Blood Pressure Monitoring. Task force I: Methodological aspects.
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Activities of Daily Living↗
Biomedical subjects
R Fagard
Publications and source records attributed to R Fagard.
Structural heart adaptations in triathletes.
OBJECTIVE: To perform a triathlon in aerobic conditions, a variety of cardiovascular, haemodynamic and metabolic adaptations are required. The heart is the central concern and also the most important limiting factor. In this study we investigate the structural and functional heart adaptations of a group of triathletes. METHODS AND RESULTS: A group of 52 male triathletes was divided into 4 subgroups in function of their athletic results and compared with a control group of 22 healthy, very active but no athletic men. The groups had comparable anthropometric and general physical characteristics. Very significant differences in cardiac structure and cardiac function were observed between the groups. In the triathletes, we registered distinct signs of significantly mixed eccentric and concentric hypertrophy. Unlike the findings in a pathological left ventricular hypertrophy, the diastolic left ventricular function in triathletes was completely normal and even better than in the control group. The late passive diastolic filling period of the triathlete, in particular, seemed to have specific characteristics. The comparison between the subgroups of triathletes shows us that genetic factors probably play an important role in the cardiac adaptations in triathletes. CONCLUSIONS: In our opinion the "athletic heart" in triathletes is not a specific "physiological entity" but is a transitional phase to a dilated hypertrophic cardiomyopathy. Our study yields some arguments for the following proposition: "People are born as elite athletes, with specific characteristics of the left ventricle and with a specifically supernormal diastolic left ventricular function."
Adaptation, Physiological↗
Diagnostic thresholds for the clinical use of ambulatory blood pressure monitoring.
The technique of noninvasive ambulatory blood pressure monitoring is now well established as an instrument in clinical research and as a diagnostic tool in clinical practice. Diagnostic thresholds for ambulatory monitoring were derived by averaging the 95th percentiles of the ambulatory blood pressure measurements in the normotensive subjects enrolled in various large-scale studies. Subjects normotensive on conventional sphygmomanometry, in the absence of other risk factors, have a low cardiovascular risk profile in comparison with their hypertensive counterparts. The evidence from prospective outcome studies also supports the proposed thresholds. More outcome studies are still ongoing. However, their results are unlikely to change the proposed thresholds, which are in line with the recommendations of the JNC VI (the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) and those of many other national expert committees.
Blood Pressure↗
Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial.
BACKGROUND: Systolic hypertension increases the risk of dementia in elderly people. The vascular dementia project, set up in the framework of the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial, investigated whether antihypertensive drug treatment could reduce the incidence of dementia. METHODS: Eligible patients had no dementia, were at least 60 years old, and had a blood pressure when seated of 160-219 mm Hg systolic and below 95 mm Hg diastolic. Active treatment consisted of nitrendipine (10-40 mg/day) with the possible addition of enalapril (5-20 mg/day), hydrochlorothiazide (12.5-25 mg/day), or both drugs, titrated or combined to reduce the systolic blood pressure by at least 20 mm Hg to reach a value below 150 mm Hg. Cognitive function was assessed by the mini mental state examination (MMSE). If the MMSE score was 23 or less, diagnostic tests for dementia were done (DSM-III-R criteria). The cause of dementia was established by the modified ischaemic score with brain imaging or the Hachinski score. FINDINGS: Median follow-up by intention to treat was 2.0 years. Compared with placebo (n=1180), active treatment (n=1238) reduced the incidence of dementia by 50% from 7.7 to 3.8 cases per 1000 patient-years (21 vs 11 patients, p=0.05). The median MMSE score at randomisation was 29 in both treatment groups. At the last available assessment, systolic and diastolic blood pressure were, respectively, 8.3 mm Hg and 3.8 mm Hg lower (p<0.001) in the active-treatment group, but on average the MMSE scores did not change in either group. In the control patients, however, the MMSE decreased (p=0.04) with decreasing diastolic blood pressure, whereas in the active-treatment group MMSE scores improved slightly (p=0.01) with greater reduction in diastolic blood pressure (p=0.002 for between-group difference). INTERPRETATION: In elderly people with isolated systolic hypertension, antihypertensive treatment was associated with a lower incidence of dementia. If 1000 hypertensive patients were treated with antihypertensive drugs for 5 years 19 cases of dementia might be prevented.
