Gain in net survival from hypertension control over the last half-century.

AIMS: This study determined whether the improvements in hypertension management over the last five decades have influenced subjects' prognosis. METHODS AND RESULTS: The study considered 5693 eligible subjects seen January 1969 to February 1991 (follow-up until December 2003) or January 1995 to October 2014 (follow-up until July 2016) in an all-grade hypertension reference centre. Missing data or incomplete follow-ups led to exclude 1036 subjects (18%). The outcome was all-cause death. An adjusted modelling of the excess mortality rate assessed subjects' net survival over five inclusion periods to allow for the increase in life expectancy of the general population during the same periods. The analysis of 4657 records (mean age: 47 years; 43.2% women) showed that the proportion of subjects with grade 3 hypertension decreased significantly from 43.3% (1142) to only 6.3% (22) over the five periods and that the net survival improved in men and women regardless of the hypertension grade; i.e. the gain in net survival at 15 years was estimated at 12.3% (95% confidence interval: 8.1-22.3). The 15-year restricted mean survival was estimated at 13 years over the first period and 14.8 years over the last period, which is nearly a 2-year gain in life expectancy at 15 years. CONCLUSION: Since the 70s and the advent of modern management, the excess mortality of hypertensive subjects (vs. the general population) was markedly reduced. Within a context of trivialization of blood pressure measurement and reluctance to long-term treatments, physicians should consider this advantage and use it to promote blood pressure control.

Impact of cortisol on blood pressure and hypertension-mediated organ damage in hypertensive patients.

OBJECTIVES: Patients with overt and subclinical Cushing's syndrome frequently develop hypertension, metabolism disorders, and atherosclerotic lesions. The aim of the present study was to test the association between cortisol and blood pressure (BP), organ damage, and metabolic parameters in hypertensive patients without hypercortisolism. METHODS: After exclusion of patients treated with corticosteroids or with Cushing's syndrome, the cohort included 623 hypertensive patients (mean ±â€ŠSD age 50.3 ±â€Š15.4 years, 50.9% men, median 24-h BP 146/88 mmHg) with an extended work-up (lipid profile, hypertension-mediated organ damage). Cortisol secretion was assessed by plasma cortisol at 0800 and 1600 h, and by 24-h urinary free cortisol (24 h UFC) normalized if required to urine creatinine (UFC/U creat). RESULTS: Plasma cortisol at 1600 h, 24 h-UFC, and UFC/U creat were significantly and positively correlated with daytime, night-time, and 24-h SBP; plasma cortisol at 0800 h was not associated with BP. The strongest correlations were observed in the subgroup of aged more than 50 years (correlation coefficients between 0.23 and 0.28). These correlations remained after adjustment on plasma aldosterone. Metabolic parameters were weakly associated with cortisol. Arterial stiffness (central pulse pressure and pulse wave velocity), plasma NT-proBNP, and microalbuminuria were significantly correlated with 24 h UFC, UFC/U creat, and plasma cortisol at 1600 h. CONCLUSION: Cortisol influences weakly the level of BP independently from plasma aldosterone in hypertensive patients, particularly in older patients, and that there was weak association with HMOD. It may, therefore, be of interest to test specific treatments targeting cortisol excess in selected hypertensive patients.

Risk stratification in hypertension: NT-proBNP and R wave in aVL lead combination better than echocardiographic left ventricular mass.

OBJECTIVES: Plasma N-terminal pro brain natriuretic peptide (NT-proBNP) and R wave in aVL lead (RaVL) have been associated with mortality in hypertension. The aim of the current study was to compare the prognostic value of their combination to that of the left ventricular mass index (LVMI) assessed by echocardiography. METHODS: A total of 1104 hypertensive patients who had at baseline an assessment of plasma NT-proBNP, a 12-lead ECG, and echocardiography were included. LVMI was assessable in 921 patients. After a median (interquartile range) follow-up of 8.5 (5.4-13.3) years, 110 deaths occurred, 62 of which were from a cardiovascular cause. RESULTS: Optimal thresholds of RaVL and plasma NT-proBNP to predict mortality were 0.7 mV and 150 pg/ml, respectively. A three-modality variable based on RaVL and NT-proBNP was built: 0 when none were above the threshold, 1 or 2 when only one or both were above the threshold. After adjustment for all confounders including LVMI indexed to height raised to the allometric power of 2.7 in Cox regression analysis, we observed a significant increased risk for patients having one marker above the threshold for all-cause and cardiovascular mortality [hazard ratio: 1.76; 95% confidence interval (1.08-2.86); 2.18 (1.06-4.46)] and for those having two markers above the threshold [2.76 (1.51-5.03); 3.90 (1.69-9.00)]. The prognostic value of the combination had the highest C-index (0.772 and 0.839, respectively) in comparison with LVMI (0.746 and 0.806, respectively). CONCLUSION: Risk stratification in hypertension using the combination of NT-proBNP and RaVL is a simple method that may be considered in first line screening.

Decreased plasma prorenin levels in primary aldosteronism: potential diagnostic implications.

AIM: Primary aldosteronism could exert a negative feedback on prorenin secretion, of possibly different magnitude, whether it is related to an aldosterone-producing adenoma (APA) or an idiopathic hyperaldosteronism (IHA). The objectives of this study were to evaluate the level of prorenin in three subgroups: APA, IHA, and essential hypertension; and the performance of the aldosterone-to-prorenin ratio (APR) for the diagnosis of an APA. METHODS: Seven hundred and forty-six hypertensive patients with a standardized work-up, including a prorenin measurement, were considered. Ninety-six patients without neutral treatment and 38 patients with other forms of secondary hypertension were excluded. APA and IHA were categorized according to computed tomography scan, adrenal venous sampling, pathological analysis and improvement of hypertension after surgery. RESULTS: Thirty-five patients had a diagnosis of APA, 57 of IHA and 504 of essential hypertension. Prorenin was lower in APA and IHA than in essential hypertension (32.9, 40.4 and 50.3  pg/ml, respectively; P < 0.001). APR was higher in patients with APA and IHA than in those with essential hypertension (24.0, 11.8, and 4.0  pmol/l per pg/ml, respectively; P < 0.001). The APR was more discriminant than the aldosterone-to-renin ratio to identify APA compared to IHA (area under the receiver operating curve at 0.750 and 0.639, respectively; P = 0.04). The optimal cut-off values were 22  pmol/l per pg/ml for APR (sensitivity 57.0%, specificity 93.0%) and 440  pmol/l per pg/ml for aldosterone-to-renin ratio (sensitivity 54.3%, specificity 82.5%). CONCLUSION: Primary aldosteronism and particularly its most caricatural form, that is APA, seems associated with a lower level of prorenin than essential hypertension. The APR could be included in the diagnostic strategy of APA.