Advanced practice nurse intervention versus usual care for hypertension control: study protocol for an open-label randomized controlled trial.

BACKGROUND: Hypertension is the most frequent chronic pathology in France and in the world. It is one of the main modifiable cardiovascular risk factors. In France, 50% of treated hypertensives are uncontrolled and only 30% of treated patients are fully adherent to their antihypertensive treatment. Poor adherence to drug treatments is considered as one of the main causes of non-control of hypertension. Since 2018, a new profession has entered the French healthcare system: advanced practice nurses (APN). They have many broad-based skills, at the interface of nursing and medical exercises. The purpose of this study is to assess the impact of an APN intervention versus usual care on hypertension control. METHODS: The study will take place at the Hôtel-Dieu University Hospital, Paris, France, as prospective, open-label, controlled, randomized 1-to-1, monocentric, and superiority trial. The participants will be recruited during day hospitalization for cardiovascular assessment in the context of their hypertension management. Patients will be divided into two groups: a "usual care" group which will continue traditional follow-up (day hospitalization followed by consultation with a medical doctor (MD) within approximately 2-12 months) and an "intervention" group which will meet an APN between the day hospitalization and the MD consultation. Participants will be monitored until 12 months after the day hospitalization, depending on their last follow-up study appointment (MD consultation). The primary outcome is the rate of controlled BP (BP < 140/90 mmHg in office BP measurement) in each group. The hypothesis formulated is that an individual APN intervention, included in usual hypertension management, improves hypertension control. DISCUSSION: This innovative study will be the first in France where APNs are beginning to be established in the healthcare system. It will provide an objective look at this new profession and the impact it can have in the framework of global management of hypertension. TRIAL REGISTRATION: ClinicalTrials.gov NCT0448249. Registered on June 24, 2020.

Acute coronary syndrome during pregnancy and postpartum in France: the nationwide CONCEPTION study.

BACKGROUND: Cardiovascular diseases, including acute coronary syndromes, are the leading cause of maternal death in many developed countries. OBJECTIVE: We assessed acute coronary syndrome incidences during pregnancy, peripartum, and postpartum periods. We also compared overall pregnancy (ie, covering all 3 periods) incidence with that found in nonpregnant women of childbearing age. STUDY DESIGN: All women aged between 15 and 49 years without ischemic heart disease who delivered between 2010 and 2018 in France were included in the CONCEPTION cohort. Data were extracted from the French National Health Insurance Information System database. Acute coronary syndromes were defined according to the International Classification of Diseases, Tenth Revision codes recorded in the principal hospital diagnosis. We used Poisson regression to estimate crude acute coronary syndrome incidences, and tested age-adjusted Poisson models to compare the incidence risk ratio of acute coronary syndrome between pregnant and nonpregnant women, with 95% confidence intervals. RESULTS: Among 6,298,967 deliveries in France, we observed 225 first-time acute coronary syndrome diagnoses during overall pregnancy (overall pregnancy-related acute coronary syndrome incidence, 4.34/100,000 person-years; 1 case/23,000 pregnancies). In multivariate analysis, independent factors associated with acute coronary syndrome were age, social deprivation, obesity, tobacco use, chronic hypertension, and hypertensive disorders of pregnancy (all P<.05). Among the nonpregnant women aged 15 to 49 years in the general French population, 18,247 cases of acute coronary syndrome (incidence, 16.5/100,000 person-years) occurred throughout the whole study period (>100 million person-years). Compared with the acute coronary syndrome incidence in nonpregnant women, age-adjusted overall pregnancy-related acute coronary syndrome incidence was lower (incidence rate ratio, 0.76; 95% confidence interval, 0.57-0.98; P<.05). Although compared with nonpregnant women, age-adjusted incidence rates were lower during pregnancy, risk was increased during peripartum and postpartum periods. CONCLUSION: With an incidence of 4.34 per 100,000 person-years, acute coronary syndrome still accounts for a significant proportion of maternal mortality. The peripartum and postpartum periods remain high-risk periods, and greater efforts should be made in terms of acute coronary syndrome prevention, especially because several cardiovascular risk factors are treatable, such as tobacco use and hypertensive disorders of pregnancy.

