[Menopausal hormone therapy an cardiovascular risk. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. / Traitement hormonal de ménopause et risque cardiovasculaire. RPC Les femmes ménopausées du CNGOF et du GEMVi.

Cardiovascular risk is one of the major challenges of menopausal hormone therapy (MHT). Thus, during a consultation of menopause, it is essential to considering the classic cardiovascular risk factors but also those more specific to women in order to evaluate the level of cardiovascular risk: high risk, intermediate risk or low risk. Cardiovascular disease (myocardial infarction or ischemic stroke) are rare disease in women compared to men. However, they represent the leading cause of death in women after menopause in France. Publications of randomized trials have widely questioned the expected benefit of MHT on arterial risk. It should be noted that almost all of these trials concerned the combination of orally conjugated equine estrogens (ECE) associated or not with medroxyprogesterone acetate. Meta-analyses of all randomized trials show an increased risk of ischemic stroke associated with the use of oral MHT while the use of transdermal estrogen therapy combined with progesterone will be safe. The risk of coronary heart disease is not increased and appears to be significantly reduced when the MHT is started less than 10 years after menopause or before the age of 60. These results suggest that the timing of initiation of the MHT, the type of MHT and all of the risk factors should be carefully considered before starting MHT.

[Hypertension and menopausal hormone therapy]. / HTA et traitement hormonal de la menopause.

Can menopausal hormone therapy (HT) be used in hypertensive women? The group of experts of the French Society of Hypertension has carried out a review of the recent literature in order to answer this question, based on the most recent scientific publications. If use of oral HT is associated with a discreet increase in blood pressure, the transdermal route seems to be safer. The first results of major randomized trials of HT had alerted to an increase in cardiovascular events and breast cancer with the use of oral HT, generally, tipping the benefit-risk balance of the deleterious side. Complementary analyzes have shown the importance of the window of intervention (less than 10 years after the menopause) and the age of the woman to start the HT. On the contrary, they have shown a significant decrease of the coronary events. For woman suffering from hypertension and important climacteric symptoms, it is important to evaluate the whole cardiovascular risk in order to decide the possibility of prescribing a HT. Thus, the group of experts proposes a prescription assistance algorithm based on the stratification of cardiovascular risk, always favoring, when it is authorized, HT by transdermal route of administration.

["Heart, arteries and women" an innovative care pathway for women at high risk: First evaluation at one year]. / Le circuit « cœur, artères et femmes ¼ chez la femme à haut risque cardiovasculaire : première évaluation à un an.

INTRODUCTION: Cardiovascular diseases remain the first cause of death in women. To improve women's health cardiologists and gynaecologists should work together on women's specific cardiovascular risk factor. METHOD: Our study evaluated a care pathway named "heart, arteries and women". One hundred and ninety-one women were included for vascular (n=55) or hypertensive (n=136) explorations from January the first to December the 31st of 2013. We studied their clinical presentation and medical management. RESULTS: All women were at high cardiovascular risk (38% of them at very high risk). The average age was 52 years old. A woman on three had experienced high blood pressure or diabetes during pregnancy. One on two was postmenopausal woman. We stopped twelve estrogen-progesterone contraceptions; 60% didn't have gynaecological follow-up; 146 had high blood pressures (73% at night, 50% had no dipping blood pressure profile and 15 were newly diagnosed for hypertension). Sleep apnoea syndrome was suspected in half women. Medical therapies were optimized especially for women with atheroma in which 30 to 46% were properly treated (P=0.0005). Only 18% of the gynecologists received conclusive reports. CONCLUSION: At one year, our care pathway "heart, arteries and women" allowed to optimize medical therapy and clinical management. Everyone should be aware of this program.

[Systematic screening of masked hypertension in patients with peripheral arterial disease: a pilot study]. / Dépistage systématique de l'hypertension artérielle masquée chez les patients ayant une artériopathie des membres inférieurs: une étude pilote.

