Prevalence and related factors of office and home hypotension in older treated hypertensive patients.

BACKGROUND: Older hypertensive adults under treatment are especially susceptible to hypotensive episodes, which entail an elevated risk. However, data on this subject are very scarce. AIM: The purpose of this study was to determine the prevalence and predictors of office and home hypotension in older (≥ 65 years) treated hypertensive adults. METHODS: Blood pressure (BP) was measured at the office and at home, using a validated oscillometric device. Office and home hypotension were defined as systolic BP (SBP) < 110 and/or diastolic BP (DBP) < 70 mmHg, and SBP < 105 and/or DBP < 65 mmHg, respectively. Masked hypotension was considered when office BP ≥ 110/70 and home BP < 105 and/or < 65 mmHg. We evaluated factors associated with hypotension both at the office and at home through multivariable models. RESULTS: The prevalence of hypotension among the 302 patients included in the study was 29.8% at the office and 23.9% at home, whereas the prevalence of masked hypotension was 10.4%. Older age, lower body mass index and use of calcium channel blockers were associated with office hypotension, while older age, diabetes and ischemic heart disease were predictors for home hypotension. CONCLUSION: Hypotension is frequent in older hypertensive adults under treatment. The presence of diabetes, ischemic heart disease and older age should alert for screening of hypotension at home to avoid overtreatment.

Mean platelet volume as a prognostic factor for venous thromboembolic disease.

BACKGROUND: Mean platelet volume (MPV) is a risk factor for cardiovascular and inflammatory diseases. AIM: To evaluate the association between high MPV and 90-day mortality after an episode of venous thromboembolism (VTE). MATERIAL AND METHODS: Retrospective cohort of 594 patients with a median age of 73 years (58% women) with a first episode VTE, included in an institutional Thromboembolic Disease registry between 2014 and 2015. MPV values were obtained from the automated blood cell count measured at the moment of VTE diagnosis. Volumes ≥ 11 fL were classified as high. All patients were followed for 90 days to assess survival. RESULTS: The main comorbidities were cancer in 221 patients (37%), sepsis in 172 (29%) and coronary artery disease in 107 (18%). Median MPV was 8 fl (8-9), brain natriuretic peptide 2,000 pg/ml (1,025-3,900) and troponin 40 pg/ml (19.5-75). Overall mortality was 20% (121/594) during the 90 days of follow-up. Thirty three deaths occurred within 7 days and 43 within the first month. The loss of patients from follow-up was 5% (28/594) at 90 days. Mortality among patients with high MP was 36% (23/63). The crude mortality hazard ratio (HR) for high MPV was 2.2 (95% confidence intervals (CI) 1.4-3.5). When adjusted for sepsis, oncological disease, heart disease, kidney failure and surgery, the mortality HR of high MPV was 2.4 (CI95% 1.5-3.9) in the VTE group, 2.3 (CI95% 1.5-4.4) in the deep venous thrombosis group, and 2.9 (CI95% 1.6 -5.6) in the pulmonary embolism group. CONCLUSIONS: High MPV is an independent risk factor for mortality following an episode of VTE.

Hemodynamic characterization of hypertensive patients with an exaggerated orthostatic blood pressure variation.

Exaggerated orthostatic blood pressure variation (EOV) is a poorly understood phenomenon related to high cardiovascular risk. We aimed to determine whether hypertensive patients with EOV have a distinct hemodynamic pattern, assessed through impedance cardiography. METHODS: In treated hypertensive patients, we measured the cardiac index (CI), systemic vascular resistance index (SVRI), blood pressure (BP), and heart rate (HR) in the supine and standing (after 3 minutes) positions, defining three groups according to BP variation: 1) Normal orthostatic BP variation (NOV): standing systolic BP (stSBP)-supine systolic BP (suSBP) between -20 and 20 mmHg and standing diastolic BP (stDBP)-supine diastolic BP (suDBP) between -10 and 10 mmHg; 2) orthostatic hypotension (OHypo): stSBP-suSBP≤-20 or stDBP-suDBP≤-10 mmHg; 3) orthostatic hypertension (OHyper): stSBP-suSBP≥20 or stDBP-suDBP≥10 mmHg. We performed multivariable analyses to determine the association of hemodynamic variables with EOV. RESULTS: We included 186 patients. Those with OHyper had lower suDBP and higher orthostatic SVRI variation compared to NOV. In multivariable analyses, orthostatic HR variation (OR = 1.06 (95%CI 1.01-1.13), p = 0.03) and orthostatic SVRI variation (OR = 1.16 (95%CI 1.06-1.28), p = 0.002) were independently related to OHyper. No variables were independently associated with OHypo. CONCLUSION: Patients with OHyper have a distinct hemodynamic pattern, with an exaggerated increase in SVRI and HR when standing.