Perioperative outcomes of pheochromocytoma/paraganglioma surgery preceded by Takotsubo-like cardiomyopathy.

BACKGROUND: Pheochromocytomas and paragangliomas can induce severe cardiovascular manifestations such as Takotsubo-like cardiomyopathy. What the perioperative outcomes are of patients presenting with pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy remains an unresolved question. METHODS: From 2006 to 2019, all patients who underwent surgery for pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy were included from 3 high-volume centers, with specific attention to perioperative hemodynamic instability and postoperative outcomes. RESULTS: Overall, 37 patients were included, with a median age of 45 years. Patients were operated on 2 months (1-4) after a Takotsubo-like cardiomyopathy episode; 33 (89%) had a laparoscopic approach. All those who underwent surgery presented in a hemodynamically stable situation. All except 1 of the pheochromocytomas/paragangliomas patients had at least 1 antihypertensive treatment at the time of surgery. The median preoperative systolic blood pressure in the Takotsubo-like cardiomyopathy group was 120 mm Hg (95-132). Overall, 27/34 (79%) of patients required vasoactive drugs during surgery with nicardipine (n = 22), esmolol (n = 12), and/or norepinephrine (n = 8). No patient presented a catecholamine-induced life-threatening complication such as hypertensive crisis, cardiac arrhythmias, pulmonary edema, cardiac ischemia, or Takotsubo-like cardiomyopathy in the perioperative period. Severe morbi-mortality was nil. The systematic review identified 5 studies including 38 pheochromocytomas/paragangliomas patients with at least 1 episode of acute heart failure considered as Takotsubo-like cardiomyopathy before surgery, of which 28 patients had delayed surgery with 1 postoperative death. CONCLUSION: Hemodynamically stabilized patients with pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy can be safely scheduled for an elective pheochromocytomas/paragangliomas surgery, with similar intra and postoperative outcomes as those without Takotsubo-like cardiomyopathy.

Nationwide Initiation of Cardiovascular Risk Treatments During the COVID-19 Pandemic in France: Women on a Slippery Slope?

Objectives: This study examines the initiation of prescribed medication treatments for cardiovascular risk (antihypertensives, lipid-lowering drugs, oral anticoagulants in atrial fibrillation, and smoking cessation medications) during the COVID-19 pandemic in the French population. Methods: For each year between 2017 and 2021, we used the French National Insurance Database to identify the number of people with at least one reimbursement for these medications but no reimbursement in the previous 12 months. We computed incidence rate ratios (IRRs) between 2017-2019 and, respectively 2020 and 2021 using Poisson regression adjusted for age and 2017-2019 time trends. We recorded the number of lipid profile blood tests, Holter electrocardiograms, and consultations with family physicians or cardiologists. Results: In 2020, IRR significantly decreased for initiations of antihypertensives (-11.1%[CI95%, -11.4%;-10.8%]), lipid-lowering drugs (-5.2%[CI95%, -5.5%;-4.8%]), oral anticoagulants in atrial fibrillation (-8.6%[CI95%, -9.1%;-8.0%]), and smoking cessation medications (-50.9%[CI95%, -51.1%;-50.7%]) compared to 2017-2019. Larger decreases were found in women compared to men except for smoking cessation medications, with the sex difference increasing with age. Similar analyses comparing 2021 to 2017-2019 showed an increase in the initiation of lipid-lowering drugs (+ 11.6%[CI95%, 10.7%;12.5%]) but even lower rates for the other medications, particularly in women. In addition, the 2020 number of people visiting a family physician or cardiologist decreased by 8.4 and 7.4%. A higher decrease in these visits was observed in those over 65 years of age compared to those under 65 years of age. A greater use of teleconsultation was found in women. Conclusion: The COVID-19 pandemic heavily impacted the initiation of medication treatments for cardiovascular risk in France, particularly in women and people over 65 years.

[Prevalence of chronic kidney disease in France, Esteban study 2014-2016]. / Prévalence de la maladie rénale chronique en France, Esteban 2014­2016.