AIM: Masked hypertension (MH) is defined by a normal office blood pressure (BP) and a high ambulatory BP. MH is characterized by high prevalence and poor cardiovascular prognosis. The aim of this study was to evaluate the usefulness of routine MH screening, using 24-h blood pressure monitoring (BPM), among patients with peripheral arterial disease (PAD). METHODS: Between 2011 and 2013, 54 patients with PAD were included in the Hypertension and Vascular Medicine Unit of the Lille Hospital. They had normal office BP (< 140/90mmHg). A 24 h-BPM device was set on each patient. MH diagnosis was established if the BP average over 24 hours was ≥ 130/80 mmHg and/or the daytime average ≥ 135/85 mmHg and/or the nighttime average ≥ 120/70 mmHg. RESULTS: MH prevalence was about 42.6% (23 patients). It was significantly more frequent in diabetic patients (odds ratio: 3.8 [1.1-12.8]), in patients with known hypertension (odds ratio: 5 [1.5-16.9]) or with high normal office BP (<140/90 mmHg but ≥ 130/85 mmHg) (odds ratio: 5.6 [1.7-18.2]). By multivariate analysis, only known hypertension and high normal office BP were associated with masked hypertension. CONCLUSION: The high prevalence of MH in patients with PAD shows us the importance of a careful screening of MH in this population, especially in diabetic patients, in patients with known hypertension or with a high normal office BP.

[Heart, arteries and women, a care pathway for women at high cardiovascular risk]. / Cœur, artères et femmes, un circuit de soins dédié aux femmes à risque cardiovasculaire.

Cardiovascular (CV) diseases are the primary cause of death of women. Since they kill 10 times more than breast cancer, preventive measures should be implemented. According to U.S. recommendations, a woman is either at "CV risk" or at "optimal health status" if she has no risk factors and a perfectly healthy lifestyle. Some risk factors are more deleterious to women (smoking, diabetes, stress, depression, atrial fibrillation); or specific to women (preeclampsia, gestational diabetes, contraception, menopause, headaches). The lifestyle plays a key role for them. The blood pressure measurement is the most frequent opportunity to detect women at risk. CV tests should be performed to all symptomatic women and for those over the age of 45 who want to start practicing sport. The cardiologist can play a key role to improve women's CV health by integrating their hormonal risks. Women themselves can also make a powerful contribution to prevention by adopting a healthy lifestyle. From those recommendations concerning women's CV health, there is a great opportunity to initiate a health path for women at high cardiovascular risk. The objectives of the specific path "heart, arteries and women" of University hospital of Lille will be to improve professional practice, awareness of women, educate public authorities and within a few years reduce the epidemic of CVD of French women.

[A specific questionnaire to evaluate therapeutic inertia in hypertensive patients: a pilot study]. / Évaluation de l'inertie thérapeutique chez des patients hypertendus à l'aide d'un questionnaire ciblé : étude pilote.

BACKGROUND: Therapeutic inertia (TI) is a recent concept still unknown by many physicians. In chronic diseases such as hypertension, it is defined as the tendency of physicians not to increase or change antihypertensive medications when the target blood pressure is not reached. Acting on TI could improve blood pressure control in France. METHOD: This was a single-center prospective pilot study conducted by hypertension specialist physicians at the University Cardio-Vascular Center in Lille (France). It was conducted between March and June 2011. Data was collected from 161 hypertensive patients (mean age: 61.64±11.18 years; 98 (60.9%) male; 75 secondary prevention patients). Each physician completed a questionnaire on therapeutic inertia. TI was defined as a consultation in which treatment change was indicated (systolic blood pressure [BP]≥140 and/or diastolic BP≥90mmHg in all patients), but did not occur, with absence of an adapted justification of this choice. We considered as an adapted justification: a white coat effect demonstrated by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring; scheduled reassessment of the BP by ABPM; recent change in antihypertensive treatment (less than 4 weeks); hospitalization needed for complete evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage in patients with grade 1 or 2 hypertension. Our study aimed to evaluate rates of TI, to identify factors associated with TI, and to test the TI questionnaire. RESULTS: Therapeutic inertia as defined in this study occurred in 11 consultations (8.3%) of the 133 hypertensive patients having uncontrolled BP above or equal to 140 and/or 90mmHg. Significant factors associated with TI were older age (Z=2.35, P<0.05) and sleep apnea syndrome (χ(2)=8.33, P<0.05). The absence of ambulatory blood pressure monitoring before the consultation (χ(2)=4.28, 0.1>P>0.05) and the number of consultations (Z=1.92, 0.1>P>0.05) exhibited a significant trend to be associated with TI. CONCLUSIONS: Although the rate of TI was low in our study conducted in a specialized center, a well-accepted definition of therapeutic inertia would be useful for further study. The feasibility of using the questionnaire tested with this study shows that this measurement tool could help physicians become more aware of TI, both in the hospital and primary care setting. Further multicenter studies are needed for validation.

