European guidelines on lifestyle changes for management of hypertension : Awareness and implementation of recommendations among German and European physicians.

BACKGROUND: In the 2013 European Society of Hypertension (ESH) and European Society of Cardiology (ESC) guidelines for the management of arterial hypertension, six lifestyle changes for treatment are recommended for the first time with class I, level of evidence A. We initiated a survey among physicians to explore their awareness and consideration of lifestyle changes in hypertension management. METHODS: The survey included questions regarding demographics as well as awareness and implementation of the recommended lifestyle changes. It was conducted at two German and two European scientific meetings in 2015. RESULTS: In all, 1064 (37.4% female) physicians participated (806 at the European and 258 at the German meetings). Of the six recommended lifestyle changes, self-reported awareness was highest for regular exercise (85.8%) followed by reduction of weight (66.2%). The least frequently self-reported lifestyle changes were the advice to quit smoking (47.3%) and moderation of alcohol consumption (36.3%). Similar frequencies were observed for the lifestyle changes implemented by physicians in their care of patients. CONCLUSION: A close correlation between awareness of guideline recommendations and their implementation into clinical management was observed. European physicians place a stronger emphasis on regular exercise and weight reduction than on the other recommended lifestyle changes. Moderation of alcohol consumption is the least emphasized lifestyle change.

[Management of different cardiovascular risk factors with a combination tablet (polypill)]. / Management verschiedener kardiovaskulärer Risikofaktoren mit einem Kombinationspräparat ("Polypill").

BACKGROUND: The multifactorial origin of cardiovascular diseases has led to polypharmacy in primary and secondary prophylaxis with evidence-based medications, such as statins, antihypertensive drugs and platelet aggregation inhibitors. The number of prescribed drugs correlates inversely to adherence and can lead to treatment failure. Fixed-dose combination drugs (polypills) could increase the medication adherence of patients, reduce risks and prevent cardiovascular events. METHODS: This review is based on publications that were retrieved from Medline (via PubMed) and The Cochrane Library. The clinical database ClinicalTrials.gov. was also considered. RESULTS: In the studies on primary prevention conducted to date, fixed-dose combinations showed a superior control of risk factors, e.g. hypertension and low-density lipoprotein (LDL) cholesterol compared to placebo and at least non-inferiority compared to usual care. In secondary prevention, the effect of the polypill is mostly on the reduction of blood pressure and LDL cholesterol in non-adherent patients; however, evidence that fixed-drug combinations reduce cardiovascular morbidity and mortality compared to standard therapy is lacking. CONCLUSION: The polypill can be considered as an alternative to polypharmacy after a risk-benefit assessment, especially in non-adherent patients. Ongoing studies are investigating the effect of the polypill on cardiovascular events. Current polypills are limited by the lack of sufficient dosages of the individual components to avoid overtreatment and undertreatment at the individual treatment level.

[Ambulatory 24-h blood pressure measurement in patients with glaucoma]. / Bedeutung des 24-Stunden-Blutdruckprofils beim Glaukom.

The arterial blood pressure is an important determinant for the development and progression of glaucoma. Some relevant information can be obtained only by ambulatory 24-h blood pressure measurement (ABPM). White-coat hypertension can be excluded by ABDM and the variability of blood pressure during 24 hours can be assessed. 24-h mean blood pressure should be < 130/80 mmHg. In contrast, diastolic blood pressure values below 60 mmHg during the night have been identified as a progression factor in glaucoma, as well as reductions of night-time systolic blood pressure of less than 10 % (non-dipper) and of more than 20 % (extreme dipper). The significance of the 24-h blood pressure profile for the cooperation of ophthalmology and internal medicine is discussed.

Correction factors for the calculation of metabolic equivalents (MET) in overweight to extremely obese subjects.

