On the transition from a nurse-led hypertension clinic to hypertension control in primary care: identifying barriers to and factors acting against continuous hypertension control.

Many hypertensive patients are not treated to target and hence do not benefit fully from the blood pressure-related improvements in cardiovascular health. Hypertensive patients who had primarily been treated to a target goal in a nurse-led hypertension clinic were re-examined to evaluate whether their target goal blood pressure was maintained after their discharge from the hypertension clinic for further control in primary care, and to evaluate potential barriers to and factors acting against continuous hypertension control. The median observation time was 3.6 years (range 3 months to 7.9 years). Only 45.2% of the patients were well controlled at the time of re-examination. No patient-related factors (age, body mass index, gender, attitudes towards medication) predicted the outcome. Two factors were significant in the reduction in continuous hypertension control: the cooperation between the patient and health personnel and the shared commitment towards the target goal were discontinued; and many patients did not make control visits to the general practitioner's office. In conclusion, maintained strict control of hypertension requires both continued close collaboration between the patient and health personnel, with an emphasis on treatment goals, and systematic control visits.

Cuff size influences blood pressure measurement in obese children and adolescents.

INTRODUCTION: Recently, we established that a group of obese children and adolescents had a higher blood pressure (BP) than a healthy control group. In the present study, we investigate whether the higher BP in the obese group was influenced by BP cuff sizes. METHODS: A total of 104 obese patients aged 10-18 years were compared with 50 controls. BP was measured with a validated oscillometric device using an appropriate cuff size depending on each person's arm circumferences (AC) according to the manufacturer's recommendation; small (AC < 23 cm), medium (23 ≤ AC < 32 cm) and large (AC ≥ 32 cm). RESULTS: Cuff sizes had a significant impact on BP measurements. Despite the influence of cuff size, multiple regression analyses revealed that systolic BP was 6.8 mmHg higher and diastolic BP 3.2 mmHg higher in the obese group than in the control group. A step function, i.e. a sudden fall in BP, was seen at the point of switching from small to medium cuff size in the control group, which suggests that systolic BP was overestimated when using small cuff size and underestimated when using medium cuff size in subjects with an AC near 23 cm. CONCLUSIONS: BP was higher in the obese group than in the control group although BP was influenced by BP cuff sizes. FUNDING: The present project received funding from The Health Sciences Research Foundation of Region Zealand, The Danish Heart Foundation, Kathrine og Vigo Skovgaards Fond, Det Medicinske Selskab i København, Edith og Henrik Henriksens Mindelegat and LEO Pharma's Travel Grant. TRIAL REGISTRATION: ClinicalTrials.gov id: NCT01310088.

Blood pressure variability predicts cardiovascular events independently of traditional cardiovascular risk factors and target organ damage: a LIFE substudy.

BACKGROUND: Assessment of antihypertensive treatment is normally based on the mean value of a number of blood pressure (BP) measurements. However, it is uncertain whether high in-treatment visit-to-visit BP variability may be harmful in hypertensive patients with left ventricular hypertrophy (LVH). METHODS: In 8505 patients randomized to losartan vs. atenolol-based treatment in the LIFE study, we tested whether BP variability assessed as SD and range for BP6-24 months measured at 6, 12, 18 and 24 months of treatment was associated with target organ damage (TOD) defined by LVH on ECG and urine albumin/creatinine ratio at 24 months, and predicted the composite endpoint (CEP) of cardiovascular death, nonfatal myocardial infarction (MI) or stroke occurring after 24 months (CEP = 630 events). RESULTS: In multiple regression models adjusted for mean BP6-24 months and treatment allocation, neither high BP6-24 months SD nor wide range were related to TOD at 24 months, except for a weak association between Sokolow-Lyon voltage and DBP6-24 months SD and range (both ß = 0.04, P < 0.01). Independently of mean BP6-24 months, treatment allocation, TOD and baseline characteristics in Cox regression models, CEP after 24 months was associated with DBP6-24 months SD [hazard ratio per 1 mmHg increase1.04, 95% confidence interval (95% CI) 1.01-1.06, P = 0.005], range (hazard ratio 1.02, 95% CI 1.01-1.03, P = 0.004), SBP6-24 months SD (hazard ratio 1.01, 95% CI 0.99-1.02, P = 0.07) and range (hazard ratio 1.006, 95% CI 1.001-1.01, P = 0.04). Adjusted for the same factors, stroke was associated with DBP6-24 months SD (hazard ratio 1.06, 95% CI 1.02-1.10, P = 0.001), range (hazard ratio 1.03, 95% CI 1.01-1.04, P = 0.001), SBP6-24 months SD (hazard ratio 1.02, 95% CI 1.002-1.04, P = 0.04) and range (hazard ratio 1.008, 95% CI 1.001-1.02, P = 0.05), but MI was not. CONCLUSION: In LIFE patients, higher in-treatment BP6-24 months variability was independently of mean BP6-24 months associated with later CEP and stroke, but not with MI or TOD after 24 months.