Effect of angiotensin 2 receptor blockers on chronic obstructive lung disease mortality: A retrospective cohort study.

INTRODUCTION: Chronic Obstructive Pulmonary Disease (COPD) is the fifth cause of mortality worldwide. Systemic inflammation is a crucial element in its physiopathology. As Renin-Angiotensin System is one of the main components of this inflammatory neurohumoral cascade, Angiotensin Receptor Blockers (ARBs) might have an effect on mortality in COPD patients. GOAL: To evaluate the association between ARBs treatment and mortality in COPD patients. METHODS: Retrospective cohort of patients with diagnosis of COPD from 2003 to 2013. COPD cases were detected according to the diagnosis by treating physicians in any field of the electronic clinical health records by controlled vocabulary in patients older than 18 years affiliated to the Hospital Italiano de Buenos Aires (HIBA) Health Plan. Patients were classified in two groups depending on their use of ARBs according to the hospital pharmacy records. The mortality registry of the HIBA was used to obtain the event of death. The 8 year survival experience was described using Kaplan Meier estimator and survival curve comparisons were calculated with the Cox Mantel test. Hazard Ratios (HR) were estimated using a Cox proportional risk model. A propensity score (PS) was developed for the use of ARBs. RESULTS: 1140 deaths were detected, 1063 in the no exposure group and 77 in the ARBs exposure group. The 8 year survival was 71% (CI 95% 69-72%). The survival in the non exposed group was 71% (CI 95% 69-73%) and 76% (CI 95% 0,69-0,81) in the ARBs exposed group. The unadjusted HR for mortality was 0.85 (CI 95% 0.67-1.07, p = 0.17) and the adjusted HR by PS was 0.63 (CI 95% 0.50-0.80, p < 0.001). DISCUSSION: ARBs use seems to be associated to a lower mortality in patients with COPD. Additional studies are needed to corroborate this finding.

[Clinical predictors of hemorrhagic transformation in non lacunar ischemic stroke]. / Predictores clínicos de transformación hemorrágica en accidente cerebrovascular isquémico no lacunar.

Hemorrhagic transformation is a complex phenomenon where brain tissue bleeds, which could be associated or not to an increase in the neurological deficit after the acute ischemic stroke. The aim of our study was to evaluate clinical predictors of hemorrhagic transformation in patients with non-lacunar ischemic stroke. We performed a prospective analysis of the clinical records and images of patients with non-lacunar ischemic stroke. Demographics, vascular risk factors, previous medications and the information of the event in patients with and without hemorrhagic transformation were here compared. We included in this study 747 patients with non-lacunar stroke, the mean age was 77 ± 11 years and 61% were females. In the univariate analysis, the age, a history of hypertension, atrial fibrillation, chronic kidney disease and the previous use of oral anticoagulation resulted statistically significant. In the multivariate analysis of logistic regression adjusted by age and vascular risk factors: the age > 80 years (OR 3.6, CI 95% 1.8-7.6), the pulse pressure > 60 mmHg at admission (OR 5.3, CI 95% 3.2-9.1), the chronic kidney disease (OR 3, CI 95% 2.5-3.8) and the presence of previous atrial fibrillation (OR 3.5, CI 95% 2.1-6.1) were associated with and increased risk of hemorrhagic transformation. The predictors of hemorrhagic transformation in our cohort showed a relationship with severe vascular illness. The identification of these patients could influence therapeutic decisions that could increase the risk of hemorrhagic transformation.

Meal-induced blood pressure fall in patients with isolated morning hypertension.