[Assessment of educational benefits in 73 hypertensive patients by telephone survey at distance of HTA Vasc educational program]. / Évaluation des acquis éducatifs de 73 patients hypertendus par enquête téléphonique à distance du programme HTA Vasc.

UNLABELLED: HTA Vasc offers an approved educational program for hypertensive patients at high cardiovascular risk (CVR). METHOD: A telephone survey (December 2011-July 2012) evaluated the benefits of different workshops "my treatment", "my blood pressure" and "my nutrition", more than 6 months after the end of the program. The follow-up data (TS) were compared to inclusion data (T0) and to final data (TF) in 73 hypertensive patients. RESULTS: The follow-up period was 6 to 31 months. The number of hypertensive controlled patients [blood pressure (BP)<140/90 mmHg] increased from 55.4% to 75.4% (P=0.0158) in TF, which remained over time. The practice of physical activity increased from 47.9% (T0) to 79.5% (TS) (P=0.001). The follow-up period of 18 months or more was associated with a tendency to weight gain (P=0.0059) and with a decline in physical activity [89.7% (<18 months) to 67.5% (≥ 18 months) (P=0.0198)]. The practice of self-measurement BP increased from 41.1% (T0) to 71.2% (TS) (P<0.0001); knowledge of the "rule of three" increased from 6.8% (T0) to 74% (TS) (P<0.0001). CONCLUSION: An educational support contributes to a better long-term BP control. The motivation for lifestyle rules decreases with time. The implementation of a structured motivational follow-up could maintain the lifestyle motivation at these CVR patients.

[Contribution of angioplasty of a fibromuscular angiodysplasic renal artery during early-onset gestational hypertension]. / Efficacité de l'angioplastie d'artère rénale fibrodysplasique dans un contexte d'hypertension artérielle gravidique précoce.

This clinical case illustrates the management difficulties encountered during gestational hypertension and its impact on maternal and foetal outcome. Typically, preeclampsia occurs at the end of the second trimester. If blood pressure remains high early during pregnancy, a secondary cause of hypertension such as renal artery fibromuscular dysplasia should be explored. A renal vascular etiology can be safely ruled out with a duplex ultrasound. In this particular case of renal vascular hypertension in a patient with a single kidney, angioplasty appeared to be the sole solution and was efficient.

Impact of a rehabilitation program on muscular strength and endurance in peripheral arterial occlusive disease patients.

UNLABELLED: Rehabilitation care and physical exercise are known to constitute an effective treatment for chronic peripheral arterial occlusive disease (PAOD) at the intermittent claudication (IC) stage. Improvements in functional capacities and quality of life have been reported in the literature. We decided to assess the effects of hospital-based exercise training on muscle strength and endurance for the ankle plantar and dorsal flexors in this pathology. PATIENTS AND METHODS: This prospective study included 31 subjects with chronic peripheral arterial occlusive disease (PAOD) and IC who followed a 4-week rehabilitation program featuring walking sessions, selective muscle strengthening, general physical exercise and therapeutic patient education. An isokinetic assessment of ankle plantar and dorsal flexors strength was conducted on the first and last days of the program. We also studied the concentric contractions at the angular velocity of 30°/s and 120°/s for muscle strength and at 180°/s for muscle fatigue. We also measured the walking distance for each patient. RESULTS: Walking distance improved by 246%. At baseline, the isokinetic assessment revealed severe muscle weakness (mainly of the plantar flexors). The only isokinetic parameter that improved during the rehabilitation program was the peak torque for plantar flexors at 120°/s. CONCLUSION: All patients presented with severe weakness and fatigability of the ankle plantar and dorsal flexors. Our program dramatically improved walking distance but not muscle strength and endurance.