BACKGROUND/OBJECTIVES: The metabolic equivalent (MET) is a construct that is commonly used to quantify physical activity as well as exercise performance. 'One MET' is equal to a resting oxygen uptake of 3.5 ml O2 kg(-1) min(-)(1). However, this assumption is unlikely valid in obese subjects. The aim of our study was to quantify the difference between calculated and measured METs in overweight to severely obese subjects and to provide body mass index (BMI)-specific MET correction factors. SUBJECTS/METHODS: Resting oxygen uptake (VO2-REE) was measured in 1331 patients with a BMI >25 kg m(-2) (72.0% women; age: 42.5 ± 13.0 years; BMI: 42.5 ± 7.0 kg m(-)(2)) by indirect calorimetry and MET-REE, that is, VO2-REE related to body weight was calculated. Six hundred and fifty-two subjects (70.9% women) additionally underwent a bicycle cardiopulmonary exercise test for measurement of maximal MET (MET peak). RESULTS: Mean MET-REE was 2.47 ± 0.33 ml O2 kg(-1) min(-1) in women and 2.62 ± 0.34 ml O2 kg(-1) min(-1) in men, that is, markedly lower than the expected 3.5 ml O2 kg(-1) min(-1). MET-REE decreased with increasing BMI (P<0.001 for both sexes). On this dataset, gender-specific MET correction factors were developed for distinct BMI groups. During the exercise test, women performed 4.4 ± 1.3 MET peak and men 4.7 ± 1.3. After applying our correction factors, MET peak increased to 6.2 ± 1.7 and 6.1 ± 1.6, respectively. CONCLUSIONS: Data indicate that the commonly used 1-MET value of 3.5 ml O2 kg(-)(1) min(-)(1) largely overestimates values in overweight to severely obese subjects. Our correction factors can help to reduce this systematic error and thus appear to be valuable for clinical practice as well as research studies.

[Influence of asthma severity and asthma-specific knowledge on participation in physical education among children and young people with bronchial asthma]. / Kinder und Jugendliche mit Asthma bronchiale im Schulsport: Teilnahmehäufigkeit abhängig vom Schweregrad oder vom asthmaspezifischen Wissen durch Schulung?

BACKGROUND: Physical activity is an important part of the therapy of bronchial asthma. Even if there is exercise-induced bronchoconstriction in more or less all children with bronchial asthma, the goal is an almost complete participation in physical education lessons in school. The present study investigates their participation rate. In addition, the influence of the knowledge about asthma and the severity of the disease were studied. METHODS: A questionnaire on asthma knowledge and severity, participation rate and exercise-induced symptoms was used in 217 school children suffering from asthma (9 - 16 years). RESULTS: 80 % of the patients showed a regular participation in physical education. No correlation between participation and asthma severity was found. In contrast, a significant correlation between participation and knowledge about asthma could be demonstrated (r = 0.35, p < 0.01). The knowledge about asthma was better in school children who had completed any asthma education program in the past (19 %). However, there was generally an insufficient knowledge about asthma and exercise in the investigated group. 58 subjects were not familiar with pursed lip breathing and 112 participated in physical education lessons in spite of forgotten asthma medication. CONCLUSION: Our study demonstrates a moderate increase of participation in physical education lessons in school children with bronchial asthma during the last ten years. The participation rate correlated with asthma-specific knowledge, but not with asthma severity underlining the importance of education programs on asthma and exercise.

Aerobic exercise as a therapy option for migraine: a pilot study.

Exercise is assumed to have a positive effect on migraine. However, none of the few studies on this topic can prove the expected positive influence of exercise. Therefore, the aim of this pilot study was to develop a training program suitable for migraine patients and to examine its effect on migraine. 16 patients were examined. 8 migraine patients completed a 10-week aerobic running exercise program consisting of 3 workouts per week. The program was developed by sports scientists especially to increase the fitness level. Physical fitness, i. e., physical working capacity, was assessed using a PWC 150 test. There was also a control group of 8 patients without any special physical training. Migraine patients of the exercise group showed both a reduction in the number of migraine days per month (p=0.048) and the intensity of the attacks (p=0.028). An increase in fitness level resulted in a lowered stress level. Stress strategies like "displacement activity" (r=-0.715; p=0.046), "looking for self-affirmation" (r=-0.742; p=0.035) and "feelings of aggression" (r=-0.802; p=0.017) were reduced. Increasing the level of fitness (PWC 150) is one predictor for migraine improvement (r=0.409, p=0.031). Aerobic exercise which leads to a better fitness level is an alternative therapy method for migraine.

[Bronchial asthma and sport. State of knowledge on bronchial asthma of primary physical education teachers in Schleswig-Holstein]. / Asthma bronchiale und Sport. Wissensstand der sportunterrichtenden Grundschullehrer/innen in Schleswig-Holstein über Asthma bronchiale.

