High prevalence of masked uncontrolled hypertension in people with treated hypertension.

AIM: There are limited data on the quality of treated blood pressure (BP) control during normal daily life, and in particular, the prevalence of 'masked uncontrolled hypertension' (MUCH) in people with treated and seemingly well-controlled BP is unknown. This is important because masked hypertension in 'treatment naïve' patients is associated with a high risk of cardiovascular events. We therefore conducted the first study to define the prevalence and characteristics of MUCH among a large sample of hypertensive patients in routine clinical practice in whom BP was treated and controlled to recommended clinic BP goals. METHODS AND RESULTS: We analysed data from the Spanish Society of Hypertension ambulatory blood pressure monitoring (ABPM) Registry and identified patients with treated and controlled BP according to current international guidelines (clinic BP <140/90 mmHg). Masked uncontrolled hypertension was diagnosed in these patients if despite controlled clinic BP, the mean 24-h ABPM average remained elevated (24-h systolic BP ≥130 mmHg and/or 24-h diastolic BP ≥80 mmHg). From 62 788 patients with treated BP in the Spanish registry, we identified 14 840 with treated and controlled clinic BP, of whom 4608 patients (31.1%) had MUCH according to 24-h ABPM criteria (mean age 59.4 years, 59.7% men). The prevalence of MUCH was significantly higher in males, patients with borderline clinic BP (130-9/80-9 mmHg), and patients at high cardiovascular risk (smokers, diabetes, obesity). Masked uncontrolled hypertension was most often because of poor control of nocturnal BP, with the proportion of patients in whom MUCH was solely attributable to an elevated nocturnal BP almost double that solely attributable to daytime BP elevation (24.3 vs. 12.9%, P < 0.001). CONCLUSION: The prevalence of masked suboptimal BP control in patients with treated and well-controlled clinic BP is high. Clinic BP monitoring alone is thus inadequate to optimize BP control because many patients have an elevated nocturnal BP. These findings suggest that ABPM should become more routine to confirm BP control, especially in higher risk groups and/or those with borderline control of clinic BP.

Increased pulse pressure is associated with left atrial enlargement in resistant hypertensive patients.

Resistant hypertension (RH) is frequently associated with a high prevalence of target organ damage, which impairs the prognosis of these patients. Considering cardiac alterations in RH, most attention has been devoted to left ventricular hypertrophy (LVH), but data concerning left atrial enlargement (LAE) is less known. This cross-sectional study assessed the factors associated with LAE, with special focus on blood pressure (BP) estimates obtained by ambulatory blood pressure monitoring (ABPM), in 250 patients with RH, aged 64 ± 11 years. LAE and LVH were observed in 10.0% (95% CI 6.3-13.7) and 57.1% (95% CI 50.8-63.5) of patients, respectively. Compared with patients with normal atrium size, those exhibiting LAE were older, more frequently women, had elevated pulse pressure (PP) measured both at the office and by ABPM, and showed higher prevalence of LVH (83% vs 54%; p = 0.016). In a logistic regression analysis, adjusting for age, gender, body mass index, left ventricular mass index and BP pressure estimates, night-time PP was independently associated with LAE (OR for 5 mmHg = 1.28, 95% CI 1.24-1.32; p = 0.001). In conclusion, besides classical determinants of LAE, such as age and LVH, an elevated night-time PP was independently associated with LAE in patients with RH.

Predictors of postpartum diabetes mellitus in patients with gestational diabetes. / Factores predictores de diabetes mellitus posparto en pacientes con diabetes gestacional.

INTRODUCTION: Gestational diabetes (GD) is related to development of diabetes mellitus (DM) after delivery. The predictive factors in this association are not yet well defined. Objetive: to study the predictive factors of dysglucosis in the postpartum period in a sample of patients with GD. MATERIAL AND METHODS: A total of 1765 women with DG were studied. Variables analyzed: anthropometric data and maternal history. Glycemia in OGTT with 100g (basal: 1, 2 and 3h) and HbA1c. Use of insulin in pregnancy. The OGTT with 75g and HbA1c at 3 months after delivery. RESULTS: Postpartum DM prevalence 2.1%. Among these patients, there was a higher percentage of patients with a history of GD (25.9 vs. 12.9%; P<.05), pre-pregnancy obesity (20.8 vs. 14.9%; P<.05) and insulin use during pregnancy (79.2 vs. 20%; P<.01). In the OGTT with 100g, the number of pathological points was higher (3.18±0.69 in DM vs. 2.3±0.28 normal, 2.6±0.47 IFG, 2.5±0.32 IGT; P<.001). In the OGTT 100g, the blood glucose level above which the diagnosis of postpartum DM is most likely is 189mg/dl in the 2h determination (S: 86.2%, E: 72%). A level of HbA1c>5.9% during pregnancy has a specificity of 95.9% for the diagnosis of postpartum DM in our sample. CONCLUSION: We show factors associated with the diagnosis of postpartum DM, among which are quantitative determinations such as glycemia at 2h of the OGTT with 100g and HbA1c during pregnancy in patients with DG.