[Ankle brachial index measurement at the first visit for hypertension: a safe and very useful tool for aortic coarctation screening. A case report]. / L'index de pression systolique dans un premier bilan d'hypertension: outil diagnostique de choix de la coarctation aortique. Un cas rapporté.

A 24-year-old African who had been living in France for few years first consulted at our institution for severe systemic hypertension. He had no prior medical or surgical history. The patient was strictly asymptomatic. Except for systemic hypertension at both arms, the basic physical examination was normal with no cardiac murmur and no pulse deficit. A 24-hour ambulatory blood pressure monitoring performed before the consultation confirmed the presence of systemic hypertension with a mean blood pressure at 155/90mmHg during the day and also during the night under anti-hypertensive treatment. Ankle-brachial index measurement was low at 0.8 at both legs. Subsequently, a trans-thoracic echocardiography (TTE) and an aortic CT-scanner were performed. The TTE did not find any abnormalities including no aortic dilatation or no ventricular hypertrophy. The CT-scanner revealed a partial aortic coarctation. The patient underwent aortic surgery and recovered in few days with quite normal blood pressure under medical treatment. In conclusion, systematic ankle-brachial index is useful and recommended in every patient at first visit for systemic hypertension. Its safety and simplicity make it an essential tool in the management of systemic hypertension especially in populations with no systematic screening of aortic coarctation in childhood. It was in the present case very useful for the final diagnosis and treatment. In addition, it is an efficient tool to screen patients with asymptomatic peripheral artery disease and it can help for stratification of cardiovascular risk.

[Why screening for a renal artery stenosis?]. / Pourquoi dépister une sténose artérielle rénale?

Diagnosis of renal artery stenosis (RAS) should be discussed in numerous clinical situations including refractory high blood pressure (HBP), HBP in a polyvascular patient, degradation of renal function following renin angiotensin inhibitor or flash pulmonary edema. Ultrasound-doppler coupled with gadolinium-enhanced MR or CT angiography has proven adequate for most patients with RAS. Digital subtraction angiography should be limited to revascularisation procedures. Functional testing are not sensitive or specific enough because the degree of renin activation differs widely among patients with RAS. Renal percutaneous angioplasty induces a light to moderate decrease in blood pressure, has no effect on renal function but allows to reduce the number of anti-hypertensive drugs. Stenting completed angioplasty is worthwhile in most patients with atherosclerotic RAS. ACE inhibitors decrease mortality and increase renal function in patients with RAS.

[The metabolic syndrome: marker of cardiovascular risk in hypertensive patients? The importance of definition]. / Le Syndrome métabolique: marqueur de risque chez l'hypertendu? Importance de la définition utilisée.

INTRODUCTION: Metabolic syndrome (MetS) was defined by association of abdominal obesity, hypertension, glucose intolerance and/or dyslipidemia. The objective of this study was to compare the new International Diabetes Federation (IDF) definition and the National Cholesterol Education Program Adult Treatment Panel III (NCEP) definition and their association with cardio-vascular disease in hypertensive patients. POPULATION AND METHOD: Two hundred and thirty hypertensive patients were hospitalized successively for cardio-vascular disease exploration and hs-CRP measurement. The stratification of cardio-vascular risk was made according to the French recommendations. The IDF definition and the NCEP definition were compared according frequency of resistant hypertension and cardio-vascular disease extension. RESULTS: In our study, high cardio-vascular risk hypertension represented 68.5% of patients. Diabetes was present in 23.5% of them and obesity in 45.5%. Patients with cardio-vascular disease represented 60% of our study population. Prevalence of MetS was 38.5% according to the NCEP definition and 59% according to the IDF definition. The NCEP definition was allowed to select subjects with widespread vascular disease and resistant hypertension whereas the IDF definition did not. These results could be explained by lower waist circumference and glycaemia cuts offs according to the IDF criteria. When diabetic's patients were excluded, MetS was not associated with increase of resistant hypertension frequency. Moreover, hs-CRP was independently associated to the extension of the cardiovascular disease and smoking remained the most powerfully factor associated to the cardio-vascular disease extension. CONCLUSION: In hypertensive patients, the NCEP definition seems more adapted to the diagnosis of MetS than the IDF one. Abdominal obesity could be the indispensable element to the MetS diagnosis but according to the NCEP waist circumference cut off. The use of this syndrome seems to be relevant to select the patients presenting an intermediate cardio-vascular risk in order to adapt treatment.

