTS The direct costs for treatment were lowest in the GPP group -- 2744 Swedish crowns (SEK) per patient. More patients in the MTP and ITP underwent operations for disk hernia and radiological investigations than in the GPP. Indirect costs, defined as sick-leave for LBP represent about 90% of the total cost. CONCLUSIONS With respect to total costs, the findings were similar between the three treatment programmes. The GPP had the lowest direct costs. It is not possible to conclude which treatment programme is to be recommended as a least cost alternative. The strong effect of indirect costs on the total cost stresses that further studies should focus on methods of shortening sick-leave.

High coronary mortality in cold regions of Sweden

Abstract. The hypothesis that cold climate is associated with high coronary mortality in Sweden is tested. Cold exposure was calculated in each of the 284 municipalities of Sweden. There was a significant association between cold exposure and coronary mortality in both sexes in all age groups. The strongest association was found in men aged 40–64 years (coefficient of determination k = 0.39). The decile of men aged 40–64 years who lived in the coldest municipalities had a 40% excess mortality. A significant association was also found between cold exposure and mortality from cerebrovascular diseases. We conclude that there is a strong regional association between cold exposure and high coronary mortality.

ATRIAL NATRIURETIC PEPTIDE AND BLOOD PRESSURE IN A GEOGRAPHICALLY DEFINED POPULATION

Plasma atrial natriuretic peptide (ANP) was measured in 717 subjects in a cross-sectional study of patients with hypertension (treated and untreated) and normotensive controls, representatives of a geographically defined population. ANP concentrations did not differ between the groups and there was no correlation with blood pressure. These results do not support the view that hypertensive and normotensive subjects have different ANP concentrations; they also call into question the role of ANP in the development of high blood pressure.

Detection of chronic obstructive pulmonary disease (COPD) in primary health care: role of spirometry and respiratory symptoms

OBJECTIVE To evaluate the role of spirometry and respiratory symptoms in the detection of chronic obstructive pulmonary disease (COPD) in primary health care. DESIGN A cross-sectional study. SETTING A primary health centre in Landskrona, southern Sweden. SUBJECTS 164 subjects who in 1992 had answered a postal questionnaire concerning obstructive pulmonary diseases and respiratory symptoms. They were aged 45-64 years, with a mean of 55 years. MAIN OUTCOME MEASURES In 1997, the subjects were invited to perform a spirometry and a medical examination and to answer the same questionnaire as in 1992. Subjects with a forced expiratory volume in 1 second (FEV1) < 85% of the predicted normal value performed reversibility tests. RESULTS 131 subjects participated in the examinations. 15 subjects (11.5%) were diagnosed as having COPD. Only three of them had been previously diagnosed as having a respiratory disease. Many commonly occurring respiratory symptoms were associated with a reduction in FEV1. CONCLUSIONS Spirometry examinations in primary health care improve the probability of detecting COPD. A spirometry examination should be considered for patients with respiratory symptoms. It should also be considered for middle-aged smokers, even if they are symptom-free.