We aimed to determine a possible association between isolated morning hypertension (IMH) and meal-induced blood pressure (BP) fall in adult treated hypertensive patients who underwent home BP measurements. A total of 230 patients were included, median age 73.6, 65.2% women. After adjusting for age, sex, number of antihypertensive drugs, office and home BP levels, the association between IMH and meal-induced BP fall was statistically significant. In conclusion, meal-induced BP fall and IMH detected through home blood pressure monitoring (HBPM) are independently associated in hypertensive patients. The therapeutic implications of such observation need to be clarified in large-scale prospective studies.

Predictive value of non-invasive hemodynamic measurement by means of impedance cardiography in hypertensive subjects older than 50 years of age.

The prognostic value of impedance cardiography (ICG; cardiac index [CI] and systemic vascular resistance index [SVRI] were measured) was assessed in this retrospective cohort study. A total of 1151 hypertensive outpatients >50 years with a baseline ICG were included. After median follow-up of 3.9 years, for the composite endpoint of cardiovascular events and stroke, adjusted HR for each 500 ml/min/m(2) CI increase was 0.85 (CI95% 0.73-0.9, p = 0.039), and for each 500 dynes s cm(-5) SVRI increase was 1.11 (CI95% 1.01-1.23, p = 0.046), whereas adjusted HR for all-cause mortality was not significant. ICG adds prognostic value to conventional risk factors in hypertensive patients.

Prevalence and clinical profile of resistant hypertension among treated hypertensive subjects.

We assessed prevalence and clinical characteristics of resistant hypertension (RH) and prevalence of false RH (white-coat effect [WCE] by home blood pressure [BP] monitoring), among a population of 302 treated hypertensive patients, mean age 66.6 (± 13.8), 67.5% women. Resistant hypertension was defined according to the American Heart Association criteria. Prevalence of RH was 10%, and the following five variables were independently associated with it: body mass index, diabetes, isolated systolic hypertension, orthostatic hypotension, and use of beta-blockers. Prevalence of WCE among subjects with office-RH was 27.6%. Our study identified easily measurable parameters related to RH. Standing BP should be systematically measured in individuals with RH.

[Clinical research in internal medicine residencies in Argentina. Supporters and detractors]. / La investigación clínica en residencias de medicina interna de la Argentina. Facilitadores y barreras.

Several academic and government organizations have strongly recommended the inclusion of specific competences in clinical research. So far, the current state of research within this framework has not been modified in our country. The main goal of this study was to provide a thorough description of the research activities in medical residencies, which could be used as an indicator of the acquisition of such competences and to identify the supporters and detractors to achieve them. A cross section study was carried out and several levels were analyzed in order to consider residencies as a cluster; 382 residents from 24 different residencies were included. the study showed a preponderance of women. the average age was 29 years old. A 71% of the residents asserted doing research. Half of those residents have stated being authors of papers presented in congresses; only 9% have published their experience. Factors which predict the development of research assignments were: to belong to a large residency, oR 16.99 (IC 95%, 2.096-137.87), being in the 3rd year of the residency, oR 9.95 (IC 95%, 2.84-34.82), completion of a research course, oR 2.78 (IC 95%, 1.10-7.04). Variables which reduce the chance to do research: location in Buenos Aires, oR 0.25 (IC 95%, 0.0072-0.91), being a woman, oR 0.34 (IC 95%, 0.14-0.79) and patients assistance workload, OR 0.97 (IC 95%, 0.95-0.99). We believe that the identification of factors which influence the possibility of doing research will lead to a improvement in the training of medical residents.

Cost-effectiveness of a hypertension management programme in an elderly population: a Markov model.