[The best of vascular medicine in 2006]. / L'essentiel de 2006 en médecine vasculaire.

Peripheral arterial disease (PAD) remains an under-diagnosed affection, and the ankle-brachial index (ABI), a simple diagnostic method, is poorly known and seldom used, and the vascular patient's prescription list is frequently insufficient regarding results obtained in large trials with good methodology. The French ATTEST study underlines the fact that ABI is measured in less than 1 out of 3 patients with PAD. In ATTEST study, less than 10% have the triple therapy validated in PAD : antiplatelet drugs, statins and ACE-inhibitors. The international REACH registry included more than 60 000 patients suffering from atherosclerosis, including 8 000 cases with PAD. This survey evidences that in PAD patients, the annual cardiovascular complication rate is significantly higher than in patients with coronary artery disease (18 vs 13%); again PAD appears systematically under-treated when compared to CAD. These epidemiological surveys highlight the importance of screening of atherosclerotic lesions with the aim of setting an active prevention of CV complications. The new guidelines insist on the screening of PAD in patients at risk, as well as on the importance of the global management after initiating the triple therapy, independent of the CV risk factors. In a 5-year longitudinal study from an initial cohort of 2265 subjects, Aboyans et al. studied the progression of PAD by repeated measurements of ABI at the level of ankles and toes. Factors of progression for large-vessels PAD were active smoking, the total/HDL-cholesterol ratio, Lp(a) and CRP. Importantly, diabetes was not associated to the PAD progression in large vessels, but in contrast, it was the sole factor associated to the progression of PAD in small vessels. In an Austrian study published this year in the NEJM, Schillinger et al. compared balloon angioplasty versus the use of Nitinol stent for the treatment of long stenoses of the superficial femoral artery. In case of claudication, these lesions are usually treated medically, whereas surgery is required for more severe cases. The fact that stenting these long lesions of the superficial femoral artery provides benefits in terms of restenosis opens a approach for the endovascular therapy, to be confirmed by larger trials.

Association of eNOS Glu298Asp gene polymorphism with circadian blood pressure rhythm.

Hypertensive patients with altered circadian blood pressure (BP) profile experience greater repercussion of hypertension on target organs and a higher risk of cardiovascular events, compared with those with physiological variations in BP. It has been demonstrated in animal models, that circadian variations in BP depend on several regulatory systems, in particular the nitric oxide-cGMP pathway. eNOS298 Glu/Asp polymorphism is a functional variant and may alter the amount of NO generated or eNOS activity. The objective of the present study was to find out whether eNOS298 gene polymorphism affects circadian BP regulation in 110 healthy subjects and 155 never-treated hypertensive patients recruited at Hypertension Units in Grenoble, Toulouse and Lille (France).

Attitudes to and application of the concept of overall cardiovascular risk: comparison of male and female primary care providers.