Aged↗
Rapid activation and nuclear translocation of mitogen-activated protein kinases in response to physiological concentration of glucose in the MIN6 pancreatic beta cell line.
MIN6 is one of the few pancreatic beta cell lines that respond to physiological concentrations of glucose by secreting insulin, and little is known about the triggered molecular mechanisms. We report below that the response to glucose in the MIN6 cells includes an activation of the p42 and p44 mitogen-activated protein (MAP) kinases (ERK2 and ERK1). This activation also occurred with the antidiabetic sulfonylurea glibenclamide and kainate, a specific agonist of a subtype of the ionotropic glutamate receptors, which depolarize the cytoplasmic membrane. The requirement for a calcium entry through the L-type voltage-gated channels and other characteristics of the regulation of the MAP kinase activity, such as the effect of the elevation of the cAMP concentration by forskolin, were similar to those of the secretion of insulin. However, the activation of the MAP kinases is not required for the secretion of insulin, inasmuch as this effect of glucose was not abolished when the MAP kinases were prevented from activation by PD098059, an inhibitor of the MAP kinase kinase. However, as the MAP kinases were translocated into the nucleus, they might be implicated in the calcium-dependent transcriptional response of the cells to glucose and thus regulate the expression of the insulin gene.
Animals↗
Reference values for self-recorded blood pressure: a meta-analysis of summary data.
BACKGROUND: The widespread clinical use of self-recorded blood pressure measurement is limited by the lack of generally accepted reference values. The purpose of this study was therefore to perform a meta-analysis of summary data in an attempt to determine an operational threshold for self-recorded blood pressures. STUDIES AND METHODS: Seventeen studies, including a total of 5422 subjects, were reviewed. Eight of these 17 studies included both normotensive and untreated hypertensive subjects, while the other 9 reports included normotensive subjects only. Within each study an operational cutoff point between normotension and hypertension was derived by means of the mean+2 SDs and the 95th percentiles of the self-recorded blood pressure in normotensive subjects. These 2 methods were contrasted with 2 other techniques that have been applied in the literature to calculate (1) the self-recorded pressures equivalent to a conventional pressure of 140 mm Hg systolic and 90 mm Hg diastolic by means of regression analysis and (2) the self-recorded blood pressures at the percentiles corresponding to a conventional pressure of 140/90 mm Hg. The latter 2 methods were applied in untreated subjects not selected on the basis of their blood pressure. RESULTS: With weighting for the number of subjects included in the various studies, the self-recorded blood pressure averaged 115/71 mm Hg in normotensive persons and 119/74 mm Hg in untreated subjects not selected on the basis of their blood pressure. The reference values for self-recorded blood pressures determined by the mean+2 SDs (137/89 mm Hg) or the 95th percentile (135/86 mm Hg) of the distribution in normotensive subjects were concordant within 2/3 mm Hg, whereas the cutoff points derived with the regression and percentile methods were considerably lower, ie, 125/79 and 129/84 mm Hg, respectively. CONCLUSIONS: Until the relationship between self-recorded pressure and the incidence of cardiovascular morbidity and mortality is further clarified by prospective studies, a mean self-recorded blood pressure above 135 mm Hg systolic or 85 mm Hg diastolic may be considered hypertensive.
Blood Pressure Determination↗
Neurons in primary culture are less efficiently infected by Toxoplasma gondii than glial cells.
Infection by Toxoplasma gondii is asymptomatic, leading to an immune response that controls the disease. In immune-compromised patients, however, quiescent cysts can reactivate, leading to toxoplasmic encephalitis. We studied the infection of cells of the central nervous system in an attempt to understand the process leading to this complication. Primary cultures of rat hippocampal glial cells and neurons were infected with the virulent strain RH and examined by immunofluorescent microscopy after fixation of cells and staining with antibodies specific to the different cell types. After 24 h of infection, glial cells were highly infected and showed active division of the parasite. Neurons, on the other hand, were much less efficiently infected than glial cells, but actual penetration of the parasites was demonstrated by confocal microscopy. Whereas glial cells contained vacuoles with several parasites, the vacuoles observed in neurons usually contained one parasite or, rarely, two, indicating that the parasites inside neurons did not undergo active division. This was corroborated by determination of the incorporation of [3H]-uracil. Little is known about the mechanism of neuronal infection by Toxoplasma. The experimental setup used in this study should help to improve our understanding of neuronal infection and bring insight into the physiopathology of toxoplasmic encephalitis.