Adipocytokines, C-reactive protein, and cardiovascular disease: a population-based prospective study.

BACKGROUND: Being overweight or obese is associated with a greater risk of coronary heart disease and stroke compared with normal weight. The role of the specific adipose tissue-derived substances, called adipocytokines, in overweight- and obesity-related cardiovascular disease (CVD) is still unclear. OBJECTIVE: To investigate the associations of three adipose tissue-derived substances: adiponectin, leptin, and interleukin-6 with incident CVD in a longitudinal population-based study, including extensive adjustments for traditional and metabolic risk factors closely associated with overweight and obesity. C-reactive protein (CRP) was used as a proxy for interleukin-6. METHODS: Prospective population-based study of 6.502 participants, 51.9% women, aged 30-60 years, free of CVD at baseline, with a mean follow-up time of 11.4 years, equivalent to 74,123 person-years of follow-up. As outcome, we defined a composite outcome comprising of the first event of fatal and nonfatal coronary heart disease and fatal and nonfatal stroke. RESULTS: During the follow-up period, 453 composite CV outcomes occurred among participants with complete datasets. In models, including gender, age, smoking status, systolic blood pressure, treatment for hypertension, diabetes, body mass index (BMI), total cholesterol, high-density-lipoprotein cholesterol, homeostasis model assessment of insulin resistance, estimated glomerular filtration rate, adiponectin, leptin, and CRP, neither adiponectin (hazard ratio [HR] with 95% confidence interval [CI]: 0.97 [0.87-1.08] per SD increase, P = 0.60) nor leptin (0.97 [0.85-1.12] per SD increase, P = 0.70) predicted the composite outcome, whereas CRP was significantly associated with the composite outcome (1.19 [1.07-1.35] per SD increase, P = 0.002). Furthermore, in mediation analysis, adjusted for age and sex, CRP decreased the BMI-associated CV risk by 43% (95%CI 29-72). CONCLUSIONS: In this study, neither adiponectin nor leptin were independently associated with CVD, raising questions over their role in CVD. The finding that CRP was significantly associated with an increased risk of CVD and decreased the BMI-associated CVD risk substantially, could imply that interleukin-6-related pathways may play a role in mediating overweight- and obesity-related CVD.

Higher serum concentrations of N-terminal pro-B-type natriuretic peptide associate with prevalent hypertension whereas lower associate with incident hypertension.

BACKGROUND: The role of the natriuretic peptides (NPs) in hypertension is complex. Thus, a higher blood NP concentration is a robust marker of pressure-induced cardiac damage in patients with hypertension, whereas genetically elevated NP concentrations are associated with a reduced risk of hypertension and overweight individuals presumably at high risk of hypertension have lower NP concentrations. OBJECTIVE: To investigate the associations between serum N-terminal pro-B-type natriuretic peptide (NT-proBNP), used as a surrogate marker for active BNP, and prevalent as well as 5-year incident hypertension in a Danish general population sample. METHODS: Cross-sectional and prospective population-based study. RESULTS: At baseline, among 5,307 participants (51.3% women, mean age 46.0±7.9 years) with a complete set of data, we recorded 1,979 cases with prevalent hypertension (PHT). Among 2,389 normotensive participants at baseline with a complete set of data, we recorded 324 cases with incident hypertension (IHT) on follow-up 5 years later. In models adjusted for age, sex, lifestyle, social, dietary, anthropometric, pulmonic, lipid, metabolic and renal risk factors, as well as heart rate and baseline blood pressure (only incident model), one standard deviation increase in baseline log-transformed NT-proBNP concentrations was on one side associated with a 21% higher risk of PHT (odds ratio [OR]: 1.21 [95% confidence interval (CI): 1.13-1.30], P<0.001), and on the other side with a 14% lower risk of IHT (OR: 0.86 [95%CI:0.76-0.98], P = 0.020). CONCLUSIONS: Higher serum concentrations of NT-proBNP associate with PHT whereas lower concentrations associate with IHT. This suggests that a lower amount of circulating BNP, resulting in diminished vasodilation and natriuresis, could be involved in the pathogenesis of hypertension in its early stages.