BACKGROUND: There is a high prevalence of bronchial asthma among school children in primary schools (age 6-10 years). Although physical exertion may induce acute episodes of asthma in the majority of children, exercise may also be an important part of the therapy for asthma and motor development of children with asthma. In the present study, the knowledge concerning asthma and exercise among teachers in primary schools was investigated. METHODS: 120 teachers of physical education in Schleswig-Holstein were interviewed concerning their baseline data (age, gender, education) and their knowledge about asthma and physical exercise. RESULTS: 44% do not plan their lessons with regard to possible stimuli for asthma attacks. Only 32 teachers prefer correct interval training and only a small minority check the asthma emergency medication before the exercise lessons. There were no differences with regard to gender, age or education of the teachers. CONCLUSION: Our data demonstrate an insufficient knowledge about bronchial asthma among the teachers we studied. Both the medical knowledge (reaction in case of acute episodes of asthma) and the principles of exercise in children with asthma were not satisfactory.

[Power training for patients with arterial hypertension]. / Ist Krafttraining für Hochdruckpatienten gefährlich? Räumen Sie mit den alten Vorurteilen auf.

Nowadays, not only endurance training but also power training is recommended for patients with hypertension. In appropriately doses programs (no forced respiration), a number of studies have documented a blood pressure lowering effect. In the elderly hypertensive in particular, positive effects of power training that go beyond the simple lowering of elevated blood pressure may be expected.

The use of self-measured blood pressure determinations in assessing dynamics of drug compliance in a study with amlodipine once a day, morning versus evening.

OBJECTIVE: To test whether the time of administration influences the therapeutic response to a calcium antagonist taken once a day. Also, the dynamics of drug compliance and its impact on blood pressure control were investigated. DESIGN: Twenty outpatients with mild-to-moderate hypertension were included in a randomized, placebo-controlled open study. In a crossover design, all of the patients received 5 mg amlodipine, either in the morning or in the evening, during two consecutive 4-week treatment periods. METHODS: Blood pressure was taken by casual measurement, ambulatory 24-h monitoring (SpaceLabs 90202) and self-measurement at home, performed with a semi-automatic oscillometric device during the whole study period. Compliance was assessed using the Medication-Event-Monitoring System (MEMS). RESULTS: Neither casual nor ambulatory day- or night-time readings detected a significant difference between morning and evening administration. However, self-measurement documented significantly greater blood pressure reductions for morning than for evening administration. The MEMS showed different compliance on the days of ambulatory monitoring (100% with both drug regimens) compared with the whole treatment period. The number of days with missed medication was thus significantly higher for the evening dosing regimen. The difference in self-measured blood pressure between the two regimens was lost if the days with missed medication were removed from the statistical analysis. CONCLUSIONS: Time of once-a-day amlodipine administration does not influence its efficacy for 24-h blood pressure control. Furthermore, the use of self-measurement and the MEMS may provide useful additional information on the pharmacodynamic impact of different dosing patterns in hypertensive patients.

An evaluation of self-measured blood pressure in a study with a calcium-channel antagonist versus a beta-blocker.

In recent years self-measurement of blood pressure at home has gained increasing importance but there have been only a few studies comparing casual, ambulatory, and self-measured blood pressure determinations during a single clinical trial. We therefore compared treatment-induced blood pressure-reductions in a double-blind, placebo-controlled, parallel study design with a single morning dose of either 10 mg bisoprolol (n = 26) or 20 mg nitrendipine (n = 27) with casual blood pressure readings in the morning before the dose, ambulatory 24-h monitoring, and self-recorded measurements in the morning before the dose and in the evening. Mean reductions for systolic and diastolic blood pressure after 4 weeks of therapy were significantly greater for bisoprolol than for nitrendipine. The treatment-induced blood pressure reductions were most pronounced as assessed by casual readings but showed good agreement between casual, ambulatory, and self-measured blood pressure for group comparisons. In some patients, however, marked individual differences between the three methods were observed. Correlation coefficients between ambulatory and self-measured blood pressure were 0.4 for systolic blood pressure (P less than .05) and 0.6 for diastolic blood pressure (P less than .0005). Under the conditions of this parallel study design and the usual statistical risks, a difference of 5 mm Hg in diastolic blood pressure can be detected in 118 patients at the clinic, in 70 patients if ambulatory blood pressure is used, or in 56 patients if self-measured blood pressure is used. In conclusion, bisoprolol was more effective over 24 h than nitrendipine at the doses studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Normal values of blood pressure self-measurement in view of the 1999 World Health Organization-International Society of Hypertension guidelines.

