P De Cort

Prognostic significance of blood pressure measured in the office, at home and during ambulatory monitoring in older patients in general practice

The purpose of the study was to assess the prognostic significance of out-of-the-office blood pressure (BP) measurement in older patients in general practice, and to compare the results for BP measured in the office, at home and during 24-h ambulatory monitoring. All registerd patients who were 60 years or older were eligible for the study, except when bedridden, demented or admitted in a home for sick elderly people, or when they had suffered a myocardial infarction or stroke. After baseline measurements in 1990–1993, incidence of major cardiovascular events (cardiovascular death, myocardial infarction and stroke) was ascertained in 2002–2003 and related to the BPs by use of multivariate Cox regression analysis. Age of the 391 patients averaged 71±9 years; 40% were men. During median follow-up of 10.9 years, 86 patients (22%) suffered a cardiovascular event. The adjusted relative hazard rate, associated with a 1 s.d. increment in systolic BP was 1.13 for office BP (NS), and, respectively, 1.32, 1.33 and 1.42, for home, daytime and night time BP (P⩽0.01 for all). Results were similar for diastolic BP. The prognostic significance of all out-of-the-office BPs was independent of office BP. The prognostic value of home BP was equal to (systolic) or even better (diastolic) than that of daytime BP. Night time BP predicted cardiovascular events independent of all other BPs. Prognosis of white-coat hypertension was similar to that of true normotension, but better than in sustained hypertension. In conclusion, the prognostic value of home BP is better than that of office BP in older patients in primary care, and is at least equal to that of daytime ambulatory BP. The prognosis of patients with white-coat hypertension is similar to that of true normotensives.

For how many days should blood pressure be measured at home in older patients before steady levels are obtained

This study investigated the period of time that blood pressure (BP) should be measured at home in older patients in order to obtain steady BP values. Thirty-six men and 38 women (⩾60 years) were recruited at one family practice. At one office visit the family physician measured supine, sitting and standing BPs three times consecutively in each position. During 10 consecutive days, BP was measured at home five times daily. The supine and standing BPs were measured once in the morning and in the evening and the sitting BP once at noon. These home BP values were averaged over the first day (1-day), over the first 3 days (3-day) and all 10 days (10-day) of measurements. In both the supine (−5.1 mm Hg) and sitting (−3.8 mm Hg) positions the 10-day average systolic home BP was significantly lower than the corresponding office BP. The opposite was observed for the 10-day average standing home BP values (+7.3/+3.4 mm Hg). Comparison of the 3-day and 10-day average home BP values showed only a significantly lower 10-day than 3-day systolic BP level in the supine position (−1.1 mm Hg, 95% CI −1.9 to −0.2 mm Hg). Repeated measures ANOVA, showed a small but significant decrease over time only for the supine systolic home BP (−0.29 mm Hg per day, 95% CI −0.49 to −0.08 mm Hg per day). We conclude that in older subjects, 3 days of home measurements may suffice to obtain steady values for the sitting and standing BPs. A longer interval might be required for the supine BP.

Twenty-four hour blood pressure monitoring in the Syst-Eur trial

This article describes the objectives and protocol of a study on ambulatory blood pressure in elderly patients with isolated systolic hypertension. This study constitutes an optional side-project to the Syst-Eur trial.The multicentre Syst-Eur trial investigates whether antihypertensive treatment of elderly patients with isolated systolic hypertension will influence the incidence of stroke. Secondary endpoints include cardiovascular events, such as myocardial infarction.The main objective of the side-project is to investigate whether ambulatory blood pressure monitoring will improve the prediction of cardiovascular complications based on blood pressure measurement in the clinic. The side-project also provides the opportunity to evaluate the diurnal profile of blood pressure in elderly patients with isolated systolic hypertension randomized to placebo or active antihypertensive treatment.

Relationship between blood pressure measured in the clinic and by ambulatory monitoring and left ventricular size as measured by electrocardiogram in elderly patients with isolated systolic hypertension

Objective: To assess the additional diagnostic precision conferred by ambulatory blood pressure monitoring on clinic blood pressure measurement in evaluating the severity of isolated systolic hypertension. Methods: The association between left ventricular size as determined by ECG voltages [R-wave voltages in lead V5 (RV5) and S-wave voltages in lead V1, (SV1,)] and blood pressure as assessed by clinic measurements and ambulatory blood pressure monitoring was studied in 97 elderly patients included in the placebo run-in phase of the Syst-Eur trial. The additional diagnostic precision conferred by ambulatory monitoring on clinic blood pressure measurements was assessed by relating the residual ambulatory blood pressure level to the ECG-left ventricular size. The residual ambulatory blood pressure level was calculated by subtracting the predicted ambulatory blood pressure level for each patient (using the linear regression equation relating both techniques for the group) from the observed ambulatory blood pressure. Results: Clinic systolic blood pressure was on average 20mmHg higher (P<0.001) than daytime ambulatory blood pressure while diastolic blood pressure was similar with both techniques. The sum of SV1 + RV5 was significantly related to clinic systolic pressure (r=0.25), and 24-h (systolic, r=0.37; diastolic, r=0.29), daytime (systolic, r=0.30; diastolic, r=0.19) and night-time (systolic, r=0.33; diastolic, r=0.28) ambulatory blood pressure levels. These findings were not affected by adjustment for gender, age and the body mass index. The sum of SV1 + RV5 was significantly related to the residual 24-h (systolic, r=0.30; diastolic, r=0.31), daytime systolic (r=0.20) and night-time (systolic, r=0.31; diastolic, r=0.29) ambulatory blood pressure monitoring levels. Conclusion: Ambulatory blood pressure monitoring adds to the diagnostic precision of clinic blood pressure measurement in assessing the severity of hypertension in this population. The ongoing side project on ambulatory blood pressure monitoring in the Syst-Eur study should establish whether these findings hold true for morbidity and mortality.

CVRM in Vlaanderen

Uit Belgische cijfers blijkt dat de incidentie van hart- en vaatziekten een gunstige ontwikkeling kent.1 Volgens het Intego-netwerk is de incidentie van CVA-TIA in Vlaanderen ongeveer 9600 nieuwe gevallen per jaar en van acuut myocardinfarct ongeveer 7500 per jaar.2 Bij ouderen is hartfalen verantwoordelijk voor een aanzienlijke morbiditeit en mortaliteit en vormt het de belangrijkste cardiale doodsoorzaak.3 Het krijgen van een hart- of vaatziekte wordt voor een belangrijk deel bepaald door de bekende aan- of afwezigheid van risicofactoren. Ook in Vlaanderen heeft de huisarts een unieke positie voor zowel de preventie als de behandeling van deze problemen. Wat betreft zijn praktijkbeleid baseert de Vlaamse huisarts zich op de gevalideerde Domus Medica aanbeveling voor goede medische praktijkvoering Globaal cardiovasculair risicobeheer van 2007.4 Deze richtlijn is enigszins gedateerd en het Vlaamse Gezondheidsbeleid (FOD) financiert momenteel de herziening ervan. Toch blijft het voorlopig een belangrijke richtlijn en is het de moeite waard om voor- en nadelen te bespreken. Alle relevante vragen over het cardiovasculair risico maken ook deel uit van de recente ‘Gezondheidsgids’ van Domus Medica, een vragenlijst die de geschiktste preventie-items voor 45-plussers beschrijft en inmiddels door de Vlaamse overheid is aanvaard als instrument voor bevolkingsonderzoek. Deze recente ontwikkeling wordt ook kort toegelicht.