BACKGROUND: The epidemiology of chronic kidney disease remains poorly described in France despite its burden. The objective of our study was to provide an estimate of the prevalence of chronic kidney disease stades 3-5 (without replacement therapy) in France. METHOD: The data come from the Esteban study carried out in France between 2014 and 2016 on a representative sample of the French population. This study included 3,021 adults between 18 and 74 years old. Of these, 2422 adults (80.2%) had serum creatinine assay and were included in this analysis. Renal function was estimated by calculating glomerular filtration rate using the Chronic kidney disease epidemiology collaboration (CKD-Epi) and European Kidney function consortium (EKFC) equations. RESULTS: The means glomerular filtration rate in our population were respectively 97.5 and 89.0 mL/min/1.73 m2 with the CKD-EPI and EKFC equations. The prevalence of chronic renal failure, defined by a glomerular filtration rate less than 60 mL/min/1.73 m2 was 1.5% with the CKD-EPI formula and 2.1% with the EKFC formula in adults aged 18 to 74 years. The prevalence was higher in women than in men and increased with age, reaching 6.5% and 9.9% in 65-74 years with the CKD-EPI and EKFC equations, respectively. After extrapolation to the French population, the number of adults with chronic kidney disease stades 3-5 without renal replacement therapy was around 1.6 million. CONCLUSION: In France, the prevalence of chronic kidney disease stades 3-5 without renal replacement therapy was between 1.5 and 2.1% of the adult population aged 18 to 74.

Effect of a pharmacist-led educational intervention on clinical outcomes: a randomised controlled study in patients with hypertension, type 2 diabetes and hypercholesterolaemia.

OBJECTIVES: In recent years, hospital pharmacists have gained more importance in the clinical support of patients. However, most of the studies evaluating the impact of clinical pharmacy have only studied patients' adherence or satisfaction. The aim of this study was to evaluate the direct clinical outcomes of a pharmacist-led educational intervention in patients with chronic disease. METHODS: We conducted a randomised, controlled, parallel, physician-blinded study in a day hospital and a consultation unit of a French teaching hospital over a 1-year period. Patients with hypertension, type 2 diabetes or hypercholesterolaemia who did not reach their therapeutic goals despite drug therapy were eligible. Patients in the intervention group received an intervention from a hospital pharmacist who provided patient education on pathology and drug management. The primary outcome was the proportion of patients reaching their therapeutic goals for blood pressure, glycated haemoglobin level or low-density lipoprotein cholesterol level at the 3-month follow-up consultation. RESULTS: From January to December 2015, 89 patients were included and 73 completed the study. In the intervention group, 61.7% (21/34) of the patients reached their therapeutic goals compared with 33.3% (13/39) in the control group (p=0.015). The intervention was significantly more effective in polypharmacy patients (60.0% (12/20) vs 16.7% (4/24); p=0.005), in those aged >60 years (57.9% (11/19) vs 26.1% (6/23); p=0.037) and in patients with a high education level (68.8% (11/16) vs 29.4% (5/17); p=0.024). CONCLUSION: A single pharmacist-led educational intervention has a clinical impact, doubling the proportion of patients reaching their therapeutic goals at 3 months, especially in polypharmacy patients and those aged >60 years. This study confirms the value of clinical involvement of hospital pharmacists in patient care in a consultation unit and day hospital.

A novel personalized approach to cardiovascular prevention: The VIVOPTIM programme.

BACKGROUND: Cardiovascular diseases are a leading cause of mortality, but a substantial proportion are preventable. AIMS: The Mutuelle générale de l'éducation nationale (MGEN), a provider of private health insurance in France, has developed the VIVOPTIM programme, a novel digital approach to healthcare based on individualized, multiprofessional, ranked management of cardiovascular risk factors. METHODS: Between November 2015 and June 2016, eligible individuals (age 30-70 years) from two regions of France were invited to participate. Volunteers completed a questionnaire based on the Framingham Heart Study Risk Score and were assigned to one of three cardiovascular risk levels. VIVOPTIM comprises four components: cardiovascular risk assessment, instruction on cardiovascular diseases and associated risk factors, personalized coaching (telephone sessions with a specially trained healthcare professional to provide information on risk factors and disease management, set individual health targets, monitor progress and motivate participants), and e-Health monitoring. RESULTS: Data from 2240 participants were analysed. Significant benefits were observed on mean systolic blood pressure (-3.4mmHg), weight (-1.5kg), smoking (-2.2 cigarettes/day) and daily steps (+1726 steps/day (all P<0.0001)), though not on weekly duration of exercise (-0.2hours/week, P=0.619). CONCLUSION: As a result of the positive mid-to-long-term results of the pilot programme on weight, smoking, blood pressure, and uptake of physical activity, the VIVOPTIM programme was extend to the whole of France in 2018 and has the potential to have a genuine impact on patient care and organization of the healthcare system in France.