Animals↗
Protein kinase C induced changes in erythrocyte Na+/H+ exchange and cytosolic free calcium in humans.
To investigate the interrelationship between erythrocyte Na+/H+ exchange rate and free cytosolic Ca2+ concentration, the effect of the (non)selective protein kinase C inhibitors staurosporine, Ro 31-8220 and CGP 41251 (1 micromol/L) and of the protein kinase C activator phorbol-12-myristate-13-acetate (PMA, 1 micromol/L) was studied in vitro on these variables. PKC depleted erythrocytes were obtained after 24 h PMA down-regulation of the cells and intracellular Ca2+ clamping was obtained using quin-2 AM and fluo-3 AM. PMA increased (P < .05) the erythrocyte Na+/H+ exchange activity and this rise was accompanied by an increase in the free cytosolic Ca2+ concentration. When staurosporine and Ro 31-8220 were added to erythrocytes in suspension, a decrease in free cytosolic Ca2+ concentration was also found, whereas no significant change was observed after CGP 41251 administration. The Na+/H+ exchange rate was decreased in the 24 h PMA down-regulated erythrocytes as well as in Ca2+-clamped cells. Addition of Ca2+ in a concentration range of 0 to 1 mmol/L in the presence of calcimycin resulted (P < .001) in a stimulation of Na+/H+ exchange by 74%. Calcium increased the Vmax for cellular pHi or external Na+ activation of Na+/H+ exchange, whereas it did not affect the Km for H+(i) or external Na+ activation. However, in PKC down-regulated cells, calcium did not activate the Na+/H+ exchange in erythrocytes and the calpain inhibitor E-64d did not prevent this inactivation. Our data show a concomitant increase in free cytosolic Ca2+ concentration and Na+/H+-exchange rate upon protein kinase C activation and a corresponding decrease in both variables upon PKC inhibition, indicating a Ca2+ requirement for protein kinase C activation of Na+/H+ exchange.
Calcium↗
Proliferation of human peripheral blood mononuclear cells during calcium channel blockade.
To evaluate the role of intracellular calcium and particularly Ca2+ uptake in the initiation of lymphocyte mitogenesis, the effect of mibefradil--which blocks both L- and T-type calcium channels with a more selective blockade of T-type channels--on the proliferation of human peripheral blood mononuclear cells (PBMC) is compared with the effect of nifedipine, which blocks only the L-type calcium channel. The rate of 3H-thymidine, 3H-uridine, and 3H-leucine incorporation into control and concanavalin A-stimulated PBMC in the presence or absence of the calcium channel blockers mibefradil or nifedipine (1, 10, or 50 micromol/L), and of the intracellular calcium antagonist TMB-8 or the calmodulin antagonist W-7 (1, 10, 25, or 50 micromol/L) was assayed in cells cultured for 3 days. The cellular cytotoxicity and the cell number in growing cultures was also determined in mibefradil- or nifedipine-treated control or stimulated cells. Mibefradil and nifedipine reduced the cell number and the 3H-thymidine, 3H-uridine, or 3H-leucine incorporation or the de novo DNA, RNA, or protein synthesis in control and concanavalin A-stimulated human PBMC in a concentration-dependent manner. Mibefradil exhibited a more pronounced inhibition than nifedipine. The inhibitory effect of mibefradil or nifedipine on DNA synthesis was dependent upon the timing of treatment with the drugs. The inhibitory effect of mibefradil or nifedipine on the lymphoproliferative response was nearly abolished if the drugs were added 20 h after cell stimulation. A markedly reduced inhibitory effect was found when mibefradil or nifedipine were added 1 to 7 h after cell stimulation. However, regardless of time of addition, TMB-8 and W-7 caused a persistent inhibition of the proliferation of human PBMC. Our data show that mibefradil had a more pronounced inhibitory effect on the proliferation of human PBMC than nifedipine and that this inhibitory effect on de novo DNA synthesis was dependent upon the timing of treatment with both drugs. Mibefradil and nifedipine also reduce RNA and protein synthesis in human PBMC. Therefore, administration of these calcium channel blockers to inhibit cellular proliferation might be most beneficial at anatomic sites where cellular proliferation is not already an active process, while being ineffective in the presence of ongoing active proliferation, as suggested by some prospective studies.
