Self-measurement and self-titration in hypertension: a pilot telemedicine study.

BACKGROUND: Because of poor patient compliance and clinical inertia, hypertension control rates remain poor. Home blood-pressure measurements (HBPM) improve compliance of patients and achievement of blood pressure (BP) targets. However, few studies have evaluated self-BP management by patients. METHODS: In a multicenter, prospective, single-group, open-label pilot study of 111 patients whose hypertension was uncontrolled despite monotherapy, we studied satisfaction with, and feasibility of, HBPM and self-titration of antihypertensive treatment using telemedicine for compliance, efficacy, and safety. After education (protocol, action plan, and use of the HBPM device), patients performed a sequence of HBPM every 2 weeks for 8 weeks. Following a stepwise approach, treatment was increased by the patient at weeks 4 and 6 if average HBPM values exceeded predefined limits. For each titration, the patient informed the Core Center by telemedicine, but BP values were transferred automatically. RESULTS: Overall, 80% of patients were satisfied (58%) or very satisfied (23%) with the program (95% confidence interval, 73% to 87%). Regarding compliance, 78% of patients fully complied with self-measurement, and just over 71% titrated their treatment adequately. Physicians were satisfied (52%) or very satisfied (22%) with the program. Between the first and final visits (at week 8), office systolic/diastolic BP (mean +/- SD) decreased significantly from 151 +/- 9/91 +/- 6 to 143 +/- 13/84 +/- 11 mmHg. During the trial, HBPM (mean +/- SD) decreased significantly from 149 +/- 13/86 +/- 12 to 138 +/- 16/81 +/- 10 mmHg. No significant safety issues were reported. CONCLUSIONS: This innovative approach to the management of hypertension, combining self-measurement and self-titration, is feasible, well-accepted by both patients and physicians, and safe.

A home blood pressure monitoring study comparing the antihypertensive efficacy of two angiotensin II receptor antagonist fixed combinations.

BACKGROUND: The objective of this prospective, randomized, open-label, blinded-endpoint study was to compare the antihypertensive efficacy of valsartan 80 mg v irbesartan 150 mg when combined with hydrochlorothiazide (HCTZ) 12.5 mg. METHODS: Untreated or uncontrolled hypertensive adults (n = 800) were enrolled by primary care physicians. After a 5-week open-label lead-in phase in which all patients received 12.5 mg HCTZ once daily, subjects whose blood pressure (BP) remained uncontrolled were randomized (n = 464) to valsartan/HCTZ (80/12.5 mg) or irbesartan/HCTZ (150/12.5 mg) for 8 weeks. Home BP monitoring (HBPM) was performed in the morning and in the evening for 5 days, at baseline, and after 8 weeks. Office BP measurements were obtained at baseline and after 8 weeks. RESULTS: Irbesartan/HCTZ produced greater reductions in average systolic BP (SBP) and diastolic BP (DBP) measured by HBPM than valsartan/HCTZ (SBP: -13.0 v -10.6 mm Hg, P = .0094; DBP: -9.5 v -7.4 mm Hg, P = .0007). These differences were more pronounced in the morning (trough) than in the evening. Office BP measurements also showed greater reductions in trough seated SBP and DBP with irbesartan/HCTZ compared with valsartan/HCTZ. Normalization rates observed with HBPM (SBP <135 mm Hg and DBP <85 mm Hg) were significantly greater with irbesartan/HCTZ than with valsartan/HCTZ (50.2 v 33.2%; P = .0003). The overall safety was similar in the two groups. CONCLUSIONS: The superior BP-lowering potency of the fixed combination irbesartan/HCTZ (150/12.5 mg) over valsartan/HCTZ (80/12.5 mg), evidenced independently from the investigators by HBPM, supports the use of this technique in trials with prospective, randomized, open-label, blinded-endpoint designs.

Electrocardiographic predictors of Brugada type response during Na channel blockade challenge.

AIM: To identify ECG predictors of Brugada type response during Na channel blockade challenge. METHODS: We studied prospectively 103 patients (M = 76, 45 +/- 13 years) in whom ECGs were collected during ajmaline challenge. ECG recordings included the high right precordial leads (-2V(1) and -2V(2)). A positive response was defined by a >0.2 mV J point or ST segment elevation and a down-sloping pattern of the ST segment in at least one right precordial lead. RESULTS: Ajmaline challenge was positive in 48 (47%) of the 103 cases. Baseline J wave elevation was greater in -2V(1) (0.077 +/- 0.078 mV vs. 0.038 +/- 0.046 mV, P = 0.003) and -2V(2) (0.149 +/- 0.103 mV vs. 0.043 +/- 0.088 mV, P < 0.001) in cases with a subsequent positive response. In contrast, ST segment elevation and T wave amplitudes were reduced in V(1), V(2) and V(3). Logistic regression showed that J wave elevation in -2V(2) and decreased T wave amplitude in V(3) at baseline were independent predictors of a positive response. Baseline J wave elevation >0.16 mV in -2V(2) had a specificity of 100%, a sensitivity of 40%, a positive predictive value of 100% and a negative predictive value of 28%. CONCLUSION: J wave elevation >0.16 mV in -2V(2) was the strongest predictor of a Brugada type response to Na channel blockade challenge when Brugada syndrome was suspected on a baseline ECG.