Pioglitazone decreases ambulatory blood pressure in type 2 diabetics with difficult-to-control hypertension.

Blood pressure (BP) control at recently established goals of <130/80 mm Hg is often difficult to achieve in diabetic patients. This work examines the effect of pioglitazone on 24-hour ambulatory BP monitoring in patients with type 2 diabetes and difficult-to-control hypertension. Twenty-seven participants with difficult-to-control hypertension (defined as ambulatory BP monitoring >or=125/75 mm Hg) taking antihypertensive medications (mean, 4.1+/-0.8 drugs) were enrolled in an open, prospective, blinded end point study of add-on therapy with pioglitazone 30 to 45 mg for 20 weeks. After 20 weeks of treatment, 24-hour ambulatory BP monitoring showed significant reductions (from 144+/-13 to 136+/-16 mm Hg systolic BP and from 79+/-9 to 76+/-10 mm Hg diastolic BP [P=.001]). Treatment was also associated with improvements in insulin sensitivity and glycemic and lipid profile. These findings suggest that pioglitazone could be a therapeutic option in diabetics who still have elevated BP values in spite of receiving treatment with at least 3 antihypertensive drugs.

Clinic Versus Daytime Ambulatory Blood Pressure Difference in Hypertensive Patients: The Impact of Age and Clinic Blood Pressure.

Clinic blood pressure (BP) is usually higher than daytime ambulatory BP in hypertensive patients, but some recent studies have challenged this view, suggesting that this relationship is strongly influenced by age. We used the Spanish ambulatory BP monitoring cohort to examine differences between clinic and daytime BP by age among 104 639 adult hypertensive patients (office systolic/diastolic BP ≥140/90 mm Hg or treated) in usual primary-care practice, across the wide age spectrum. To assess the impact of age, cardiovascular variables, and clinic BP on the clinic-daytime BP differences, we built multivariable regression models of the average BP differences, white-coat hypertension (high clinic BP and normal daytime BP), and masked hypertension (normal clinic BP and high daytime BP). In most patients, mean clinic BP values were higher than daytime BP at all ages. Some 36.7% of patients had white-coat hypertension (amounting to 50% at clinic systolic BP of 140-159 mm Hg) and 3.9% had masked hypertension (amounting to 18% at clinic systolic BP of 130-139 mm Hg). Age explained 0.1% to 1.7% of the variance of quantitative or categorical BP differences (P<0.001). Cardiovascular variables explained an additional 1.6% to 3.4% of the variance (P<0.001). Finally, clinic BP generally explained ≥20% more of the variance (P<0.01). In this large study in usual clinical practice, clinic BP misclassified hypertension status in >40% of patients. This misclassification was not importantly influenced by age but was more evident in patients with borderline/grade 1 hypertension. These findings reinforce the importance of ambulatory BP monitoring for defining BP status in routine clinical practice.

Left ventricular geometric patterns after 1 year of antihypertensive treatment.

Left ventricular hypertrophy increases the risk for cardiovascular target organ damage, myocardial infarction, and stroke. The authors assessed the patterns of ventricular adaptation in 107 essential hypertensives whose treatment had been withdrawn and its modification after 1 year of hypertension treatment. Blood pressure decreased from 158+/-17/96+/-12 mm Hg to 137+/-15/83+/-10 mm Hg (mean +/- SD; p<0.001); 45% of the patients (49 of 107) had their blood pressure controlled below 140 mm Hg and 90 mm Hg. Although a significant decrease of left ventricular mass index was found in the study, the percentage of patients with normal left ventricular geometry at the completion of the study increased by only 9% (27% to 36%, p>0.05). Left ventricular mass geometry improved in 31% of the patients, remained unaffected in 51%, and worsened in 18%. The data suggest that even while suboptimal antihypertensive treatment reduces left ventricular mass index, either left ventricular hypertrophy or concentric remodeling remains present in a significant number of patients at the end of a 1-year treatment period. The authors conclude that these patients should be considered as a subgroup at high risk and should be treated more aggressively.

Influence of metabolic syndrome on risk stratification in hypertensive patients: differences between 2003 and 2007 ESH-ESC guidelines.

OBJECTIVE: To investigate the influence of metabolic syndrome (MS) on risk stratification and ulterior classification in hypertensive patients at entry into a hypertension unit by comparing the criteria of ESH-ESC 2003 and 2007 guidelines. METHODS: 720 consecutive patients attending a hospital-located hypertension unit were included in the study. They were classified with or without MS according to the ATP-III 2005 report. Patients underwent repeated office BP measurements and routine blood/urine examinations. In addition ultrasensitive CRP (uCRP), echocardiogram, fasting insulin, urinary albumin excretion were determined and HOMA index was calculated. RESULTS: The prevalence of MS was 58.8 %. Abdominal obesity and fasting glucose were the most prevalent components of MS, and HDL-cholesterol the least prevalent. MS group had higher levels of LDL-cholesterol and higher prevalence of left ventricular hypertrophy and microalbuminuria. Patients with MS also presented a significant elevation in uCRP, fasting insulin and HOMA. BP was controlled in 55.6%. When we applied the 2003 guideline, 48.9% patients showed a high or very high added cardiovascular risk. With the applications of the 2007 guide the prevalence of this two categories reach 73.9%. CONCLUSIONS: A significant difference in the risk pattern distribution is found when MS is considered in risk stratification in our hypertensive population. The accompanying increase in the levels of other cardiovascular risk factors and in the prevalence of target organ damage justifies the global intervention on cardiovascular risk recommended by 2007 ESH-ESC guidelines.