Adult↗
Ambulatory blood pressure monitoring and postprandial hypotension in elderly patients with isolated systolic hypertension. Systolic Hypertension in Europe (SYST-EUR) Trial Investigators.
The present analysis was undertaken to evaluate postprandial (PP) changes in blood pressure (BP) assessed with ambulatory BP monitoring (ABPM) in elderly subjects with isolated systolic hypertension (ISH) on conventional measurement. A total of 530 patients (335 women and 195 men, aged 60-100 years, median 70 years) who performed an ABPM during the placebo run-in period of the Syst-Eur trial were included into the analysis. The PP changes in BP and heart rate (HR) were calculated by subtracting the mean systolic BP (SBP), diastolic BP (DBP) and HR in the 2 h preceding the main meal from the corresponding means covering the 2 h after the meal. The reproducibility of the postprandial fall in BP and heart rate (PPH) was assessed by contrasting the first and second ABPM in a subgroup of 147 patients who performed two ABPM's during the placebo run-in period. The mean SBP and DBP decreased and reached the nadir 2 h after the main meal while HR did not change. When PPH was assessed by comparing BP in the 2 h before and after the meal, both SBP and DBP decreased significantly (respectively -6.6 mm Hg, -5.4 mm Hg; P < 0.001). In 67.6% of all patients a decrease in SBP was observed and in 24.1% it exceeded 16 mm Hg. The corresponding values for DBP were 71.3% and 24.5% (DBP decreased more than 12 mm Hg). A greater fall in DBP was associated with a greater decrease in HR (r = 0.20, P < 0.001), while changes in SBP and HR were not interrelated. Regression analysis did not identify any significant covariate of PPH. Group means of PPH could be reproduced without significant changes in their values, but the within-subject reproducibility of the PP changes was low. There were no differences in PPH according to the place of residence of the patients. In conclusion, the descriptive analysis of the meal-induced changes in ABPM in elderly subjects with ISH showed that in every day circumstances most of them experience falls in both SBP and DBP within 2 h after the meal.
Aged↗
The epidemiology of the association between hypertension and menopause.
Menopause is a normal aging phenomenon in women and consists of the gradual transition from the reproductive to the non-reproductive phase of life. The median age at the menopause is currently around 50 years. As a result of the increasing life expectancy in the first and second worlds, many women will be postmenopausal for over one-third of their lives. The influence of menopause per se on blood pressure remains uncertain. Recent experimental and epidemiological evidence supports the hypothesis that oestrogen deficiency may induce endothelial and vascular dysfunction and potentiate the age-related increase in systolic pressure, possibly as a consequence of a reduced compliance of the large arteries. However, the latter hypothesis requires further investigation.
Adult↗
Limitations of the difference between clinic and daytime blood pressure as a surrogate measure of the 'white-coat' effect. Syst-Eur investigators.
