V. Immordino

Adherence to Antihypertensive Medications and Cardiovascular Morbidity Among Newly Diagnosed Hypertensive Patients

Background— Nonadherence to antihypertensive treatment is a common problem in cardiovascular prevention and may influence prognosis. We explored predictors of adherence to antihypertensive treatment and the association of adherence with acute cardiovascular events. Methods and Results— Using data obtained from 400 Italian primary care physicians providing information to the Health Search/Thales Database, we selected 18 806 newly diagnosed hypertensive patients ≥35 years of age during the years 2000 to 2001. Subjects included were newly treated for hypertension and initially free of cardiovascular diseases. Patient adherence was subdivided a priori into 3 categories—high (proportion of days covered, ≥80%), intermediate (proportion of days covered, 40% to 79%), and low (proportion of days covered, ≤40%)—and compared with the long-term occurrence of acute cardiovascular events through the use of multivariable models adjusted for demographic factors, comorbidities, and concomitant drug use. At baseline (ie, 6 months after index diagnosis), 8.1%, 40.5%, and 51.4% of patients were classified as having high, intermediate, and low adherence levels, respectively. Multiple drug treatment (odds ratio, 1.62; 95% CI, 1.43 to 1.83), dyslipidemia (odds ratio, 1.52; 95% CI, 1.24 to 1.87), diabetes mellitus (odds ratio, 1.40; 95% CI, 1.15 to 1.71), obesity (odds ratio, 1.50; 95% CI, 1.26 to 1.78), and antihypertensive combination therapy (odds ratio, 1.29; 95% CI, 1.15 to 1.45) were significantly (P<0.001) associated with high adherence to antihypertensive treatment. Compared with their low-adherence counterparts, only high adherers reported a significantly decreased risk of acute cardiovascular events (hazard ratio, 0.62; 95% CI, 0.40 to 0.96; P=0.032). Conclusions— The long-term reduction of acute cardiovascular events associated with high adherence to antihypertensive treatment underscores its importance in assessments of the beneficial effects of evidence-based therapies in the population. An effort focused on early antihypertensive treatment initiation and adherence is likely to provide major benefits.

Use of lipid-lowering drugs and blood pressure control in patients with arterial hypertension.

A large proportion of patients have both hypertension and hypercholesterolemia, two of the most important risk factors for cardiovascular diseases. Statins are the most widely used drugs for the treatment of plasma lipid abnormalities and have been reported to interact with elevated blood pressure. A reduction in blood pressure associated with the use of these agents has been reported in patients with untreated hypertension and in patients treated with antihypertensive drugs, particularly angiotensin‐converting enzyme inhibitors and calcium channel blockers. This effect on blood pressure control has also been observed in diabetic patients. The mechanism responsible for the hypotensive effect seems to be largely independent of the effect of statins on plasma cholesterol, and probably is related to the interaction of the medications with endothelial function or angiotensin II receptors. The capacity of statins to improve blood pressure control may represent a useful tool for improvement in the prevention of cardiovascular diseases.

Hemodynamic and neurohumoral profile in patients with different types of hypertension in pregnancy

Hypertension in pregnancy is a frequent disorder that includes a spectrum of conditions. We aimed at comparatively evaluating the hemodynamic, echocardiographic and biohumoral profile of a sample of pregnant Caucasian women with different form of pregnancy-related hypertension. We enrolled 39 non-hypertensive pregnant women (NP), 26 with Chronic HBP in pregnancy (CH), 24 with gestational hypertension (G-PIH), and 33 with pre-eclampsia. We recorded and compared blood pressure (BP), echocardiographic parameters, resting plasma renin activity (PRA) and plasma aldosterone (PA), Plasma levels of atrial (ANP) and brain natriuretic peptide (BNP). PE patients had a significantly higher BP than either G-PIH or NP patients. PE patients had also significantly lower cardiac output than NP, G-PIH and CH. In comparison to NP patients, the total peripheral vascular resistance was 61% higher in PE women and 38% higher in CH patients. All echographic parameters were significantly more altered in PE patients when compared with NP, in respect to any other form of hypertension. Either ANP (+35%) and BNP (+40%) were significantly higher in PE patients than in controls. The PRA was reduced in PE and CH patients when compared either with NP (−38 and −35%, respectively) or G-PIH (−47 and −43%, respectively). On the basis of our data, we can conclude that PE is the gestation associated hypertension with the largest anatomical, functional and biohumoral involvement, and so it has to be involved in a more intensive monitoring and evaluation.

