Effects of a Novel Nutraceutical Combination (Aquilea Colesterol®) on the Lipid Profile and Inflammatory Biomarkers: A Randomized Control Trial.

BACKGROUND: Cholesterol-lowering nutraceuticals are useful in the management of moderate hypercholesterolemia. METHODS: In a parallel-group, randomized, placebo-controlled double-blind trial we evaluated the effects on plasma total cholesterol, low-density lipoprotein cholesterol (LDL-c), and inflammatory biomarkers of a nutraceutical combination (Aquilea Colesterol®) containing phytosterols (1.5 g), red yeast rice providing monacolin K (10 mg), hydroxytyrosol (5 mg), and plasma cholesterol values >5.17 mmol/L (>200 mg/dL) and LDL-c >2.97 mmol/L (>115 mg/dL). At baseline and at one and three months we recorded dietary habits; anthropometric parameters; blood pressure; lipid profile; fasting glucose; liver, renal, and muscle function tests, C-reactive protein (hs-CRP); and interleukin-6. RESULTS: 13 men and 27 women (mean age 61.8 years) completed the trial; 20 participants received the nutraceutical and 20 received placebo. No adverse effects were noted. Compared to placebo, at one and three months the nutraceutical reduced total cholesterol by 11.4% and 14.1%, LDL-c by 19.8% and 19.7%, and apolipoprotein B by 12.4% and 13.5%, respectively (p < 0.001; all). hs-CRP decreased significantly (p = 0.021) in the nutraceutical group. CONCLUSION: The nutraceutical Aquilea Colesterol® is useful for reducing total cholesterol, LDL-c, and inflammation in individuals with moderate hypercholesterolemia.

Practical application of the ATOM study: Treatment efficacy of antihypertensive drugs in monotherapy or combination (ATOM metaanalysis according to PRISMA statement); tables for the use of antihypertensive drugs in monotherapy or combination.

BACKGROUND: The response to antihypertensive drugs is predictable. The absence of precise prescription recommendations to treat arterial hypertension (HT) lead to use drugs unable to reduce blood pressure (BP) to target values.We published ATOM study, in which we found significant differences in the ability to reduce BP between the different drugs.The objective of the study was to determine the expected decrease in blood pressure with the use of commercialized doses of the drugs commonly used in the treatment of HT in clinical practice, to avoid the use of drugs or combinations that even with the best response, are unable to obtain the necessary BP decrease to reach the goal. METHODS: The analysis was based on the results of the ATOM study. To convert the mean doses of the different drugs and combinations in commercialized doses, the conclusions of the study by Law et al have been applied. RESULTS: Based on the results, two tables were drawn, one for systolic BP and the other for diastolic BP, where the doses of the different drugs and combinations are classified according to the BP decrease that can be expected from them. In order to favor the use of the tables in clinical practice, the different drugs have been grouped in intervals of 10 millimeters of mercury (mmHg) for the decrease of the systolic BP and of 5 mmHg for the diastolic BP. CONCLUSIONS: Recommendations for the use of antihypertensive treatments should not be limited to pharmacological families. They should also consider differences between drugs or specific combinations. From the data of the ATOM study we have implemented tables that express the effect of the drugs commonly used in clinical practice and that should allow the clinicians to choose with care the treatment to use.

Perspectiva clínica sobre el tratamiento antihipertensivo en adultos con hipertensión grado 1 y riesgo cardiovascular bajo a moderado: consulta internacional de expertos

[RESUMEN]. La hipertensión arterial es el principal factor de riesgo de la carga global de las enfermedades. Una pregunta en debate es si la hipertensión arterial grado 1 (140–159/90–99 mm Hg) con riesgo cardiovascular (RCV) total bajo (mortalidad cardiovascular < 1% a los 10 años) a moderado (mortalidad cardiovascular > 1% y < 5% a los 10 años) debe ser tratada con agentes antihipertensivos. Un proceso de consulta virtual internacional fue realizado para resumir las opiniones de los expertos seleccionados. Después del análisis holístico de todos los elementos epidemiológicos, clínicos, psicosociales y de salud pública, este proceso de consulta llegó al siguiente consenso para adultos hipertensos < 80 años de edad: 1) La interrogante, de si el tratamiento medicamentoso en la hipertensión grado 1 debe ser precedido por un periodo de algunas semanas o meses, durante el cual solo se recomienden medidas sobre el estilo de vida no está basada en evidencia, pero el consenso de opinión es reservar un periodo para solo cambios en el estilo de vida únicamente en los pacientes con hipertensión grado 1 “aislada” (hipertensión grado 1 no complicada con RCV total absoluto bajo, y sin otros factores de RCV mayores ni modificadores del riesgo). 2) El inicio del tratamiento antihipertensivo medicamentoso en pacientes con hipertensión grado 1 y RCV absoluto moderado no debe demorarse. 3) Los hombres ≥ 55 años y las mujeres ≥ 60 años con hipertensión grado 1 no complicada deben ser automáticamente clasificados dentro de la categoría de RCV total absoluto moderado, incluso en ausencia de otros factores de riesgo mayores y modificadores del riesgo. 4) Las estatinas deben tenerse en cuenta junto con la terapia antihipertensiva, independientemente de los valores de colesterol, en pacientes con hipertensión grado 1 y RCV moderado.