BACKGROUND: The difference between clinic and ambulatory average daytime blood pressures is frequently taken as a surrogate measure of the 'white-coat effect' (i.e. the pressor reaction triggered in the patient by the physician's visit). OBJECTIVE: To assess the reproducibility of this difference and its relationship with clinic and average ambulatory daytime blood pressure levels. DESIGN AND METHODS: These issues were addressed with two large groups of subjects in whom both clinic and ambulatory blood pressures were measured, namely 783 outpatients with systolic and diastolic essential hypertension [Group 1, aged 50.8+/-9.4 years (mean +/- SD)], participating in standardized Italian trials of antihypertensive drugs, and 506 elderly patients (group 2, age 71+/-7 years) with isolated systolic hypertension, participating in the European Syst-Eur trial. RESULTS: The clinic-daytime blood pressure difference for the essential systolic and diastolic hypertensive patients (group 1) was 13.6+/-14.3 mmHg for systolic and 9.1+/-8.6 mmHg for diastolic blood pressure (P always < 0.01). This difference for the elderly patients with isolated systolic hypertension (group 2) was 21.2+/-16.0 mmHg for systolic and only 1.3+/-10.2 mmHg for diastolic blood pressure (P < 0.01 and P < 0.05, respectively). In both studies little or no systematic clinic-daytime difference could be observed for heart rate. The reproducibility of the clinic-daytime blood pressure difference, tested for 108 essential systolic and diastolic hypertensive patients from group 1 and 128 isolated systolic hypertensives from group 2, was invariably lower than that both of daytime and of clinic blood pressure values. Finally, the clinic-daytime blood pressure difference was progressively higher for increasing levels of clinic blood pressure and progressively lower for higher levels of ambulatory daytime blood pressure. CONCLUSIONS: Thus, the clinic-daytime blood pressure difference has a limited reproducibility; depends not only on clinic but also on daytime average blood pressure, which means that its size is a function of the blood pressure criteria employed for selection of the patients in a trial; and is never associated with a systematic clinic-daytime difference in heart rate, which further questions its use as a reliable surrogate measure of the true pressor response induced in the patient by the doctor's visit.
Adolescent↗
Activation by calcium of erythrocyte Na+/H+ exchange in men.
OBJECTIVE: To determine whether protein kinase C is necessary for the calcium activation of the Na+/H+ exchange in human erythrocytes by studying activation by calcium of erythrocyte Na+/H+ exchange in control cells, in protein kinase C-depleted cells after downregulation of protein kinase C with phorbol-12-myristate-13-acetate and in cells that had been treated beforehand with phorbol-12-myristate-13-acetate with and without the calpain inhibitor E-64d. METHODS: Erythrocyte Na+/H+ exchange was measured by determining the initial rates of the influx of Na+ into Na+-depleted, acid loaded cells. The effects of various concentrations (0-1 mmol/l) of CaCl2 and the effects of 1 mmol/l CaCl2 on activation of the intracellular pH and on the external Na+ activation of Na+/H+ exchange were studied. The effects of 1 mmol/l CaCl2 on Na+/H+ exchange in control cells and cells that had been incubated beforehand with and without 1 micromol/l phorbol-12-myristate-13-acetate and with E-64d and 1 micromol/l phorbol-12-myristate-13-acetate for 1, 2, 3 and 24 h were also investigated. RESULTS: Addition of Ca2+ to a concentration in the range 0-1 mmol/l in the presence of calcimycin resulted in stimulation of Na+/H+ exchange: 1 mmol/l CaCl2 increased (P< 0.001) the erythrocyte Na+/H+ exchange by 74%. Calcium increased the maximum rate for activations by intracellular pH and by external Na+ of Na+/H+ exchange, whereas it did not affect the Michaelis-Menten constants for activation by intracellular H+ and external Na+. However, calcium did not activate the Na+/H+ exchange in protein kinase C downregulated erythrocytes and administration of the calpain inhibitor E-64d could not prevent this inactivation. CONCLUSION: Our data indicate that protein kinase C is necessary for the activation by calcium of the erythrocyte Na+/H+ exchange.
Calcium↗
Antihypertensive drugs and cognitive function in older people.
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Aged↗
Human erythrocytes contain Ca2+, calmodulin-dependent cyclic nucleotide phosphodiesterase which is involved in the hydrolysis of cGMP.