Home blood pressure monitoring in France: Device possession rate and associated determinants, the Esteban study.

Home blood pressure monitoring (HBPM) is increasingly being promoted in hypertension guidelines to improve hypertension management. Possessing a HBPM device could improve blood pressure (BP) control and prognostic impact. The aims of this study were to estimate the possession rate of HBPM devices in the French population and in hypertensive adults, and to investigate the determinants of possessing such devices at home. Cross-sectional analyses were performed using data from the Esteban survey, which comprised a representative sample of the French population. Among the 2,054 study participants, 673 had hypertension. Of these, 385 were aware they had it. Weighted logistic regressions were performed to investigate the factors (socioeconomic, clinical, drug treatment, and healthcare visits) associated with possessing a HBPM device. 20.9% of the study sample, 42.1% of those with hypertension, and 54% of those aware of their hypertension, possessed a HBPM device. Female gender (OR = 2.03, 95%CI [1.46; 2.60]), smoking (OR = 2.33, 95%CI [1.51; 3.15]), antihypertensive drugs (OR = 1.75, 95%CI [1.06; 2.44]), general practitioner (GP) visits (OR = 3.28, 95%CI [1.84; 4.68]), and diabetes (OR = 0.41 95% CI [0.14; 0.68]) were associated with possessing a HBPM device among those aware of their hypertension. Over 20% of the study population possessed a HBPM device at home. This proportion rose to one in two in those aware or their hypertension. Among the latter, possessing a device was positively associated with female gender, GP visits, and antihypertensive drug use. Increasing possession of HBPM devices in the hypertensive population could foster better management of the condition.

Associations between urinary cadmium levels, blood pressure, and hypertension: the ESTEBAN survey.

Cadmium is inconsistently associated with blood pressure (BP) and hypertension. Our study focuses to understand the association between urinary cadmium levels, blood pressure, and hypertension in a French representative sample. Our study included 2015 subjects from the ESTEBAN survey (2014-2015) with measured urinary cadmium. Associations between natural logarithm-transformed cadmium levels and BP (systolic (SBP) and diastolic blood pressure (DBP)) were performed by adjusted linear regression models. Associations between cadmium and hypertension were performed by adjusted logistic regression models. Models were stratified by gender, smoking habits, body mass index (BMI), and kidney function categories. Men present higher SBP (131.7 vs. 121.5 mmHg, p < 0.0001) and DBP (78.9 vs. 74.7 mmHg, p < 0.0001) in comparison to women. Creatinine-adjusted urinary cadmium levels (0.48 vs. 0.39 µg/L, p < 0.0001) were higher in hypertensive subjects. Nevertheless, no difference was observed after adjustment for age, gender, and smoking habits. No correlation between urinary cadmium, BP, and hypertension was observed in overall population. Stratified models showed inverse correlations between urinary cadmium and hypertension among obese (OR = 0.39, 95% CI [0.21-0.57], p = 0.0009), chronic kidney function (OR = 0.68 95%CI [0.75-0.97], p = 0.003), and current smokers (OR = 0.78, 95% CI [0.64-0.92], p = 0.04). A correlation between urinary cadmium levels, BP, and hypertension is observed in subpopulations. Nevertheless, directions and significance of these associations differs by gender, BMI, smoking, and kidney function categories.

The association of four-limb blood pressure differences with cardiovascular risk factors and target organ changes in elderly Chinese: The Northern Shanghai Study.