[ABSTRACT]. Hypertension is a leading risk factor for disease burden globally. An unresolved question is whether grade 1 hypertension (140-159/90-99 mmHg) with low (cardiovascular mortality < 1% at 10 years) to moderate (cardiovascular mortality > 1% and < 5% at 10 years) absolute total cardiovascular risk (CVR) should be treated with antihypertensive agents. A virtual international consultation process was undertaken to summarize the opinions of select experts. After holistic analysis of all epidemiological, clinical, psychosocial, and public health elements, this consultation process reached the following consensus in hypertensive adults aged < 80 years: (1) The question of whether drug treatment in grade 1 should be preceded by a period of some weeks or months during which only life style measures are recommended cannot be evidence based, but the consensus opinion is to have a period of lifestyle alone reserved only to patients with grade 1 “isolated” hypertension (grade 1 uncomplicated hypertension with low absolute total CVR, and without other major CVR factors and risk modifiers). (2)The initiation of antihypertensive drug therapy in grade 1 hypertension with moderate absolute total CVR should not be delayed. (3) Men ≥ 55 years and women ≥ 60 years with uncomplicated grade1 hypertension should automatically be classified within the moderate absolute total CVR category, even in the absence of other major CVR factors and risk modifiers. (4) Statins should be considered along with blood-pressure lowering therapy, irrespective of cholesterol levels, in patients with grade 1 hypertensive with moderate CVR.

Clinical Perspective on Antihypertensive Drug Treatment in Adults With Grade 1 Hypertension and Low-to-Moderate Cardiovascular Risk: An International Expert Consultation.

Hypertension is a leading risk factor for disease burden globally. An unresolved question is whether grade 1 hypertension (140-159/90-99mmHg) with low (cardiovascular mortality <1% at 10 years) to moderate (cardiovascular mortality ≥1% and <5% at 10 years) absolute total cardiovascular risk (CVR) should be treated with antihypertensive agents. A virtual international consultation process was undertaken to summarize the opinions of select experts. After holistic analysis of all epidemiological, clinical, psychosocial, and public health elements, this consultation process reached the following consensus in hypertensive adults aged <80 years: (1) The question of whether drug treatment in grade 1 should be preceded by a period of some weeks or months during which only lifestyle measures are recommended cannot be evidence based, but the consensus opinion is to have a period of lifestyle alone reserved only to patients with grade 1 "isolated" hypertension (grade 1 uncomplicated hypertension with low absolute total CVR, and without other major CVR factors and risk modifiers). (2) The initiation of antihypertensive drug therapy in grade 1 hypertension with moderate absolute total CVR should not be delayed. (3) Men ≥55 years and women ≥60 years with uncomplicated grade 1 hypertension should automatically be classified within the moderate absolute total CVR category, even in the absence of other major CVR factors and risk modifiers. (4) Statins should be considered along with blood-pressure lowering therapy, irrespective of cholesterol levels, in patients with grade 1 hypertensive with moderate CVR.

Lercanidipine valuable effect on urine protein losses: the RED LEVEL study.