The aim of this observational study was to assess whether there were differences in perception of overall cardiovascular risk (OCVR) in hypertensive patients depending on the gender of the primary care provider (PCP). We performed this study in 2003: 2979 male PCPs (MPCPs) and 562 female PCPs (FPCPs) participated throughout France. The patients included were hypertensive either treated or untreated, uncontrolled (blood pressure (BP) >or=140/90 mm Hg) with at least one other cardiovascular risk factor (CVRF) associated. OCVR of patients was both calculated according to French Agence Nationale d'Accréditation et d'Evaluation en Santé guidelines for uncontrolled hypertensive patients and subjectively estimated by the PCP as 'low', 'moderate', 'high' or 'very high'. About 11 770 patients were included, mean age was 63.7+/-11.2 years and 54.1% were men. Mean BP was 157+/-13/90+/-9 mm Hg. According to French guidelines, the calculated OCVR was 'moderate' in 23.7% of patients, 'high' in 47.5% and 'very high' in 28.8%. The PCP perceived OCVR was that 9.1% of patients were considered to be at 'low risk', 40.7% at 'moderate risk', 38.1% at 'high risk', and only 11.2% at 'very high risk' (OCVR was not estimated for 0.9% of patients). The overall agreement rate between the PCPs' estimation of OCVR and its calculation was 43.5%. Thus, in spite of extensive diffusion of ANAES guidelines, we found that PCPs in France generally underestimated OCVR though there were no significant differences between male and female physicians (45% for FPCPs and 43.2% for MPCPs).

[Benefits of a healthcare network in the management of cardiovascular disease: HTA Vasc, an innovation in the Nord Pas de Calais region]. / Apport d'un réseau de santé dans la prise en charge des maladies cardiovasculaires: HTA Vasc, une innovation dans la région Nord-Pas-de-Calais.

Created in 2004, the HTA vasc healthcare network intensified detection, multi-disciplinary management and follow up of atheromatous cardiovascular disease and complicated hypertension in the Nord Pas de Calais region. The participating doctors gave their patients a Patient Dossier, as a function of predefined inclusion criteria (patients at elevated cardiovascular risk, as defined by the Haute Autorité de Santé (Higher Authority of Health) stratification. The dossier was presented in the form of a file containing all the information needed to optimise multi-disciplinary management, while at the same time reinforcing therapeutic compliance by patients. Therapeutic education workshops were organised, in order to complement the existing service. In parallel, HTA vasc set up a pilot medical education programme for vascular rehabilitation in six hospitals in the region. HTA vasc also established partnerships with other healthcare networks in the region. A patients' association 'Notre Coeur, Nos Artères', (Our Hearts, Our Arteries) was created in September 2006. About 250 healthcare professionals had joined the network by the end of January 2006, an increase of almost 40% over the year. More than two thirds were independent doctors, and they included cardiologists, neurologists, nephrologists, diabetologists, general practitioners, radiologists, cardiovascular surgeons, rehabilitation doctors, paramedics and pharmacists. More than 260 patients received a follow up dossier. The results of a survey carried out in May 2006 showed a high level of satisfaction: 82% of patients considered the Patient Dossier to be useful and appropriate; 78% of the healthcare professionals stated that the network was of help in the management of patients. HTA vasc received the scientific support of the Sociétés Françaises de Médecine Vasculaire, d' Hypertension Artérielle (French Societies of Vascular Medicine and Hypertension), and the Vascular Group of the Société Française de Cardiologie, with an external audit of the tools and activities undertaken in the region.

[Usefulness of magnetic resonance angiography in the screening of renal artery stenosis in hypertensive patients: proposition of a diagnostic algorithm: a study of 245 patients]. / Apport de l'angiograpliie par résonance magnétique pour le dépistage de ia sténose artérielle rénale cliez le palient fiypertendu. Proposition d'un organigramme diagnostique: étude de 245 patients.

Usefulness of magnetic resonance angiography in the screening of renal artery stenosis in hypertensive patients: proposition of a diagnostic algorithm: a study on 245 patients. Different non-invasive techniques, including Duplex, spiral angioscan, and magnetic resonance angiography (MRA) are available for the diagnosis of renal artery stenosis (RAS). The aim of this study was to assess the diagnostic performances of MRA and the MRA-Duplex couple in the diagnosis of RAS. Between September 2003 and January 2005, 245 patients benefited from a renal MRA for the assessment of hypertension etiology. The MRA-Duplex couple was performed in 228 patients. Renal arteriography was performed in case of abnormalities observed with MRA and/or Duplex (n=41). The sensitivity and specificity of MRA were respectively at 100% and 23%. The sensitivity was notably higher in the right renal artery (100 vs. 73%). The sensitivity and specificity of Duplex were respectively at 71 and 85%. The concordance between the two exams was disappointing (kappa at 0.39 for the right side and 0.62 for the left side), leading to the interest of the MRA-Duplex association for excluding the presence of RAS (sensitivity and negative predictive value=100%). However, using the MRA-Duplex couple led to a high number of false positive cases, due to MRA, leading to 11 angiograms out of 41 exams, without any significant RAS. In case of suspicion of RAS, the MRA-Duplex couple permits to exclude definitely the diagnosis of RAS. In case of discordance between the 2 exams, it would be useful to require a spiral angioscan and/or redo a Duplex exam using contrast agents, prior to angiography with a therapeutic goal. These management modalities might be useful to avoid the number of normal angiograms, with an inherent risk of complications and cost excess.