Background: The association of four-limb systolic blood pressure differences (SBPDs) including inter-arm (IASBPD), inter-leg (ILSBPD) and ankle-brachial index (ABI) with cardiovascular risk factors and target organ changes (TOCs) remains controversial. This study aims at investigating the association of those parameters with cardiovascular risk factors and TOCs in an elderly Chinese population.Methods: A total of 1528 subjects derived from the Northern Shanghai Study were studied. Four-limb BPs were simultaneously measured by VP-1000 device. Cardiovascular risk factors and TOCs including parameters of left ventricular structure and function, carotid intima-media thickness, carotid-femoral pulse-wave velocity (CF-PWV), estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio, were evaluated with standardized methods.Results: ABI significantly associated age (ß = -0.004, p < .01), female gender (ß = 0.02, p < .01), body mass index (ß = -0.004, p < .01), smoking (ß = -0.04, p < .01), high-density lipoprotein (ß = 0.04, p < .01), low-density lipoprotein (ß = -0.01, p = .01) and diabetes mellitus (ß = -0.02, p < .01), while the fourth root of IASBPD significantly associated with body mass index (ß = 0.03, p < .01), high-density lipoprotein (ß = -0.10, p = .02) and brachial SBP (ß = 0.003, p < .01); the fourth root of ILSBPD significantly associated with high-density lipoprotein (ß = -0.12, p < .01) and diabetes mellitus (ß = 0.09, p = .01). IASBPD, ILSBPD, and ABI all significantly associated with CF-PWV and eGFR (all p < .05) in either unadjusted or adjusted models, but not with other TOCs.Conclusion: Four-limb SBPDs, namely ABI, IASBPD, and ILSBPD, bore various burdens of cardiovascular risk factors and significantly and independently associated with CF-PWV and eGFR.

Spécificités du traitement médicamenteux antihypertenseur chez la femme.

The impact of antihypertensive drugs on blood pressure does not differ according to the sex. There are women-specific conditions or medical conditions encountered more frequently among womens that guide the selection of therapy such as a desire to become pregnant, a pregnancy, a polycystic ovarian syndrome, breast cancer, osteoporosis or migraine.

Application of a decision tree to establish factors associated with a nomogram of aortic stiffness.

Aortic stiffness is a marker of vascular aging and may reflect occurrence of cardiovascular (CV) diseases. Aortic pulse wave velocity (PWV), a marker of aortic stiffness, can be measured by applanation tonometry. A nomogram of aortic stiffness was evaluated by the calculation of PWV index. Theoretical PWV can be calculated according to age, gender, mean blood pressure, and heart rate, allowing to form an individual PWV index [(measured PWV - theoretical PWV)/theoretical PWV]. The purpose of the present cross-sectional study was to investigate the determinants of the PWV index, by applying a decision tree. A cross-sectional study was conducted from 2012 to 2017, and 597 individuals were included. A training decision tree was constructed based on seventy percent of these subjects (N = 428). The remaining 30% (N = 169) were used as the testing dataset to evaluate the performance of the decision trees. The input variables for the models were clinical and biochemical parameters. The different input variables remained in the model were diabetes, tobacco status, carotid plaque, albuminuria, C-reactive protein, total cholesterol, BMI, and previous CV diseases. For the validation decision model, the sensitivity, specificity, and accuracy values for identifying the related risk factors of PWV index were 70%, 78%, and 0.73. Since determinants of PWV index were all well-accepted CV risk factors, a nomogram of aortic stiffness could be considered as an integrator of CV risk factors on their duration of exposure and could be utilized to develop future programs for CV risk assessment and reduction strategies.

[Epidemiology of hypertension: Differences between women and men]. / Épidémiologie de l'HTA : différences femme/homme.

PREVALENCE OF HYPERTENSION LESS FREQUENT IN WOMEN BEFORE MENOPAUSE: In adults, up to the age of 50-60, hypertension is an uncommon disease, less frequent in women than in men. The literature review does not determine whether this difference is related to a protective effect of endogenous estrogens on the risk of high blood pressure, to genetic or immuno-enzymatic differences related to sex but of non-hormonal origin or to a large number of confounding variables (salt consumption, alcohol consumption, fruit and vegetable consumption, body mass index, psycho-socio-economic factors, sedentary lifestyle). PREVALENCE OF HYPERTENSION INCREASES AT MENOPAUSE: After menopause, the risk of hypertension in women increases and quickly reaches that of men, even exceeding it from the seventh decade onwards. The factors that make hypertension more frequent after the seventh decade in women are related to differences in cardiovascular risk and life expectancy between men and women, as well as a likely surviving effect in older men. The mechanisms by which estrogen-progestin deficiency increases the risk of hypertension have been extensively studied. These mechanisms are obviously numerous. However, it has not been clearly demonstrated that hormone replacement therapy during menopause reduces blood pressure levels. It should be noted that the route of administration, the choice of molecules, the respect of the intervention window and the dosage seem to modulate the potential vascular effects.