OBJECTIVE: The RED LEVEL study (REnal Disease: LErcanidipine Valuable Effect on urine protein Losses) directly compares, in an explorative fashion, the effects of lercanidipine + enalapril and amlodipine + enalapril combinations on renal parameters in hypertensive subjects. RESEARCH DESIGN AND METHODS: This was a 1 year, prospective, multi-center, randomized, open-label, blinded-endpoint (PROBE) study in hypertensive patients with albuminuria. MAIN OUTCOME MEASURES: Renal function (albuminuria, serum creatinine, creatinine clearance, estimated glomerular filtration rate and proteinuria); blood pressure. RESULTS: Albuminuria was significantly reduced, compared with baseline values, with the lercanidipine + enalapril combination over the entire study period; at month 3, month 6 and month 12, changes from baseline were: -162.5 (p-value = 0.0439), -425.8 (p-value = 0.0010), -329.0 (p-value = 0.0011) mg/24 h), respectively. On the other hand, this improvement was not observed with enalapril + amlodipine. Other parameters of renal function such as serum creatinine, creatinine clearance, estimated glomerular filtration rate and proteinuria did not change over the study. Both lercanidipine + enalapril and amlodipine + enalapril significantly reduced systolic and diastolic blood pressure values from baseline all over the study period with no significant differences between groups. Safety outcomes were comparable between the two groups. CONCLUSIONS: Overall, the results of this explorative study lend support to the anti-albuminuric effect of the lercanidipine + enalapril combination and to the long term renal-protective effects of this combination in patients with hypertension.

Prevalence of masked hypertension and associated factors in normotensive healthcare workers.

BACKGROUND AND OBJECTIVE: Evidence on the elevated cardiovascular risk associated with masked hypertension (MHT) is becoming stronger. Determining the prevalence of MHT in apparently healthy individuals may enable better risk stratification and management. METHODS: This was a cross-sectional study of normotensive healthcare workers recruited from 52 hypertension units. We included individuals aged at least 18 years with no known history of hypertension and office blood pressure (BP) less than 140/90 mmHg. MHT was defined as mean daytime ambulatory BP of at least 135/85 mmHg. RESULTS: Overall, 485 individuals (mean age 43.1 years, 55% women) were included. The prevalence of MHT was 23.9% [95% confidence interval (CI): 20.1-27.7]. The most prevalent associated cardiovascular risk factors in the total population were smoking (24.9%), dyslipidemia (16.4%), a family history of premature cardiovascular disease (15.9%), and obesity (7.4%). A total of 45.4% of individuals had a family history of hypertension. MHT was associated with male sex [odds ratio (OR) 1.722, 95% CI: 1.091-2.718] and prehypertension (OR 4.561, 95% CI: 2.880-7.222). In univariate analysis, the OR of the diagnosis of MHT increased by 2.3% per year of age. CONCLUSION: The prevalence of MHT in normotensive healthcare workers in Spain is almost 25%. Therefore, 24-h ambulatory BP monitoring should be routine in occupational health checks in health workers, especially men.

Prevalencia de hipertensión arterial enmascarada en una cohorte de pacientes hipertensos controlados en España / Prevalence of masked hypertension in a cohort of controlled hypertensive patients in Spain

Fundamento y objetivo: La evidencia sobre el elevado riesgo cardiovascular asociado a la hipertensión arterial enmascarada (HTAE) es cada vez más sólida, por lo que conocer su prevalencia en nuestro entorno permitirá una mejor estratificación y manejo de los pacientes hipertensos. Sin embargo, los datos sobre su prevalencia en España son escasos y con una elevada variabilidad en función de la población estudiada. Por ello, el grupo para el ESTudio de la Hipertensión arterial Enmascarada (ESTHEN) de la Sociedad Española de Hipertensión promovió el siguiente estudio con el objetivo de conocer la prevalencia de la HTAE entre la población de pacientes hipertensos atendidos y controlados en las Unidades de Hipertensión de hospitales de todo el territorio español. Pacientes y métodos: Estudio prospectivo de una cohorte de pacientes hipertensos atendidos en 75 Unidades de HTA de todo el territorio español. Se incluyeron hipertensos tratados ≥ 18 años con buen control de las cifras de presión arterial (PA) clínica definida por cifras de PA < 140/90mmHg. Se definió HTAE si la media de PA del período diurno era ≥ 135/85mmHg.Resultados: Se analizaron datos de 302 pacientes. La edad media fue de 56,2 años y el 56% eran varones. La prevalencia de HTAE fue del 48% (intervalo de confianza del 95% [IC 95%] 42-53). En cuanto a los factores de riesgo asociados, el más prevalente fue la obesidad abdominal (22,5%), fumador activo (24,2%), antecedentes familiares de enfermedad cardiovascular prematura (22,5%) y diabetes (11,6%). La prevalencia de hipertrofia ventricular izquierda fue del 23,8%, el 22,2% tenían enfermedad cardiovascular establecida y el 6,3% enfermedad renal. La HTAE se asoció con la ausencia de enfermedad cardiovascular establecida (odds ratio [OR] 0,306; IC 95% 0,139-0,676) y la proximidad de las cifras de PA clínica a los límites considerados para el control (OR 0,901; IC 95% 0,842-0,963) (AU)