Factores predictores de diabetes mellitus posparto en pacientes con diabetes gestacional / Predictors of postpartum diabetes mellitus in patients with gestational diabetes

Introducción: La diabetes gestacional (DG) está relacionada con el desarrollo de la diabetes mellitus (DM) tras el parto. Los predictores en esta asociación aún no están bien definidos. El objetivo de nuestro trabajo es estudiar los factores predictores de disglucosis en el posparto en una muestra de pacientes con DG. Material y métodos: Un total de 1.765 mujeres con DG fueron estudiadas. Variables analizadas: datos antropométricos y antecedentes maternos. Glucemia en sobrecarga de glucosa (SOG) con 100g (basal: 1, 2 y 3h) y HbA1c. Uso de insulina en la gestación. La SOG con 75g y HbA1c a los 3 meses tras el parto. Resultados: Prevalencia DM posparto: 2,1%. Entre estas pacientes hubo mayor porcentaje de pacientes con antecedentes de DG (25,9 vs. 12,9%; p<0,05), obesidad pregestacional (20,8 vs. 14,9%; p<0,05) y uso de insulina durante el embarazo (79,2 vs. 20%; p<0,01). En la SOG con 100g, el número de puntos patológicos fue mayor (3,18±0,69 en DM vs. 2,3±0,28 normal, 2,6±0,47 GBA, 2,5±0,32 IHC; p<0,001). En la SOG con 100g, el nivel de glucemia por encima del cual es más probable el diagnístico de DM posparto es 189mg/dl en la determinación a las 2h (S: 86,2%; E: 72%). Un nivel de HbA1c>5,9% durante la gestación tiene una especificidad del 95,9% para el diagnóstico de DM posparto en nuestra muestra. Conclusión: Evidenciamos factores asociados al diagnóstico de DM posparto entre los que se encuentran determinaciones cuantitativas como la glucemia a las 2h de la SOG con 100g y la HbA1c durante la gestación en pacientes con DG

Introduction: Gestational diabetes (GD) is related to development of diabetes mellitus (DM) after delivery. The predictive factors in this association are not yet well defined. Objetive: to study the predictive factors of dysglucosis in the postpartum period in a sample of patients with GD. Material and methods: A total of 1765 women with DG were studied. Variables analyzed: anthropometric data and maternal history. Glycemia in OGTT with 100g (basal: 1, 2 and 3h) and HbA1c. Use of insulin in pregnancy. The OGTT with 75g and HbA1c at 3 months after delivery. Results: Postpartum DM prevalence 2.1%. Among these patients, there was a higher percentage of patients with a history of GD (25.9 vs. 12.9%; P<.05), pre-pregnancy obesity (20.8 vs. 14.9%; P<.05) and insulin use during pregnancy (79.2 vs. 20%; P<.01). In the OGTT with 100g, the number of pathological points was higher (3.18±0.69 in DM vs. 2.3±0.28 normal, 2.6±0.47 IFG, 2.5±0.32 IGT; P<.001). In the OGTT 100g, the blood glucose level above which the diagnosis of postpartum DM is most likely is 189mg/dl in the 2h determination (S: 86.2%, E: 72%). A level of HbA1c>5.9% during pregnancy has a specificity of 95.9% for the diagnosis of postpartum DM in our sample. Conclusion: We show factors associated with the diagnosis of postpartum DM, among which are quantitative determinations such as glycemia at 2h of the OGTT with 100g and HbA1c during pregnancy in patients with DG

High prevalence of secondary hypertension and insulin resistance in patients with refractory hypertension.

OBJECTIVE: To determine causes of treatment resistance in patients with refractory hypertension, and to estimate the prevalence of true resistant hypertension. METHODS: We studied 50 consecutive patients referred with refractory hypertension after exclusion of hypokalemia and stenosis of the renal artery. Ambulatory blood pressure monitoring was performed in all patients to detect white-coat effect. The patients were hospitalized, antihypertensive drugs were withdrawn and a screening for secondary hypertension was performed. In addition, these patients, and a control group of essential hypertensives controlled with three antihypertensive drugs, underwent a OGTT with 75 g of glucose. RESULTS: Primary normokalemic hyperaldosteronism was diagnosed in seven patients. Two patients had a pheochromocytoma and six had white-coat effect. The 35 remaining patients with true resistant hypertension shown significant differences in serum insulin and HOMA IR when compared with the control group. CONCLUSIONS: These findings show that among normokalemic treatment-resistant hypertension, the presence of hyperaldosteronism and pheochromocytoma is quite high. Moreover, treatment resistance in hypertensive patients appears to be associated with insulin resistance.