[After weight loss a child fits a smaller blood pressure cuff but gets elevated blood pressure]. / Overvægtigt barn taber sig til en mindre blodtryksmanchet, men højere blodtryk.

A ten-year-old boy referred to childhood obesity treatment lost weight after one year of lifestyle intervention to a degree where he was no longer obese. Contrary to anticipated beyond the effect of a normal growth, his clinical blood pressure (BP) was higher after weight loss. This observation was caused by the use of a smaller BP cuff compared to a larger cuff at baseline. In general, weight loss in obese children during growth and development pose a challenge in regard to which BP cuff size should be used and in regard to interpretive challenges of the BP.

Five-year weight changes associate with blood pressure alterations independent of changes in serum insulin.

OBJECTIVE: In overweight-related hypertension, the effect of weight changes on blood pressure (BP) is believed to be mediated by insulin. To test this hypothesis, we studied 5-year changes in weight, BP, and insulin in a general population of Danish adults (n = 3443; mean age 45.7 ±â€Š7.6 years). METHODS: We assessed the glucose-insulin metabolism by a standard oral glucose tolerance test. We divided the antihypertensive and antidiabetic medication-free participants into three groups: weight loss (n = 515), weight stable (n = 1778), and weight gain (n = 1150). RESULTS: Losing on average 6.5 kg body weight, the weight loss group experienced a 28.2% reduction [(95% confidence interval [CI] -31 to -25); P < 0.001] in fasting insulin and a 23.9% reduction [(95% CI -28 to -19); P < 0.001] in 2-h insulin. Gaining on average 6.4 kg, the weight gain group experienced a 12.5% increase [(95% CI 9 to 16); P < 0.001] in fasting insulin and 32.8% increase [(95% CI 28 to 38); P < 0.001] in 2-h insulin. Using linear regression adjusting for differences in sex, age, family history of hypertension, baseline BMI, SBP and DBP, lifestyle risk factors, and their 5-year changes, weight loss was associated with a decrease in SBP of -1.8 mmHg (95% CI -2.8 to -0.7), whereas weight gain with an increase in SBP of 1.9 mmHg (95% CI 1.2 to 2.6), both with P less than 0.001. Adding fasting insulin, 2-h insulin, Δfasting insulin, and Δ2-h insulin only marginally attenuated the association, and furthermore, none of the insulin variables was significantly associated with SBP or DBP (P ≥ 0.08). The results for changes in DBP were similar to SBP. CONCLUSION: Five-year weight changes associate with BP alterations independent of the insulin changes.

Impact of age and gender on the prevalence and prognostic importance of the metabolic syndrome and its components in Europeans. The MORGAM Prospective Cohort Project.