Introduction and objective: In recent years the evidence that masked hypertension is associated with a highest cardiovascular risk is well established. Knowing the prevalence of masked hypertension in our country will allow a better cardiovascular risk stratification and management of hypertensive patients, although the information is scant and heterogeneous. For this reason, the working group for the study of masked hypertension (ESTHEN) in Spain developed the present study with the objective to know the prevalence of masked hypertension in a cohort of hypertensive patients follows in several Hypertension Units in Spain.Patients and methods: Prospective study of a cohort of hypertensive patients followed in 75 Hypertension Units in Spain. Eligible patients were hypertensive cases aged ≥ 18years receiving antihypertensive drug treatment and showing an adequate BP control at the clinic (BP < 140/90mmHg). Masked hypertension was defined when mean daytime BP ≥ 135/85mmHg. Results: We analyzed data from 302 patients. Mean age was 56.2years and 56% were male. Prevalence of masked hypertension was 48% (95%CI 42-53). The most prevalent accompanying risk factors were abdominal obesity (39.7%), smoking (24.2%), family with premature cardiovascular disease (22.5%), and diabetes (11.6%). Prevalence of left ventricular hypertrophy was 23.8%, and 22.2% of patients had established cardiovascular disease, and 6.3% had renal disease. Masked hypertension was related to the absence of established cardiovascular disease (OR 0.306, 95%CI 0.139-0.676) and to the proximity of the clinic BP levels to the control thresholds (0.901, 95%CI 0.842-0.963). The OR of masked hypertension diminished 10% for each mmHg below the threshold of control. Conclusions:The prevalence of masked hypertension was approximately 50% in treated hypertensive patients. ABPM constitutes a basic tool for detection of this abnormality (AU)

[Prevalence of masked hypertension in a cohort of controlled hypertensive patients in Spain]. / Prevalencia de hipertensión arterial enmascarada en una cohorte de pacientes hipertensos controlados en España.

INTRODUCTION AND OBJECTIVE: In recent years the evidence that masked hypertension is associated with a highest cardiovascular risk is well established. Knowing the prevalence of masked hypertension in our country will allow a better cardiovascular risk stratification and management of hypertensive patients, although the information is scant and heterogeneous. For this reason, the working group for the study of masked hypertension (ESTHEN) in Spain developed the present study with the objective to know the prevalence of masked hypertension in a cohort of hypertensive patients follows in several Hypertension Units in Spain. PATIENTS AND METHODS: Prospective study of a cohort of hypertensive patients followed in 75 Hypertension Units in Spain. Eligible patients were hypertensive cases aged ≥ 18 years receiving antihypertensive drug treatment and showing an adequate BP control at the clinic (BP < 140/90 mmHg). Masked hypertension was defined when mean daytime BP ≥ 135/85 mmHg. RESULTS: We analyzed data from 302 patients. Mean age was 56.2 years and 56% were male. Prevalence of masked hypertension was 48% (95%CI 42-53). The most prevalent accompanying risk factors were abdominal obesity (39.7%), smoking (24.2%), family with premature cardiovascular disease (22.5%), and diabetes (11.6%). Prevalence of left ventricular hypertrophy was 23.8%, and 22.2% of patients had established cardiovascular disease, and 6.3% had renal disease. Masked hypertension was related to the absence of established cardiovascular disease (OR 0.306, 95%CI 0.139-0.676) and to the proximity of the clinic BP levels to the control thresholds (0.901, 95%CI 0.842-0.963). The OR of masked hypertension diminished 10% for each mmHg below the threshold of control. CONCLUSIONS: The prevalence of masked hypertension was approximately 50% in treated hypertensive patients. ABPM constitutes a basic tool for detection of this abnormality.

Multicenter cluster-randomized trial of a multifactorial intervention to improve antihypertensive medication adherence and blood pressure control among patients at high cardiovascular risk (the COM99 study).