[The best of vascular medicine in 2005]. / L'essentiel de 2005 en médecine vasculaire.

It is illusory to think that one year is long enough to establish all the truths that will guide our clinical practice in vascular medicine. On the contrary, one year was long enough to contradict what the preceding twelve months had set out to demonstrate. Consequently, promising trials in the treatment of abdominal aortic aneurysms by endoprostheses have been the object of contradictory debate with regards to the long-term benefits. In fundamental research, circulating progenitors of endothelial cells have been shown to be a marker of atherosclerosis, but is it a better marker than LDL-cholesterol values? The demonstration that these progenitors are of value in the treatment of essential ischaemia of the lower limbs is awaited. Finally, ximelagatran, a direct thrombin antagonist, seemed to have all the qualities of an ideal anticoagulant: easy to use, safe... until the report of raised hepatic enzymes, the clinical relevance of which remains to be determined. In the good news section: the Systolic Pressure Index, an unquestioned marker of arterial disease. Its reduction was known to be correlated with the prevalence of cardiovascular complications. However, it has now been shown that an increase in the index is also associated with cardiovascular complications, a real U-shaped curve. Renal arterial stenosis should be considered in patients with left ventricular failure presenting with flash pulmonary oedema. In the absence of cardiac pathology, BNP would seem to be a good biological marker of haemodynamically significant renal arterial stenosis. Finally, should superficial femoral artery stenosis be treated by an active stent. To date, there is no formal proof.

Control of cardiovascular risk factors in patients with type 2 diabetes and hypertension in a French national study (Phenomen).

UNLABELLED: For some years now, the recommendations of scientific societies have significantly reduced the therapeutic targets for blood pressure, glycaemia and lipid levels in diabetic patients. However, little is known regarding the synchronization between effective risk factor management and the guidelines. To examine this issue, the Phenomen survey was conducted between January and July 2001 on 16358 patients suffering from hypertension followed by a general practitioner in France. AIM: To evaluate the control of cardiovascular risk factors in patients with diabetes and hypertension according to the French guidelines. METHODS AND PATIENTS: 8177 general practitioners, selected from a national database according to quotas, taking into account age, practice and area, had to include the first two hypertensive patients they came across in their practice and to collect their demographic data, cardiovascular risk factors and medications. RESULTS: 2346 out of 16358 hypertensive patients presented with type 2 diabetes (14.3% of the cohort). The number of GP consultations in the last 12 months averaged 8.31. According to the French guidelines, 6.5% had a blood pressure<140/80 mmHg, a total of 38.7% patients met the goal of LDL cholesterol level and 26.6% of patients had an HbA1c<6.5%, 53.4% of patients had an HbA1c between 6.6 and 8%. 37.1% of patients continued to receive antihypertensive monotherapy but only 3% in this monotherapy group reached the target of 130/85 mmHg. 29% of the patients were on antiplatelet therapy. 64.6% of these hypertensive diabetic patients presented with more than three other cardiovascular risk factors. Based on WHO recommendations, 0.3% of the patients met all of the blood pressure, lipid and glycaemic treatment objectives. CONCLUSION: Despite frequent monitoring by a general practitioner, the overall management of modifiable risk factors in this diabetic hypertensive population is clearly inadequate. The impact of the guidelines on effective management remains limited and additional information is required to understand why physicians are not more aggressive in managing modifiable risk factors in diabetic patients.