New guidelines for the management of hypertension have been published in 1999 by the World Health Organization (WHO) and the International Society of Hypertension (ISH). The WHO/ISH Committee has adopted in principle the definition and classification of hypertension provided by the JNC VI (1997). The new classification defines a blood pressure of 120/80 mm Hg as optimal and of 130/85 mm Hg as the limit between normal and high-normal blood pressure. It is unclear which self-measured home blood pressure values correspond to these office blood pressure limits. In this study we reevaluated data from our Dübendorf study to determine self-measured blood pressure values corresponding to optimal and normal office blood pressure using the percentiles of the (office and home) blood pressure distributions of 503 individuals (age, 20 to 90 years; mean age, 46.5 years; 265 men, 238 women). Self-measured blood pressure values corresponding to office values of 130/85 mm Hg and 120/80 mm Hg were 124.1/79.9 mm Hg and 114.3/75.1 mm Hg. Thus, we propose 125/80 mm Hg as a home blood pressure corresponding to an office blood pressure of 130/85 mm Hg (WHO 1999: normal) and 115/75 mm Hg corresponding to 120/80 mm Hg (optimal).

Arterial blood pressure. Correlation with erythrocyte count, hematocrit, and hemoglobin concentration.

The relationship between arterial blood pressure and red blood cell variables was investigated in 1013 unselected persons with a blood pressure range of 90 to 225 mm Hg systolic and 50 to 145 mm Hg diastolic. Statistically significant correlations were demonstrated between mean (as well as systolic and diastolic) arterial blood pressure and red blood cell count (r = 0.27; P less than .0001), hematocrit (r = 0.28; P less than .0001), and hemoglobin concentration (r = 0.29; P less than .0001). Average arterial blood pressure was higher in men than in women (133 +/- 16/83 +/- 10 v 124 +/- 16/79 +/- 9 mm Hg, P less than .0001) and this was associated with higher values for erythrocyte count, hemoglobin concentration, and hematocrit in men as compared to women. The significant correlation of blood pressure and hematocrit, which represents one important determinant of blood viscosity, points to a role for rheological factors in the long-term control of blood pressure. Moreover, it might be speculated that the sex difference in blood pressure as observed in the present study may be due, at least in part, to stimulated erythropoiesis in men as compared to women.

Antihypertensive drug treatment and fibrinolytic function.

Thromboembolic complications such as ischemic stroke and myocardial infarction are significantly more frequent in patients with arterial hypertension. From the available intervention studies, it appears that pharmacologic treatment of hypertension-at least with diuretics and beta-blockers-may more effectively protect against cerebrovascular as compared to coronary thromboembolic events. Whether other antihypertensive substances provide a more effective protection with respect to cardiac morbidity and mortality is the subject of numerous studies presently underway. These studies will help to answer the question of whether the extent of protection from coronary events during antihypertensive treatment depends on factors beyond blood pressure control. The fibrinolytic system is crucially involved in the pathogenesis of thromboembolic events. One determinant of this system is the balance between plasminogen activators (tissue-type plasminogen activator [t-PA]) and inhibitors (plasminogen activator inhibitor 1 [PAI-1]). Experimental and clinical evidence suggests that at least some of the drugs used in the treatment of hypertension may alter the activity of the fibrinolytic system. Scarce and controversial data with respect to such an interaction exist with respect to diuretics, beta-blockers, and calcium antagonists. In addition, experimental evidence demonstrates that PAI-1 is stimulated by angiotensin II (A II), whereas t-PA is activated by bradykinin. Thus, antihypertensive drugs acting within the renin angiotensin system should exert effects also within the fibrinolytic system. However, results from clinical studies with angiotensin converting enzyme (ACE) inhibitors and A II receptor antagonists do not unequivocally support such a concept. The discrepancy in the results may, at least in part, be explained by studies performed in healthy volunteer subjects showing that ACE inhibition profoundly affected fibrinolysis only during stimulation of the renin angiotensin system by NaCL restriction.