BACKGROUND: Medication nonadherence is common and results in preventable disease complications. This study assessed the effectiveness of a multifactorial intervention to improve both medication adherence and blood pressure control and to reduce cardiovascular events. METHODS AND RESULTS: In this multicenter, cluster-randomized trial, physicians from hospital-based hypertension clinics and primary care centers across Spain were randomized to receive and provide the intervention to their high-risk patients. Eligible patients were ≥ 50 years of age, had uncontrolled hypertension, and had an estimated 10-year cardiovascular risk greater than 30%. Physicians randomized to the intervention group counted patients' pills, designated a family member to support adherence behavior, and provided educational information to patients. The primary outcome was blood pressure control at 6 months. Secondary outcomes included both medication adherence and a composite end point of all-cause mortality and cardiovascular-related hospitalizations. Seventy-nine physicians and 877 patients participated in the trial. The mean duration of follow-up was 39 months. Intervention patients were less likely to have an uncontrolled systolic blood pressure (odds ratio 0.62, 95% confidence interval 0.50 to 0.78) and were more likely to be adherent (odds ratio 1.91, 95% confidence interval 1.19 to 3.05) than control group patients at 6 months. After 5 years, 16% of the patients in the intervention group and 19% in the control group met the composite end point (hazard ratio 0.97, 95% confidence interval 0.67 to 1.39). CONCLUSIONS: A multifactorial intervention to improve adherence to antihypertensive medication was effective in improving both adherence and blood pressure control, but it did not appear to improve long-term cardiovascular events.

Isolated clinic hypertension: diagnostic criteria based on 24-h blood pressure definition.

OBJECTIVE: The use of diagnostic criteria based on 24-h ambulatory blood pressure (BP) values could improve prognostic value by incorporating night BP, minimize biases and improve the diagnostic reproducibility of isolated clinic hypertension (ICH). We estimate the 24-h BP cut-off points that best discriminate and predict the two diagnostic thresholds of mean daytime BP for ICH (135/85 and 130/80 mmHg). METHODS: Cross-sectional, comparative, multicentre study in 6176 untreated hypertensive patients, whose BP was measured by ambulatory BP monitoring. ICH was defined with an office BP of ≥140/≥90 mmHg and a daytime BP of <135/<85 mmHg (ICH1) or <130/80 mmHg (ICH2). Sensitivity, specificity, positive likelihood ratio (LR+), odds ratio (OR), error rate, predictive values, κ values and 95% confidence interval were calculated for each possible cut-off point for ICH1 and ICH2. RESULTS: One thousand eight hundred and seven patients (29.2%) and 960 patients (15.5%) met ICH1 and ICH2 criteria, respectively. The 24-h BP cut-off points that best predict ICH1 and ICH2 are less than 132/82 mmHg (sensitivity: 93.6%, specificity: 94.3%, LR+: 16.6, OR: 1367.1, error rate: 5.9, κ 0.86) and less than 127/77 mmHg (sensitivity: 90.8%, specificity: 97.4%, LR+: 34.6, OR: 1041.5, error rate: 3.6,κ 0.86), respectively. These values achieved the best balance of sensitivity and specificity, together with the highest values of LR+ and OR and the lowest error rate. CONCLUSION: The 24-h BP cut-off point that best predicts the daytime criterion of less than 135/85 and less than 130/80 mmHg are 132/82 and 127/77 mmHg, respectively. These 24-h cut-off points may add value to ambulatory blood pressure monitoring for both diagnostic and management future decisions.

Manidipine treatment in patients with albuminuria not sufficiently reduced with renin-angiotensin system blockers.

Microalbuminuria is an issue of great concern in hypertensive patients owing to its close relation with cardiovascular morbidity and mortality. Treatment should aim to reduce microalbuminuria to the normal range. Drugs that block the renin-angiotensin system have specific antiproteinuric properties, but more than one drug is needed to achieve blood pressure control in most cases. The aim of this study was to compare the effects of adding manidipine to the treatment of patients with essential hypertension and persistent albuminuria, despite full-dose treatment with a renin-angiotensin system blocker on urinary albumin excretion (UAE) after 24 weeks of therapy. Patients with diabetes and renal insufficiency were excluded. At baseline, blood pressure and UAE were 155.1 +/- 12/87.76 +/- 11 mmHg and 293.19 +/- 285 mg/g, respectively. At study end, blood pressure was 137.1 +/- 13.1/77.24 +/- 10.4 mmHg (p < 0.001 vs baseline). UAE was reduced by 45% to 161.52 +/- 163 mg/g (p < 0.001 vs baseline). No correlations were found between systolic blood pressure reduction and UAE reduction (Pearson's R = -0.034; p = not significant) nor between estimated glomerular filtration rate and UAE reduction (Pearson's R = -0.0056; p = not significant). No patient withdrew from the study owing to side effects. In conclusion, treatment with manidipine resulted in a large reduction in UAE rates, and this reduction appeared to be independent of the degree of blood pressure reduction or changes in estimated glomerular filtration rate. Our data supports the added value of manidipine in the treatment of patients with hypertension and microalbuminuria.