BACKGROUND: Mounting evidence shows that multi-intervention programmes for hypertension treatment are more effective than an isolated pharmacological strategy. Full economic evaluations of hypertension management programmes are scarce and contain methodological limitations. The aim of the study was to evaluate if a hypertension management programme for elderly patients is cost-effective compared to usual care from the perspective of a third-party payer. METHODS: We built a cost-effectiveness model using published evidence of effectiveness of a comprehensive hypertension programme vs. usual care for patients 65 years or older at a community hospital in Buenos Aires, Argentina. We explored incremental cost-effectiveness between groups. The model used a life-time framework adopting a third-party payer's perspective. Incremental cost-effectiveness ratio (ICER) was calculated in International Dollars per life-year gained. We performed a probabilistic sensitivity analysis (PSA) to explore variable uncertainty. RESULTS: The ICER for the base-case of the "Hypertension Programme" versus the "Usual care" approach was 1,124 International Dollars per life-year gained. PSA did not significantly influence results. The programme had a probability of 43% of being dominant (more effective and less costly) and, overall, 95% chance of being cost-effective. DISCUSSION: Results showed that "Hypertension Programme" had high probabilities of being cost-effective under a wide range of scenarios. This is the first sound cost-effectiveness study to assess a comprehensive hypertension programme versus usual care. This study measures hard outcomes and explores robustness through a probabilistic sensitivity analysis. CONCLUSIONS: The comprehensive hypertension programme had high probabilities of being cost-effective versus usual care. This study supports the idea that similar programmes could be the preferred strategy in countries and within health care systems where hypertension treatment for elderly patients is a standard practice.

[Reproducibility and reliability of a 4-day HBPM protocol with and without first day measurements]. / Reproducibilidad y confiabilidad de un protocolo de 4 días de monitoreo domiciliario de presión arterial con y sin exclusión del primer día.

HBPM guidelines state that morning and evening measurements should be recorded and, to improve stability, the first day of measurements should be discarded. Our objective was to assess the reproducibility and reliability of a 4-day HBPM protocol with and without first day measurements. We analyzed a retrospective cohort of ambulatory patients who required a HBPM for diagnostic purposes or evaluation of treatment efficacy. A 4-day protocol was implemented, with daily duplicate measurements in the morning, afternoon and evening, using an OMRON 705 CP validated equipment. HBPM reproducibility was quantified by test-re-test correlations and standard deviation of differences (SDD) between BP measurements obtained during the entire 4 days, with and without exclusion of the first day. The reliability criterion was the stabilization of the mean and standard deviation (SD). We included 353 subjects with a total of 8224 BP recordings (median of 24 recordings per patient). We found a strong test-re-test correlation between days 1 to 4, which improved when we excluded the first day (p<0.001). We also found a reduction of the mean BP when we increased the number of days and a reduction of SDD when we excluded day 1. Therefore, we conclude that the exclusion of the first day of measurements improves the reproducibility and reliability of a 4-day protocol, and such two factors are not affected by the inclusion of afternoon measurements.

Comparing Office, Central, Home and Ambulatory Blood Pressure in Predicting Left Ventricular Mass.

The blood pressure measurement method that more accurately predicts a left ventricular mass is controversial, and the evidence suggesting superiority of central over brachial measurements is contradictory. The aim of this study was to compare the relationship between the different clinic and out-of-clinic blood pressure measurements methods with left ventricular mass in patients who attended a specialised hypertension centre for a central blood pressure measurement. An analysis was performed on the correlations between left ventricular mass and central and brachial blood pressure measurements made in the clinic, and home, as well as 24-h systolic blood pressure measurements. A linear regression analysis was then performed to assess the independent relationship of each blood pressure measurement with left ventricular mass. The results on 824 treated and 123 untreated patients showed no significant differences between correlations, although home readings tended to have the best correlations. In regression adjusted models, for each 10 mmHg increase in systolic home blood pressure the left ventricular mass increased 10 g/m2 (95% CI; 3.7-27, p=.01, adjR2 0.38), and for 24-h ambulatory systolic blood pressure it increased 2.3 g/m2 (95% CI 0.76-3.9, p<.01, adjR2 0.15) in treated and untreated patients, respectively. The association of systolic blood pressure with left ventricular mass was better explained by home and 24-h ambulatory monitoring than to clinic-based measurements in treated and untreated patients, respectively. In the clinic, however, the central measurement was not superior to brachial blood pressure.

Validation of a new piezoelectric device for noninvasive measurement of central aortic systolic blood pressure.