Independent Determinants of Maternal and Fetal Outcomes in a Sample of Pregnant Outpatients With Normal Blood Pressure, Chronic Hypertension, Gestational Hypertension, and Preeclampsia

The aim of this retrospective study was to evaluate the main independent prognostic factors of negative maternal and fetal outcomes in a relatively large sample of pregnant outpatients (N=906) who were normotensive or affected by chronic hypertension, gestational hypertension, or preeclampsia. Among the studied parameters, the ones significantly associated with negative maternal outcomes were a diagnosis of preeclampsia (vs other forms of hypertension or normotension) and higher serum uric acid level, while antihypertensive treatment, number of previous deliveries, and blood pressure (BP) control at deliveries seemed to be protective. Regarding negative fetal outcomes, the parameters significantly associated with a negative maternal outcome were a diagnosis of preeclampsia (vs other forms of hypertension or normotension) and mother pre‐pregnancy body mass index, while antihypertensive treatment and BP control at delivery seemed to be protective. Specific patient characteristics should help to predict the risk of negative maternal and fetal outcomes.

Low Dose of ACE-Inhibitor Enhances Sodium Excretion in Volume Expanded Patients with Borderline Hypertension

The purpose of the present study was to separately investigate the effects of two different dosages of captopril on pressor, vascular and humoral response to acute extracellular volume expansion in patients with borderline hypertension (BHT). Thirty-five patients were randomly allocated in two groups undergoing acute saline infusion (0.40 ml/min/kg for 45 min and 0.15 ml/min/kg for 75 min)before and after a 7-day period of treatment with either placebo or captopril at the dose of 12.5 (LD-CAP) or 50 mg (HD-CAP) twice a day. At baseline the effects of LD-CAP were limited to an increase in PRA and to a decrease in plasma aldosterone whereas HD-CAP decreased systolic and diastolic blood pressure (SBP, DBP), forearm vascular resistance (FVR) and increased venous distensibility (VV(30)) as well. After saline loading patients treated with HD-CAP showed an increase in SBP, DBP not observed in patients allocated to LD-CAP. Urinary sodium excretion in response to NaCl loading was selectively enhanced by LD-CAP (+25%) whereas HD-CAP did not (+6.3%). The present data suggest that low-doses of ACE-inhibitors acting through a selective blockade of RAA not associated with hemodynamic changes can enhance the natriuretic response to acute volume expansion in borderline hypertensives.

L20. Differences in the hemodynamic profile between pre-eclampsia and other forms of hypertension in pregnancy.

attenuated in normal pregnancy, but augmented in preeclampsia. There are consistent results demonstrating that preeclampsia leads to a state of increased arterial stiffness, generalised vasoconstriction and higher TVR. In contrast, there are contradictory results on hemodynamic, myocardial and cardiac chamber function in preeclampsia. There are numerous possible methodological, technical and analytic reasons for the conflicting conclusions of these studies. Studies using afterload-corrected indices, tissue Doppler derived deformation indices and validated algorithms for analysis have provided more reliable evaluation of the cardiovascular system in this disease state. These studies have demonstrated that both preterm and term preeclampsia exhibit global biventricular diastolic dysfunction, LV altered geometry and widespread myocardial impairment. However, only preterm preeclampsia is characterized by global biventricular systolic dysfunction and severe LV hypertrophy. The cardiovascular implications of preeclampsia also do not end with the birth of the baby and placenta. At one year postpartum, LV moderate-severe dysfunction, hypertrophy and stage B asymptomatic heart failure was present in the majority of women who had previously had preterm preeclampsia. The risk of developing essential hypertension within 2 years was 40% in these women. The cardiac assessment of women with preterm PE may be of relevance in identifying women at higher risk of developing cardiovascular morbidity and mortality in later life. Conventional risk factors for cardiovascular morbidity are linked to aging and only become apparent at advanced stages when intervention is less efficacious. A strategy of echocardiographic assessment to screen and treat those women at highest risk of subsequent cardiovascular morbidity needs to be evaluated in larger prospective interventional studies. Such targeted cardiac assessment may serve to reduce the gender discrepancy in outcomes of cardiovascular disease.