Relationship between Nutrition and Alcohol Consumption with Blood Pressure: The ESTEBAN Survey.

BACKGROUND: Dietary interventions are recommended for the prevention of hypertension. The aim of this study was to evaluate and quantify the relationship between alcohol consumption and the DASH (Dietary Approaches to Stop Hypertension) score with blood pressure (BP) stratified by gender. METHODS: Cross-sectional analyses were performed using data from 2105 adults from the ESTEBAN survey, a representative sample of the French population. Pearson correlation analyses were used to assess the correlation between the DASH score and alcohol with BP. Regressions were adjusted by age, treatment, socio-economic level, tobacco, exercise, Body mass index (BMI), and cardiovascular risk factors and diseases. RESULTS: The DASH score was negatively correlated with systolic (SBP) and diastolic BP (DBP) (p < 0.0001). Alcohol was positively associated with increased BP only in men. The worst quintile of the DASH score was associated with an 1.8 mmHg increase in SBP and an 0.6 mmHg increase in SBP compared to the greatest quintile in men and with a 1.5 mmHg increase in SBP and an 0.4 mmHg increase in SBP in women. Male participants in the worst quintile of alcohol consumption showed an increase of 3.0 mmHg in SBP and 0.8 mmHg in DBP compared to those in the greatest quintile. CONCLUSION: A high DASH score and a reduction in alcohol consumption could be effective nutritional strategies for the prevention of hypertension.

Association Between Blood Pressure and Adherence to French Dietary Guidelines.

BACKGROUND: Adopting a healthy diet like the Dietary Approach to Stop Hypertension (DASH) or Mediterranean diet (MD) represents a major lifestyle for blood pressure (BP) control in general population. Nutritional policies, such as the French Nutrition and Health Program (Programme National Nutrition Santé or PNNS), have been implemented in several countries with the aims of preventing chronic diseases. The objective of our study was to investigate association between BP and adherence to PNNS guidelines compared with adherence to DASH or MD. METHODS: We conducted a cross-sectional study in 11,302 untreated participants from the NutriNet-Santé study, a French web-based cohort study. Three validated scores reflecting adherence to PNNS guidelines, DASH diet, and MD were calculated from repeated 24-hour records. Three BP measurements using a standardized protocol were collected. Multivariate linear models were used to assess the associations between the dietary scores and BP. RESULTS: In women, independent of age, socioeconomic status, body mass index, tobacco use, alcohol consumption, and physical activity, adherence to PNNS guidelines was inversely significantly associated with systolic BP (ß = -0.63, P < 0.0001). This association was of similar amplitude that between BP and adherence to DASH-style diet (ß = -0.66, P < 0.0001) or MD (ß = -0.63, P = 0.0002). No significant association was found in men. CONCLUSION: Adherence to French nutritional recommendations was found negatively associated with BP at the same magnitude as adherence to well-known dietary pattern in the prevention and treatment of hypertension.

Pulse Pressure and Risk for Cardiovascular Events in Patients With Atherothrombosis: From the REACH Registry.