OBJECTIVE: The objective of this study was to compare the aortic piezoelectric device for noninvasive measurement of central aortic systolic blood pressure (cSBP) with the SphygmoCor. PARTICIPANTS AND METHODS: A total of 85 participants from both sexes, aged 18-80 years, were stratified into three age groups (<30, 30-60, >60 years), with an equal number of healthy volunteers and hypertensive patients. We performed three cSBP measurements with each device, in an alternate manner, using the Bland-Altman method to determine the level of agreement. The standard of the Association for the Advancement of Medical Instrumentation for brachial blood pressure evaluation was used for the comparison. RESULTS: The mean cSBPs were 109.3±12.05 and 109.0±12.2 mmHg with the SphygmoCor and the Aortic device, respectively, showing a strong correlation (r=0.98, P<0.001). A mean difference of 0.35±2.43 mmHg (95% confidence interval: 0.17-0.87, P=NS) was obtained with the Bland-Altman method. The 95% limits of agreement was -4.4 to +5.1 mmHg. CONCLUSION: Complying with the Association for the Advancement of Medical Instrumentation criteria, cSBP measurements obtained with the Aortic and the SphygmoCor devices are equivalent.

Alerting Reaction in Office Blood Pressure and Target Organ Damage: An Innocent Phenomenon?

BACKGROUND: An alerting reaction is a physician-induced phenomenon which produces a transient blood pressure rise in the office. OBJECTIVE: To determine its relationship with target organ damage in treated hypertensives. METHOD: We used three different indexes for calculating alerting reaction depending on the first, second or third office blood pressure measurement. We correlated these indexes with glomerular filtration rate, left ventricular mass index and pulse wave velocity. Thereafter, for multivariate analysis, we selected the index which better correlated with each target organ damage subtype. RESULTS: We included 174 adults, mean age 67(±13.7) years. 75% of the patients had some degree of blood pressure fall between measurements 1-3. In multivariate linear regression models, after adjusting for classic risk factors, two out of the three systolic alerting reaction indexes showed an independent association with target organ damage. After further adjusting for office blood pressure and white coat effect (calculated with standardized home blood pressure monitoring), left ventricular mass index maintained a statistically significant association. CONCLUSION: A higher alerting reaction in the office seems to be related to increased target organ damage in treated hypertensives and should not be considered an innocent phenomenon.

Arterial Stiffness in Treated Hypertensive Patients With White-Coat Hypertension.

Arterial stiffness, assessed through pulse wave velocity (PWV), independently predicts cardiovascular outcomes. In untreated persons, white-coat hypertension (WCH) has been related to arterial stiffness, but data in treated patients with WCH are scarce. The authors aimed to determine a possible association between WCH and arterial stiffness in this population. Adult treated hypertensive patients underwent home blood pressure monitoring and PWV assessment. Variables associated with PWV in univariable analyses were entered into a multivariable linear regression model. The study included 121 patients, 33.9% men, median age 67.9 (interquartile range 18.4) years, 5.8% with diabetes, and 3.3% with a history of cardiovascular or cerebrovascular disease. In multivariable analysis, WCH in treated hypertensive patients remained a determinant of PWV: ß=1.1 (95% confidence interval, 0.1-2.1 [P=.037]; adjusted R2 0.49). In conclusion, WCH is independently associated with arterial stiffness in treated hypertensive patients. Whether this high-risk association is offset by antihypertensive treatment should be further investigated.

Institutional Registry of Elderly Patients With Hip Fracture in a Community-Based Tertiary Care Hospital in Argentina (RIAFC).

BACKGROUND: A clinical registry encompasses a selective set of rigorously collected and stored clinical data focused on a specific condition. Hip fracture is a common complication of osteoporosis in elderly patients. Hip fracture substantially increases the risk of death and major morbidity in the elderly patients. Limited data regarding hip fracture are available from Latin America and Argentina. The purpose of this project is to create an institutional registry of elderly patients with hip fracture in order to obtain data that reveal the impact of this disease in our environment, allowing us to evaluate different strategies of patient's care and clinical outcomes. OBJECTIVE: To describe the implementation of an institutional registry of elderly patients with hip fracture in Argentina. METHODS: In this article, we described the creation, implementation, and data management of a prospective registry of elderly patients with hip fracture. The registry contains information on baseline demographics, comorbidities, laboratory, and radiological data. Follow-up at 3 and 12 months postfracture is done by phone interview to assess physical function, readmissions, and morbi-mortality. Clinical Trials registry number NCT02279550. CONCLUSION: In this project, we have created a hip fracture registry. We hope that this registry will provide valuable data that can lead us to new lines of research, addressed to answer questions raised in clinical practice.