Atrial septal pacing to prevent atrial fibrillation in patients with sinus node dysfunction: results of a randomized controlled study.

BACKGROUND: In order to assess the preventive effects of right atrial septal pacing on atrial fibrillation (AF) in patients with sinus node dysfunction, we conducted a prospective randomized controlled study in patients requiring atrial pacing. METHODS: The inclusion criterion was the presence of a sinus node dysfunction with or without episodes of AF. Pacing sites were randomized to either the right atrial septum or appendage. Patients with permanent AF or with atrioventricular (AV) block without sinus node dysfunction were excluded. Patients were discharged at a pacing rate of 65 beats per minute after setting of the optimal AV delay. The antiarrhythmic therapy remained unchanged until the first recurrence of AF. Sequential analyses were performed with the triangular test. RESULTS: Mean baseline characteristics were not different between the septum (n = 57) and the appendage (n = 67) groups. The triangular test evidenced a lack of effect of septal pacing at the last sequential analysis. The rates of AF-free survival were not different between the septum and the appendage group (65% vs 64%, P =.28). In the subgroup of patients with at least 1 episode of AF 3 months before pacing, AF-free survival was increased by atrial septal pacing (70% vs 40%, P =.018). The mean follow-up was 16 +/- 13 months (range, 1-54). CONCLUSIONS: Atrial septal pacing does not have a preventive effect on the occurrence of AF in patient requiring atrial pacing for sinus node dysfunction. Subgroup analysis suggests that atrial septal pacing may benefit patients with >or=1 episode of AF in the 3 months preceding pacing.

Prevalence of drug-induced electrocardiographic pattern of the Brugada syndrome in a healthy population.

To determine the prevalence of drug-induced Brugada's syndrome (BrS) electrocardiograms (ECGs) in a healthy population, a sodium channel blockade challenge was performed in previously identified subjects with BrS-compatible (BrC) ECGs. These subjects were detected in 1,000 normal patients in whom first ECGs were systematically recorded. Because of the intermittent nature of electrocardiographic modifications in BrS, second ECGs were also recorded in a representative sample of the population presenting with first ECGs with normal results. The prevalence of typical drug-induced BrS ECGs was 5 of the 1,000 patients. This value was fivefold greater than the reported prevalence of spontaneous BrS ECGs in the healthy population.

Radioiodine ablation of the thyroid to prevent recurrence of amiodarone-induced thyrotoxicosis in patients with resistant tachyarrhythmias.

UNLABELLED: Amiodarone-induced thyrotoxicosis (AIT) is a common complication of amiodarone therapy. Although permanent withdrawal of amiodarone is recommended due notably to the risk of worsening of tachyarrhythmias, some patients may require the reintroduction of amiodarone several months after normalizing their thyroid function. We, retrospectively, assessed the effects of (131)I therapy to prevent recurrence of AIT in euthyroid patients requiring reintroduction of amiodarone. SUBJECTS AND METHODS: Amiodarone was required in 10 cases of recurrent symptomatic paroxysmal atrial fibrillation (AF) and in 5 cases of ventricular tachycardia (VT) (M = 12, F = 3, mean age: 63 +/- 14). The underlying heart disease was dilated cardiomyopathy (n = 4), ischaemic heart disease (n = 4), hypertensive heart disease (n = 2), arrhythmogenic right ventricular dysplasia (n = 27) and valvulopathy (n = 1). Two patients had idiopathic paroxysmal AF. RESULTS: A mean (131)I dose of 579 +/- 183 MBq was administered 34 +/- 37 after the episode of AIT. Amiodarone was reintroduced in 14 of 15 patients after a mean interval of 103 +/- 261 d. Fourteen patients developed definite hypothyroidism necessitating l-thyroxine but we observed no late recurrence of AIT. After a mean follow-up of 22 +/- 16 months, tachyarrhythmias were controlled in 12 of 14 patients. CONCLUSION: (131)I therapy appears to be an effective and safe approach to prevent the recurrence of AIT in a patient requiring the reintroduction of amiodarone for tachyarrhythmias.

Atrial septal versus atrial appendage pacing: feasibility and effects on atrial conduction, interatrial synchronization, and atrioventricular sequence.

Atrial septal (Se-P) and atrial appendage pacing (Ap-P) were compared in a randomized, controlled study to assess the feasibility, the reliability, and the effects of Se-P on atrial conduction, interatrial synchronization, and the AV sequence. The main baseline characteristics of the patients were comparable in both groups. There was no difference in feasibility or reliability between the two techniques. Compared to Ap-P (n = 28), Se-P (n = 28) decreased the P wave duration, left atrial electromechanical delay (LAEMD), and interatrial interval (-1.6% vs +28%, P < 0.001; -3% vs +30%, P < 0.001; -130% vs +78%, P < 0.001); it induced a smaller increase of the right AEMD, a slight reversal of the timing of the atrial systoles and a shortening of the PR interval (-13% vs +25%, P < 0.001) and of the interval separating atrial systoles from ventricular activation. Finally, the shortening of the PR interval was smaller during high Se-P versus low Se-P. Se-P avoids the undesirable prolongation of the atrial, interatrial, and AV conductions observed during Ap-P. In addition, Se-P creates a slight reversal of the timing of the atrial systoles and induces a shortening of PR interval, the extent of which could depend on the height of the pacing site on the septum.