OBJECTIVE: To investigate the influence of age and gender on the prevalence and cardiovascular disease (CVD) risk in Europeans presenting with the Metabolic Syndrome (MetS). METHODS: Using 36 cohorts from the MORGAM-Project with baseline between 1982-1997, 69094 men and women aged 19-78 years, without known CVD, were included. During 12.2 years of follow-up, 3.7%/2.1% of men/women died due to CVD. The corresponding percentages for fatal and nonfatal coronary heart disease (CHD) and stroke were 8.3/3.8 and 3.1/2.5. RESULTS: The prevalence of MetS, according to modified definitions of the International Diabetes Federation (IDF) and the revised National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII), increased across age groups for both genders (P<0.0001); with a 5-fold increase in women from ages 19-39 years to 60-78 years (7.4%/7.6% to 35.4%/37.6% for IDF/NCEP-ATPIII) and a 2-fold increase in men (5.3%/10.5% to 11.5%/21.8%). Using multivariate-adjusted Cox regressions, the associations between MetS and all three CVD events were significant (P<0.0001). For IDF/NCEP-ATPIII in men and women, hazard ratio (HR) for CHD was 1.60/1.62 and 1.93/2.03, for CVD mortality 1.73/1.65 and 1.77/2.06, and for stroke 1.51/1.53 and 1.58/1.77. Whereas in men the HRs for CVD events were independent of age (MetS*age, P>0.05), in women the HRs for CHD declined with age (HRs 3.23/3.98 to 1.55/1.56; MetS*age, P=0.01/P=0.001 for IDF/NCEP-ATPIII) while the HRs for stroke tended to increase (HRs 1.31/1.25 to 1.55/1.83; MetS*age, P>0.05). CONCLUSION: In Europeans, both age and gender influenced the prevalence of MetS and its prognostic significance. The present results emphasise the importance of being critical of MetS in its current form as a marker of CVD especially in women, and advocate for a redefinition of MetS taking into account age especially in women.

Overweight, adipocytokines and hypertension: a prospective population-based study.

OBJECTIVE: The adipocytokines, leptin, adiponectin, and interleukin-6, which stimulate liver C-reactive protein (CRP) production, are regarded as potential candidate intermediates between adipose tissue and overweight-induced hypertension. METHODS: We examined the associations between leptin, adiponectin, and CRP levels with both prevalent and 5-year incident hypertension (IHT) in a general population of Danish adults (n = 5,868, 51.3% women, mean age 45.8 ± 7.9 years). RESULTS: We recorded 2195 prevalent and 379 incident cases of hypertension. In models including leptin, CRP, adiponectin, sex, age, lifestyle risk factors, lipids, insulin, hemoglobin A1c, and in the incident model also baseline heart rate and blood pressure, only leptin of the three candidate intermediates was significantly associated with both prevalent and IHT [odds ratio (OR) = 1.18, 95% confidence interval (CI) 1.06-1.32, P = 0.002, and OR = 1.24, 95% CI 1.01-1.54, P = 0.044] for one standard deviation increase in log-transformed leptin levels, respectively. Log-transformed CRP was associated with prevalent (OR = 1.16, 95% CI 1.07-1.26, P < 0.001) but not IHT (OR = 0.98, 95% CI 0.84-1.14, P = 0.76). Log-transformed adiponectin was neither associated with prevalent nor IHT (OR = 0.94, 95% CI 0.87-1.02, P = 0.11 and OR = 0.93, 95% CI 0.80-1.08, P = 0.33). Comparing the lowest with the highest quintile of sex-specific BMI levels, there was an almost two-fold increase in IHT (OR = 1.89, 95% CI 1.10-3.25, P = 0.023) in the fully adjusted model. The population attributable risk estimate of IHT owing to overweight was 31%. CONCLUSION: Leptin, but not adiponectin or CRP, may play a mediating role in overweight-induced hypertension. However, as BMI was a strong independent predictor of hypertension, other factors than leptin must be involved in the pathogenesis of overweight-related hypertension.

Effect of changes in BMI and waist circumference on ambulatory blood pressure in obese children and adolescents.

BACKGROUND: Weight reduction has been accompanied with a reduction in clinic blood pressure (BP) in children and adolescents; however, the effect on ambulatory BP (ABP) is uncertain. The objective was to investigate the impact of weight changes on ABP in obese children and adolescents. METHODS: Sixty-one severely obese patients aged 10-18 years underwent lifestyle intervention at the Children's Obesity Clinic. Patients were examined with ABP monitoring at baseline and after 1 year of treatment (follow-up). To account for growth, BP and BMI were standardized into z scores, whereas waist circumference was indexed by height [waist/height ratio (WHR)]. RESULTS: Patients experienced a reduction at follow-up in the degree of obesity [ΔBMI z score: -0.21, 95% confidence interval (CI) -0.32 to -0.10, P = 0.0003; and ΔWHR: -0.02, 95% CI -0.03 to -0.004, P = 0.009]. Δ24-h, Δdaytime and Δnight-time SBP and DBP in mmHg and changes in equivalent z scores were related to ΔBMI z scores and ΔWHR. These relationships were reproduced in multiple regression analyses adjusted for relevant confounders, for example, a reduction in one BMI z score corresponds to a reduction in 24-h SBP by 6.5 mmHg (P < 0.05). No relationship was found between changes in these anthropometric obesity measures and changes in clinic BP. CONCLUSION: Changes in obesity measures were closely related to changes in ABP, but not to changes in clinic BP, in severe obese children and adolescents after 1 year of lifestyle intervention. The findings emphasize the use of 24-h ABP measurements in children and adolescents.