BACKGROUND: Pulse pressure (PP) provides valuable prognostic information in specific populations, but few studies have assessed its value on cardiovascular outcomes in a broad, worldwide population. OBJECTIVES: The aim of this study was to determine whether PP is associated with major adverse cardiovascular outcomes, independently of mean arterial pressure. METHODS: Participants from the international REACH (Reduction of Atherothrombosis for Continued Health) registry, which evaluates subjects with clinical atherothrombotic disease or risk factors for its development, were examined. Those with incomplete 4-year follow-up or PP data (final n = 45,087) were excluded. Univariate and multivariate regression analyses were performed to determine the association between PP and cardiovascular outcomes, including cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, all myocardial infarction, all stroke, cardiovascular hospitalization, and a combined outcome. PP was analyzed as a continuous and categorical (i.e., by quartile) variable. RESULTS: The mean age of the cohort was 68 ± 10 years, 35% were women, and 81% were treated for hypertension. The mean blood pressure was 138 ± 19/79 ± 11 mm Hg, rendering a mean PP of 49 ± 16 mm Hg. On univariate analysis, increasing PP quartile was associated with worse outcomes (p < 0.05 for all comparisons). After adjusting for sex, age, current smoking status, history of hypercholesterolemia, history of diabetes, aspirin use, statin use, blood pressure medication use, and mean arterial pressure, PP quartile was still associated with all outcomes except all stroke and cardiovascular death (p < 0.05 for all comparisons). Analysis of PP as a continuous variable yielded similar results. CONCLUSIONS: In an international cohort of high-risk subjects, PP, a readily available hemodynamic parameter, is associated with multiple adverse cardiovascular outcomes and provides prognostic utility beyond that of mean arterial pressure.

[Hypertensive emergencies and urgencies]. / Vraies et fausses urgences hypertensives.

Hypertension is a common disease, the most common chronic disease. Hypertensive emergency is much less frequent and only affects 1 to 2 % of all hypertensive patients. The true hypertensive emergency is characterized by the serious damage of one hypertensive target organ and requires an urgent intravenous treatment. Isolated blood pressure elevation should not be regarded as a hypertensive emergency if there is no target organ damage, even if the blood pressure is very high. These situations of "false hypertensive emergency", or hypertensive urgencies, often requires an immediate treatment, but oral. Signs of visceral pain of true hypertensive emergency often are a poor general condition, severe headache, decreased visual acuity, neurological deficit of ischemic or hemorrhagic cause, confusion, dyspnea with orthopnoea revealing heart failure, angina, chest pain revealing an aortic dissection, proteinuria, acute renal failure or eclampsia. True hypertensive emergencies include several entities, namely: severe hypertension, malignant hypertension and accelerated hypertension. If malignant hypertension is not treated, the prognosis is poor with 50 % death risk in the following year.

Cholesterol and breast cancer risk: a systematic review and meta-analysis of prospective studies.

The objective of the present study was to conduct the first systematic review and meta-analysis of prospective studies investigating the associations between total cholesterol (TC), HDL-cholesterol (HDL-C) and LDL-cholesterol (LDL-C) levels and the risk of breast cancer. Relevant studies were identified in PubMed (up to January 2014). Inclusion criteria were original peer-reviewed publications with a prospective design. Random-effects models were used to estimate summary hazard ratios (HR) and 95% CI. Distinction was made between studies that did or did not exclude cancer cases diagnosed during the first years of follow-up, thereby eliminating potential preclinical bias. Overall, the summary HR for the association between TC and breast cancer risk was 0.97 (95% CI 0.94, 1.00; dose-response per 1 mmol/l increment, thirteen studies), and that between HDL-C and breast cancer risk was 0.86 (95% CI 0.69, 1.09; dose-response per 1 mmol/l increment, six studies), with high heterogeneity (I2= 67 and 47%, respectively). For studies that eliminated preclinical bias, an inverse association was observed between the risk of breast cancer and TC (dose-response HR 0.94 (95% CI 0.89, 0.99), seven studies, I2= 78%; highest v. lowest HR 0.82 (95% CI 0.66, 1.02), nine studies, I2= 81%) and HDL-C (dose-response HR 0.81 (95% CI 0.65, 1.02), five studies, I2= 30 %; highest v. lowest HR 0.82 (95% CI 0.69, 0.98), five studies, I2= 0%). There was no association observed between LDL-C and the risk of breast cancer (four studies). The present meta-analysis confirms the evidence of a modest but statistically significant inverse association between TC and more specifically HDL-C and the risk of breast cancer, supported by mechanistic plausibility from experimental studies. Further large prospective studies that adequately control for preclinical bias are needed to confirm the results on the role of cholesterol level and its fractions in the aetiology of breast cancer.