A comparative review of the adverse effects of treatments for hyperlipidaemia.

Various lipid-lowering drugs have been shown to reduce serum cholesterol and serum triglycerides effectively. In view of trials indicating that lipid-lowering drugs may reduce cardiac morbidity and mortality but not the overall mortality in the study group, increased attention must be focused on potential harmful side effects during treatment with these agents. The adverse effects of many of the principal drugs in this category are discussed. Gastrointestinal symptoms, usually self-limited and reversible, are the most common side effects. Potential harmful adverse effects include drug interactions (cholestyramine), myopathy and hepatic injury (HMG-CoA reductase inhibitors), and increased gallstone formation and ventricular arrhythmias (clofibrate). Not all lipid-lowering drugs have been studied adequately on a long term basis, so that medications given for an indefinite period must be reevaluated frequently. However, there are several agents that lower serum lipid levels effectively and that have been used for more than 20 years without serious side effects.

Converting enzyme inhibition and vascular prostacyclin synthesis: effect of kinin receptor antagonism.

The effects of angiotensin I-converting enzyme (ACE) inhibitors and bradykinin (BK) on prostacyclin (PGI2) production in isolated arterial tissue were investigated. Rings of rat abdominal aorta were incubated in Krebs-Ringer bicarbonate buffer and PGI2 generation was assessed by the determination of its stable hydrolysis product; 6-keto-PGF1 alpha. The addition of both ACE inhibitors, captopril and lisinopril, and bradykinin resulted in dose-dependent stimulation of PGI2 biosynthesis when the individual substance was added into the incubation buffer at final concentrations between 10(-8) and 10(-5) M. The bradykinin-induced stimulation of PGI2 synthesis was dose dependently inhibited by the BK receptor antagonist, D-Arg[Hyp3, Thi5,8, D-Phe7]BK. The captopril- and lisinopril-induced stimulation of vascular 6-keto-PGF1 alpha production was also significantly decreased when the BK antagonist was added to the incubation medium together with the ACE inhibitors. Our results show that both captopril and lisinopril stimulate PGI2 synthesis in arterial tissue and that this effect may be secondary to changes in the activity of the kinin system.

The Dübendorf Study: a population-based investigation on normal values of blood pressure self-measurement.

There is evidence that self-measurement of BP increases precision, reproducibility and prognostic value of BP measurement. However, generally accepted normal values for BP values obtained by self-measurement are still missing. The present study was undertaken to investigate differences between office and self-measured blood pressure; 503 randomly selected inhabitants (265 men and 238 women, age 20-90 years, mean age 46.5 +/- 12.9 years) of the small town of Dübendorf in Switzerland were studied. The subjects were not preselected according their BP levels, only patients taking antihypertensive drugs were excluded. Self-measurement was performed at home by the subjects during 14 days in the morning between 6 and 8 am and in the evening between 6 and 8 pm (mean of 26.7 measurements). Office BP was taken before and after the two week period. Mean office BP (130.0 +/- 16.5/82.1 +/- 11.1 mmHg) was significantly (P < 0.01) higher than mean self-measured BP (123.1 +/- 14.6/77.6 +/- 10.7 mmHg). There was no significant difference between first and second office BP measurement. Morning self-measured BP was lower than evening pressure (delta 4.0/1.4 mmHg, both P < 0.01) and the mean was taken for comparison with office BP.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of captopril on fibrinolytic function in healthy humans.

Several lines of evidence point to an interrelation of the renin angiotensin system (RAS) with the endogenous fibrinolytic system. In the present study, we have therefore investigated the effect of the ACE-inhibitor captopril on various parameters of the fibrinolytic system in healthy volunteer subjects. 10 male subjects aged 28-38 years were given captopril 25 mg b.i.d. over 2 weeks. Venous blood was drawn before and at the end of the treatment period at 09.00 AM, after the volunteers had received their last dose of captopril by 07. 30 AM. Blood samples were processed for the determination of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1). Both parameters were determined with respect to their abundance (as antigen concentrations) and function (activity). In addition, the concentration and activity of the von Willebrand factor were also determined. Two weeks of captopril treatment had no significant effect on any of the above mentioned parameters. Our results thus show that short-term treatment with the ACE-inhibitor captopril, at least in healthy subjects on an unrestricted NaCl intake, does not affect the fibrinolytic balance between t-PA and PAI-1 or the von Willebrand factor.