Home blood pressure profile in very elderly hypertensives: should we use the same thresholds as in younger patients?

We aimed to determine the characteristics of home blood pressure (BP) in very elderly hypertensives. A total of 485 treated hypertensive patients ≥18 years (median age, 70.8 [interquartile range, 18]; 67.2% women) underwent home BP measurements. Characteristics of patients ≥80 and <80 years of age and prevalence of office and home uncontrolled hypertension, isolated morning (IMH), isolated evening, isolated office, and masked hypertension were compared. Very elderly subjects had higher levels of systolic and lower levels of diastolic BP at home, a higher prevalence of home uncontrolled hypertension (68.5% vs. 37.7%; P < .001), masked hypertension (30.6% vs. 14.9%; P = .02), and IMH (19.4% vs. 10.9%; P = .02), and a lower prevalence of isolated office hypertension (8.3% vs. 18.8%; P = .01). When using differential home BP thresholds in the very elderly, determined through the percentile method, statistical differences disappeared, except for IMH. The very elderly depict a particular home BP profile. Benefit from using differential home BP thresholds should be determined in prospective studies.

Comparison of atenolol versus bisoprolol with noninvasive hemodynamic and pulse wave assessment.

We aimed to compare atenolol versus bisoprolol regarding general hemodynamics, central-peripheral blood pressure (BP), pulse wave parameters, and arterial stiffness. In this open-label, crossover study, we recruited 19 hypertensives, untreated or with stable monotherapy. Patients were randomized to receive atenolol (25-50 mg) or bisoprolol (2.5-5 mg), and then switched medications after 4 weeks. Studies were performed at baseline and after each drug period. In pulse wave analyses, both drugs significantly increased augmentation index (P < .01) and ejection duration (P < .02), and reduced heart rate (P < .001), brachial systolic BP (P ≤ .01), brachial diastolic BP (P ≤ .001), and central diastolic BP (P ≤ .001), but not central systolic BP (P ≥ .06). Impedance cardiographic assessment showed a significantly increased stroke volume (P ≤ .02). There were no significant differences in the effects between drugs. In conclusion, atenolol and bisoprolol show similar hemodynamic characteristics. Failure to decrease central systolic BP results from bradycardia with increased stroke volume and an earlier reflected aortic wave.

Defining thresholds for home blood pressure monitoring in octogenarians.

To generate outcome-driven thresholds for home blood pressure (BP) in the elderly, we analyzed 375 octogenarians (60.3% women; 83.0 years [mean]) enrolled in the International Database on home BP in relation to cardiovascular outcome. Over 5.5 years (median), 155 participants died, 76 from cardiovascular causes, whereas 104, 55, 36, and 51 experienced a cardiovascular, cardiac, coronary, or cerebrovascular event, respectively. In 202 untreated participants, home diastolic in the lowest fifth of the distribution (≤65.1 mm Hg) compared with the multivariable-adjusted average risk was associated with increased risk of cardiovascular mortality and morbidity (hazard ratios [HRs], ≥1.96; P≤0.022), whereas the HR for cardiovascular mortality in the top fifth (≥82.0 mm Hg) was 0.37 (P=0.034). Among 173 participants treated for hypertension, the HR for total mortality in the lowest fifth of systolic home BP (<126.9 mm Hg) was 2.09 (P=0.020). In further analyses of home BP as continuous variable (per 1-SD increment), higher diastolic BP predicted lower cardiovascular mortality and morbidity and cardiac and coronary risk (HR≤0.65; P≤0.039) in untreated participants. In those treated, cardiovascular morbidity was curvilinearly associated with systolic home BP with nadir at 148.6 mm Hg and with a 1.45 HR (P=0.046) for a 1-SD decrease below this threshold. In conclusion, in untreated octogenarians, systolic home BP ≥152.4 and diastolic BP ≤65.1 mm Hg entails increased cardiovascular risk, whereas diastolic home BP ≥82 mm Hg minimizes risk. In those treated, systolic home BP <126.9 mm Hg was associated with increased total mortality with lowest risk at 148.6 mm Hg.