Diferencias entre el control clínico y ambulatorio de la hipertensión arterial en pacientes muy ancianos. Proyecto CARDIORISC–MAPAPRES / Differences between office and ambulatory control of hypertension in very elderly patients. The CARDIORISC – MAPAPRES project

Fundamento y objetivos: La hipertensión arterial (HTA) afecta a la mayoría de la población muy anciana. El objetivo de este estudio fue estimar el grado de control de la HTA según se registre la presión arterial (PA) en la consulta o por monitorización ambulatoria de PA (MAPA). Pacientes y método: Estudio transversal y multicéntrico sobre pacientes hipertensos de 80 o más años de edad con tratamiento farmacológico antihipertensivo incluidos en el proyecto CARDIORISC–MAPAPRES. Entre junio de 2004 y abril de 2007 se obtuvo una base de datos de 33.829 registros de MAPA que cumplieron estándares de calidad preestablecidos. Se definió como buen control clínico a valores de PA menores de 140/90mmHg, y como buen control ambulatorio a valores de PA por MAPA en período de 24h menores de 130/80mmHg.Resultados: Se identificaron 2.311 pacientes (6,8%) de 80 o más años de edad. La edad media fue de 83,1 años (DE de 3,2) y un 63% fueron mujeres. El 21,5% (intervalo de confianza [IC] del 95%: 19,1–23,9) presentó buen control clínico y un 42,1% (IC del 95%: 39,7–45,3) presentó buen control ambulatorio (p<0,001). La prevalencia de HTA enmascarada fue del 7,0% (IC del 95%: 6,0–8,0) y la prevalencia de resistencia aislada en la clínica fue del 27,6% (IC del 95%: 25,7–29,4). La diabetes, la enfermedad renal crónica y la duración de la HTA fueron los factores más asociados al mal control de la HTA (p<0,001) en la MAPA de 24h.Conclusiones: Sólo 2 de cada 10 pacientes muy ancianos hipertensos tuvieron controlada adecuadamente su HTA por medida casual. Sin embargo, prácticamente el doble estaban controlados con el criterio de la MAPA. Estos hallazgos justifican un uso más amplio de la MAPA en el paciente hipertenso de edad muy avanzada (AU)

Background and objective: Hypertension is highly prevalent in the very elderly. We studied control rates of hypertension according to clinic blood pressure (BP) and ambulatory BP monitoring (ABPM) in treated hypertensives aged ≥80 years.Patients and method: Data came from the Spanish Society of Hypertension ABPM Registry (CARDIORISC – MAPAPRES project), which comprises a nation-wide network of more than 1,000 physicians sending standardized ABPM registries via web. Between June 2004 and April 2007 we obtained a 33.829-patient database. Control of hypertension was defined at the clinic when office BP was <140/90mmHg and at the ABPM when mean BP during the 24-h period was <130/80mmHg.Results: We identified 2,311 patients (6.8%) aged ≥80 years. Mean age (SD) was 83.1 (3.2) years and 63% were women. Control of clinic BP was observed in 21.5% of cases (95%CI: 19.1–23.9) and control of 24-h BP in ABPM was 42.1% (95%CI: 39.7–45.3). Prevalence of masked hypertension was 7.0% (95%CI: 6.0–8.0) and prevalence of office-resistant control (white coat) was 27.6% (95% CI: 25.7–29.4). Diabetes, kidney disease, and duration of hypertension were associated with lack of control in ABPM. Conclusions: In very old hypertensives, control of clinic BP was 21.5% but ambulatory-based hypertension control was 42.1%. Physicians should be aware that the likelihood of misestimating BP control is high in these subjects. A wider use of ABPM in the elderly with hypertension should be considered (AU)

[Differences between office and ambulatory control of hypertension in very elderly patients. The CARDIORISC - MAPAPRES project]. / Diferencias entre el control clínico y ambulatorio de la hipertensión arterial en pacientes muy ancianos. Proyecto CARDIORISC-MAPAPRES.