Assessment of beta-blocking activity of low-dose bupranolol.

In the present study an investigation was made on the pharmacodynamic effect of the beta-blocking agent bupranolol in the low-dose range. Bupranolol is usually given in doses of 100 mg twice daily in the treatment of hypertension, however the dose range between 20 and 100 mg was studied using graded isoproterenol injections in healthy volunteers. A significant beta-1-blocking activity was observed for the 20 mg dose already. This effect was reduced after a treatment of 10 days. The effect increased with the higher doses, there might be a linear correlation between the logarithm of the dose and the reduction of the tachycardia after the isoproterenol injections in the low-dose range. It was concluded that using the safe and sensitive isoproterenol injection method, the clinical effect of very low doses of bupranolol may be demonstrated. The low dose might be useful to reduce the reflex tachycardia seen in the treatment of hypertension with vasodilating drugs.

Baroreceptor activity in man during administration of the calcium channel blocker felodipine.

The mechanisms responsible for the resetting of the baroreceptor reflex during long-term administration of 1,4 dihydropyridine calcium channel blockers are incompletely understood. The present study investigated the effect of 10 mg per day of felodipine on arterial blood pressure (BP), heart rate (HR), urinary norepinephrine, and cardiac beta-1-receptor sensitivity in 10 healthy volunteers. Blood pressure heart rate and urinary norepinephrine were determined during control and on days 1,4, and 14 of felodipine administration. Dose response curves of intravenous bolus injections of isoproterenol were performed on the same days to measure cardiac beta-1-receptor sensitivity. Felodipine significantly reduced the blood pressure from 131 +/- 6/74 +/- 3 mm Hg (mean +/- s.e.m.) to 123 +/- 6/65 +/- 2 mm Hg on day 1 (p less than 0.01). The blood pressure remained decreased during the entire protocol. The initial increase in the heart rate (62 +/- 5 to 67 +/- 4 min-1) remained elevated on day 4 and returned within the control range by day 14 (63 +/- 4 min-1) in spite of unchanged felodipine plasma levels (1.71 +/- 1.13 ng/ml (day 1) and 1.66 +/- 0.66 ng/ml (day 14). Urinary norepinephrine rose significantly with short-term felodipine administration (62 +/- 12 versus 50 +/- 6 micrograms/24 h; p less than 0.01). With long-term felodipine administration this value returned to pretreatment levels (55 +/- 12 micrograms/24 h). Cardiac beta-1-receptor sensitivity was not changed at any point of the protocol.(ABSTRACT TRUNCATED AT 250 WORDS)

Betablocking drugs in essential hypertension: transdermal bupranolol compared with oral metoprolol.

In the present study the antihypertensive efficacy and tolerability of transdermal bupranolol (30 mg once-daily) was compared with oral metoprolol (100 mg once-daily). Blood pressure measurements were performed in the office, at home, and with ambulatory 24-h blood pressure devices. Systemic and local side-effects, as well as compliance and acceptance, were evaluated every two weeks. The treatment period lasted eight weeks. The results showed a significant decrease in blood pressure under the bupranolol transdermal therapeutic system in the office, at home, and with 24-h blood pressure measurements day- (08h00-20h00) and night-time (20h00-08h00). Under oral metoprolol there was a significant blood pressure decrease in the office, at home, and in the mean daytime values of the 24-h blood pressure measurements. The night-time values, however, demonstrated only a slight decrease in blood pressure, being significant only for diastolic values. Systemic side-effects were comparable in both groups. 69% of the patients had local side-effects at the patch side (erythema, papulous exanthema, pruritus). Six patients dropped out because of localized urticarial exanthema (five patients treated with transdermal bupranolol, one patient treated with oral metoprolol). In comparison to the oral form, twice as many patients had admitted to have been non-compliant with the patches (13 versus 7 patients). At the end of the study, 24 out of 32 patients preferred to be treated with capsules.