Obese children and adolescents have elevated nighttime blood pressure independent of insulin resistance and arterial stiffness.

BACKGROUND: Insulin resistance has been related to elevated blood pressure (BP) in obese children and may adversely affect the vasculature by arterial stiffening. The objective was to investigate whether daytime and nighttime BP were elevated and related to insulin resistance and arterial stiffness in obese children and adolescents. METHODS: Ninety-two obese patients aged 10-18 years were compared with 49 healthy control individuals. Insulin resistance was measured as the homeostatic assessment model (HOMA), and arterial stiffness was measured as carotid-femoral pulse wave velocity (cfPWV). RESULTS: Mean ± SD daytime systolic BP (SBP) (obese: 125±8.3mm Hg; control: 121±10.1mm Hg; P = 0.03) and nighttime SBP (obese: 108±10.7mm Hg; control: 102±8.2mm Hg; P = 0.0001) were higher in the obese group when compared with the control group. No difference was found in daytime diastolic BP (DBP), whereas nighttime DBP (obese: 60±6.6mm Hg; control: 57±4.8mm Hg; P = 0.001) and night-to-day BP ratios were higher in the obese group. Nighttime SBP was related to BMI z score (ß = 6.0; 95% confidence interval (CI) = 2.9-9.1; P = 0.0002) and waist/height ratio (ß = 36.7; 95% CI = 5.6-67.9; P = 0.02) in the obese group. HOMA index (obese: median = 3.7, interquartile range (IQR) = 2.3-6.0; control: median = 2.6, IQR = 1.8-3.4; P = 0.002) was higher, whereas cfPWV (obese: 4.8±0.8 m/s; control: 5.1±0.6 m/s; P = 0.03) was lower in the obese group. CfPWV was not related to logHOMA index. In multiple regression analyses, the higher nighttime BP in the obese group was independent of logHOMA and cfPWV. CONCLUSIONS: Obese children had a higher nighttime BP when compared with the control group independently of insulin resistance and arterial stiffness. No relationship was found between insulin resistance and arterial stiffness. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01310088.

Association between albuminuria, atherosclerotic plaques, elevated pulse wave velocity, age, risk category and prognosis in apparently healthy individuals.

METHOD: Two thousand and fifty-nine healthy individuals aged 41, 51, 61 and 71 years examined in 1993, were divided in age, SCORE and Framingham risk score (FRS) groups. Subclinical vascular damage (SVD) was defined as carotid-femoral pulse wave velocity (cfPWV) at least 12 m/s, carotid atherosclerotic plaques or albuminuria defined as urine albumin/creatinine ratio at least 90th percentile of 0.73/1.06 mg/mmol men/women. In 2006, the composite endpoint (CEP) of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and hospitalization for ischemic heart disease was recorded (n = 229). RESULTS: With increasing age, SCORE or FRS risk group, prevalence of cfPWV at least 12 m/s (5.2, 14.5, 35.3, 53.5% or 4.4, 15.6, 50.9, 66.1% or 4.0, 9.5, 32.1, 56.1%), atherosclerotic plaque (4.0, 19.0, 35.3, 53.5% or 3.5, 16.8, 43.7, 55.9%, or 6.6, 7.6, 9.8, 20.0%) and albuminuria (7.9, 8.7, 11.4, 20.6% or 7.9, 8.2, 16.6, 19.5% or 6.6, 7.6, 9.8, 20.0%) increased, all P < 0.001.CEP was associated with albuminuria in individuals aged 61 or 71 years, with moderate or very high SCORE or intermediate or high FRS (all P < 0.05), with atherosclerotic plaques in individuals aged 41, 51 or 61 years, with moderate SCORE or with high-intermediate or high FRS (all P < 0.01), and with cfPWV at least 12 m/s in individuals aged 51 years (P < 0.001) or high FRS (P < 0.05). Presence of at least one SVD was significantly associated with an increased risk in individuals aged 51 [hazard ratio 2.7 (1.6-4.8)] and 61 years [hazard ratio 2.7 (1.5-4.7)], moderate [hazard ratio 2.4 (1.6-3.7)] or high SCORE risk group [hazard ratio 2.3 (1.2-4.7)] and low-intermediate [hazard ratio 3.3 (1.5-7.0)], high-intermediate [hazard ratio 2.3 (1.5-3.5)] and high FRS risk group [hazard ratio 2.0 (1.4-3.0)]. CONCLUSION: SVD and especially atherosclerotic plaques or urine albumin/creatinine ratio (UACR) at least 0.73/1.06 mg/mmol (men/women) added prognostic information in individuals aged 51 or 61 years or with moderate or intermediate risk.