BACKGROUND AND OBJECTIVE: Hypertension is highly prevalent in the very elderly. We studied control rates of hypertension according to clinic blood pressure (BP) and ambulatory BP monitoring (ABPM) in treated hypertensives aged > or =80 years. PATIENTS AND METHOD: Data came from the Spanish Society of Hypertension ABPM Registry (CARDIORISC - MAPAPRES project), which comprises a nation-wide network of more than 1,000 physicians sending standardized ABPM registries via web. Between June 2004 and April 2007 we obtained a 33.829-patient database. Control of hypertension was defined at the clinic when office BP was <140/90mmHg and at the ABPM when mean BP during the 24-h period was <130/80mmHg. RESULTS: We identified 2,311 patients (6.8%) aged > or =80 years. Mean age (SD) was 83.1 (3.2) years and 63% were women. Control of clinic BP was observed in 21.5% of cases (95%CI: 19.1-23.9) and control of 24-h BP in ABPM was 42.1% (95%CI: 39.7-45.3). Prevalence of masked hypertension was 7.0% (95%CI: 6.0-8.0) and prevalence of office-resistant control (white coat) was 27.6% (95% CI: 25.7-29.4). Diabetes, kidney disease, and duration of hypertension were associated with lack of control in ABPM. CONCLUSIONS: In very old hypertensives, control of clinic BP was 21.5% but ambulatory-based hypertension control was 42.1%. Physicians should be aware that the likelihood of misestimating BP control is high in these subjects. A wider use of ABPM in the elderly with hypertension should be considered.

Prevalence and factors associated with circadian blood pressure patterns in hypertensive patients.

Ambulatory blood pressure (BP) monitoring has become useful in the diagnosis and management of hypertensive individuals. In addition to 24-hour values, the circadian variation of BP adds prognostic significance in predicting cardiovascular outcome. However, the magnitude of circadian BP patterns in large studies has hardly been noticed. Our aims were to determine the prevalence of circadian BP patterns and to assess clinical conditions associated with the nondipping status in groups of both treated and untreated hypertensive subjects, studied separately. Clinical data and 24-hour ambulatory BP monitoring were obtained from 42,947 hypertensive patients included in the Spanish Society of Hypertension Ambulatory Blood Pressure Monitoring Registry. They were 8384 previously untreated and 34,563 treated hypertensives. Twenty-four-hour ambulatory BP monitoring was performed with an oscillometric device (SpaceLabs 90207). A nondipping pattern was defined when nocturnal systolic BP dip was <10% of daytime systolic BP. The prevalence of nondipping was 41% in the untreated group and 53% in treated patients. In both groups, advanced age, obesity, diabetes mellitus, and overt cardiovascular or renal disease were associated with a blunted nocturnal BP decline (P<0.001). In treated patients, nondipping was associated with the use of a higher number of antihypertensive drugs but not with the time of the day at which antihypertensive drugs were administered. In conclusion, a blunted nocturnal BP dip (the nondipping pattern) is common in hypertensive patients. A clinical pattern of high cardiovascular risk is associated with nondipping, suggesting that the blunted nocturnal BP dip may be merely a marker of high cardiovascular risk.

Ambulatory blood pressure monitoring (ABPM) in nonagenarians.

The objective of the study is to investigate ambulatory blood pressure monitoring (ABPM) in a sample of Spanish nonagenarians. We also analyzed the misdiagnosis of hypertension and investigated blood pressure (BP) control in treated hypertensive nonagenarians. Twenty-four-hour ABPM was undertaken in a group of 42 nonagenarians. The 24-h mean, daytime BP, nighttime BP and heart rate (HR) were extracted from the ABPM. Sociodemographic data, the ability to perform basic daily activities, measured by the Barthel index (BI) or instrumental activities revealed by the Lawton and Brody index (LI), cognition, and comorbidity were evaluated. Thirty-one subjects were receiving antihypertensive drug treatment. Twenty-four hour, daytime and sleeping pressures averaged 130/65, 131/68 and 128/63mmHg, respectively. Seventeen (40.5%) of the 42 patients had a daytime BP of 135/85 or higher. In terms of the BP pattern, 8 (19%) subjects were dippers, 19 (45%) non-dippers, and 15 (36%) were risers. Five (45.46%) out of 11 patients with no evidence of hypertension (normotensive patients) had a daytime BP of 135/85 or higher. The mean daytime BP was 135/85 or higher in 12 (38.7%) out of 31 nonagenarians who had previously received therapy for hypertension. In, conclusion a high prevalence of hypertension, misdiagnosis and inadequate BP control was found in nonagenarians treated for hypertension.

Gender differences in office and ambulatory control of hypertension.

BACKGROUND: Gender differences in hypertension control have not been explored fully. METHODS: We studied 15,212 white men and 13,936 white women with treated hypertension who were drawn from the Spanish Ambulatory Blood Pressure Registry. For each participant, we obtained office blood pressure (BP) (average of 2 readings) and 24-hour ambulatory BP (average of measurements performed every 20 minutes during day and night). RESULTS: Only 16.4% of women and 14.7% of men had both office (<140/90 mm Hg) and ambulatory (<130/80 mm Hg) BP controlled (P<.001). Women had a lower frequency of masked hypertension (office BP<140/90 mm Hg and ambulatory BP> or =130/80 mm Hg) than men (5.9% vs 7.9%, P<.001). Women had a higher frequency of isolated office hypertension (office BP> or =140/90 mm Hg and ambulatory BP<130/80 mm Hg) (32.5% vs 24.2%, P<.001). Although office BP control (office BP<140/90 mm Hg, regardless of ambulatory values) was similar in women and men (22.3% vs 22.6%, P=.542), ambulatory BP control (ambulatory BP<130/80 mm Hg, regardless of office values) was higher in women than in men (48.9% vs 38.9%, P<.001). After adjustment for age, number of antihypertensive drugs, hypertension duration, and risk factors, gender differences in BP control remained practically unchanged. CONCLUSION: Ambulatory BP control was higher in women than in men. This may be due to the higher frequency of isolated office hypertension in women, and it is not explained by gender differences in other important clinical characteristics.

Clinical characteristics of isolated clinic hypertension.

OBJECTIVE: To analyze the clinical characteristics of patients with isolated clinic hypertension (ICH) compared with other hypertensive patients, and to evaluate the capacity of physicians to predict a diagnosis of ICH. METHODS: A cross-sectional, comparative multicenter descriptive study was made of 6176 hypertensive individuals without pharmacological treatment, subjected to ambulatory blood pressure monitoring (ABPM). In 2611 cases, ABPM was prescribed due to suspected ICH. The participants were consecutively selected in primary care centers and hospital hypertension units in all Spanish Autonomous Communities. ICH was defined by clinical blood pressure (BP) >or= 140 mmHg (systolic) or >or= 90 mmHg (diastolic), with diurnal ambulatory BP < 135 and < 85 mmHg (ICH1) or BP < 130 and < 80 mmHg (ICH2) or 24-h BP < 125 and < 80 mmHg (ICH3). RESULTS: ICH1, ICH2 and ICH3 criteria were met by 1807 (29.2%), 960 (15.5%) or 1133 (18.3%) subjects, respectively. Total sample mean age (SD) was 51.8 (14.1) years, and clinical BP 145.7 +/- 17.3/89.3 +/- 11.3 mmHg. Compared with the rest of the hypertensive individuals, the patients with ICH were predominantly female, of older age, with fewer smokers, and increased frequency of obesity. Moreover, they were more frequently nondippers, and with greater systolic BP in the office (P < 0.05), except when we used ICH3 criteria. The sensitivity and specificity of the physician predictions in relation to suspected ICH1, ICH2 and ICH3 were 48.7 and 60.4%, 52.9 and 59.7%, and 52.3 and 60.0%, respectively. CONCLUSIONS: The prevalence of ICH is between 15 and 29%, depending on the defining criterion used. The 24-h ICH criteria are not affected by awake/sleep biases, and should be preferred. Clinical capacity for predicting ICH is low.

Reproducibility of the circadian blood pressure pattern in 24-h versus 48-h recordings: the Spanish Ambulatory Blood Pressure Monitoring Registry.

OBJECTIVES: To assess the reproducibility of the circadian blood pressure (BP) pattern over a 48-h period by comparing the first 24 h of ambulatory blood pressure monitoring (ABPM) with the following 24 h and with the mean over 48 h. PATIENTS AND METHODS: Patients undergoing 48-h ABPM within the National ABPM Registry of the Spanish Society of Hypertension, based on 800 Spacelabs 90207 monitors distributed throughout Spain in hypertension units and primary healthcare centres, were included. Between June 2004 and September 2005, 611 valid 48-h ABPM recordings were obtained, 235 corresponded to patients without antihypertensive treatment. RESULTS: The percentages of patients classified as non-dipper for the first 24 h, the second 24 h and the 48-h average were 47, 50 and 48%, respectively. When the first and second 24-h periods were compared, 147 (24%) subjects switched from dipper (D) to non-dipper (ND) or vice-versa. When the first 24-h period was compared to the 48-h average, 66 (11%) subjects switched patterns. The proportions were similar separately for systolic blood pressure (SBP) and diastolic blood pressure (DBP) and between treated and untreated patients. In subjects with poor ABPM reproducibility, night-to-day ratios were of an intermediate value between those of subjects always classified as D or ND. CONCLUSION: Categorization of D or ND based on a single 24-h ABPM is moderately reproducible, since one out of every five patients change profile over the following 24 h. Nevertheless, the use of 48-h ABPM in clinical practice should be assessed according to cost-effectiveness criteria. Night-to-day ratios may be helpful in identifying patients with a stable profile.