Self-reported knowledge and awareness about blood pressure and hypertension: a cross-sectional study of a random sample of men and women aged 60-74 years.

BACKGROUND: In general, it is assumed that patient education, by increasing knowledge, may change behavior and lifestyle and promote health. In this context, it is a surprise that knowledge and awareness about blood pressure and hypertension among elderly people is poor. We hypothesized that knowledge about blood pressure and hypertension would be better among individuals with self-reported hypertension compared with subjects without self-reported hypertension. METHODS: We mailed a questionnaire to a random sample of 1,000 subjects living in the municipality of Silkeborg, Denmark. The study sample was drawn from the Central Person Registry. RESULTS: The response rate was 72%. Of these, 43% of responders had self-reported hypertension. The people with self-reported hypertension were older, less educated, had higher self-reported blood cholesterol levels, had higher body weight, and more often had a family history of hypertension. More than 80% reported that overweight and obesity increases blood pressure. More than 60% reported that untreated hypertension may cause heart disease or stroke. More than half of the responders did not know their blood pressure, and only 21% knew that hypertension can occur without symptoms. Knowledge about hypertension was independent of self-reported hypertension status, but awareness about blood pressure was most prominent among those with self-reported hypertension. CONCLUSION: General knowledge about blood pressure and hypertension was reasonable, but there is still room for improvement in elderly people's knowledge and awareness of blood pressure.

Do other cardiovascular risk factors influence the impact of age on the association between blood pressure and mortality? The MORGAM Project.

OBJECTIVE: To investigate age-related shifts in the relative importance of SBP and DBP as predictors of cardiovascular mortality and all-cause mortality and whether these relations are influenced by other cardiovascular risk factors. METHODS: Using 42 cohorts from the MORGAM Project with baseline between 1982 and 1997, 85 772 apparently healthy Europeans and Australians aged 19-78 years were included. During 13.3 years of follow-up, 9.2% died (of whom 7.2% died due to stroke and 21.1% due to coronary heart disease, CHD). RESULTS: Mortality risk was analyzed using hazard ratios per 10-mmHg/5-mmHg increase in SBP/DBP by multivariate-adjusted Cox regressions, including SBP and DBP simultaneously. Because of nonlinearity, SBP and DBP were analyzed separately for blood pressure (BP) values above and below a cut-point wherein mortality risk was the lowest. For the total population, significantly positive associations were found between stroke mortality and SBP [hazard ratio = 1.19 (1.13-1.25)] and DBP at least 78 mmHg [hazard ratio = 1.08 (1.02-1.14)], CHD mortality and SBP at least 116 mmHg [1.20 (1.16-1.24)], and all-cause mortality and SBP at least 120 mmHg [1.09 (1.08-1.11)] and DBP at least 82 mmHg [1.03 (1.02-1.05)]. BP values below the cut-points were inversely related to mortality risk. Taking into account the age × BP interaction, there was a gradual shift from DBP (19-26 years) to both DBP and SBP (27-62 years) and to SBP (63-78 years) as risk factors for stroke mortality and all-cause mortality, but not CHD mortality. The age at which the importance of SBP exceeded DBP was for stroke mortality influenced by sex, cholesterol, and country risk. CONCLUSION: Age-related shifts to the superiority of SBP exist for stroke mortality and all-cause mortality, and for stroke mortality was this shift influenced by other cardiovascular risk factors.