To determine whether phosphodiesterase (PDE) is involved in the degradation of cGMP in human erythrocytes, we studied the cell cGMP content in the presence of different PDE inhibitors: zaprinast and dipyridamole, specific inhibitors of cGMP-binding, cGMP-specific PDE (cG-BPDE); vinpocetine, a specific inhibitor of Ca2+, calmodulin-dependent phosphodiesterase (CaM-PDE); an unspecific inhibitor, 3-isobutyl-1-methylxanthine (IBMX). IBMX, zaprinast, and dipyridamole at 30 microM did not affect the intracellular cGMP content. However, vinpocetine at this concentration increased the cGMP content by 102 +/- 14% (p < 0.05). The effect of vinpocetine was dose-dependent, reached the maximal level after 1 min of incubation and flattened at the same level. Ca2+ (10 microM) in the presence of the Ca(2+)-ionophore, A23187 (5 microM), decreased the cGMP content (-23% +/- 4; p < 0.05), which can be explained by the CaM-PDE activation. The Ca(2+)-induced decrease in cGMP was completely inhibited by the CaM antagonist, W-7 (100 microM). These data suggest that erythrocytes contain Ca2+, CaM-PDE.
1-Methyl-3-isobutylxanthine↗
Conventional and ambulatory measurements of blood pressure in old patients with isolated systolic hypertension: baseline observations in the Syst-Eur trial.
OBJECTIVES: To compare clinic and am measurements of blood pressure in old patients with isolated systolic hypertension and their reproducibilities. PATIENTS: In total 610 patients aged >/= 60 years with isolated systolic hypertension detected by clinic measurement were monitored during the placebo run-in phase of the Syst-Eur trial. METHODS: The time-weighted 24 h blood pressure, clock-time day and night blood pressures, the cumulative-sum-derived crest and trough blood pressures and the high and low blood pressure levels according to the square-wave model were computed. The daily alteration between the high and low spans of blood pressure was quantified using the day-night difference, the cumulative-sum-derived magnitude of circadian alteration, the Fourier amplitude and the difference between the high and low blood pressure levels of the square-wave model. RESULTS: The daytime am systolic blood pressure was, on average, 21 mmHg lower than the clinic systolic blood pressure, whereas diastolic pressure was, on average, similar with both techniques of measurement. Clinic levels of blood pressure in the 141 patients who underwent repeat measurements and the parameters describing the difference between the daily high and low spans of blood pressure were equally reproducible. However, both were less reproducible than the ambulatory blood pressure levels. The reproducibility coefficients, expressed as percentages of near maximum variation, were 49 and 50% for the clinic systolic and diastolic blood pressures, 30 and 32% for the mean 24 h systolic and diastolic blood pressures and 45-55% for the parameters describing the daily alteration between the high and low spans of blood pressure. CONCLUSION: Values of blood pressure in old patients with isolated systolic hypertension were more reproducible for ambulatory than they were for clinic measurements. Levels in patients selected because they have a high clinic blood pressure may be substantially higher with conventional than they are with daytime ambulatory measurement. The prognostic significance of this difference for the present patients is currently under investigation.
Journal Article↗
Antihypertensive treatment based on conventional or ambulatory blood pressure measurement. A randomized controlled trial. Ambulatory Blood Pressure Monitoring and Treatment of Hypertension Investigators.
CONTEXT: Ambulatory blood pressure (ABP) monitoring is used increasingly in clinical practice, but how it affects treatment of blood pressure has not been determined. OBJECTIVE: To compare conventional blood pressure (CBP) measurement and ABP measurement in the management of hypertensive patients. DESIGN: Multicenter, randomized, parallel-group trial. SETTING: Family practices and outpatient clinics at regional and university hospitals. PARTICIPANTS: A total of 419 patients (> or =18 years), whose untreated diastolic blood pressure (DBP) on CBP measurement averaged 95 mm Hg or higher, randomized to CBP or ABP arms. INTERVENTIONS: Antihypertensive drug treatment was adjusted in a stepwise fashion based on either the average daytime (from 10 AM to 8 PM) ambulatory DBP (n=213) or the average of 3 sitting DBP readings (n=206). If the DBP guiding treatment was above (>89 mm Hg), at (80-89 mm Hg), or below (<80 mm Hg) target, 1 physician blinded to the patients' randomization intensified antihypertensive treatment, left it unchanged, or reduced it, respectively. MAIN OUTCOME MEASURES: The CBP and ABP levels, intensity of drug treatment, electrocardiographic and echocardiographic left ventricular mass, symptoms reported by questionnaire, and cost. RESULTS: At the end of the study (median follow-up, 182 days; 5th to 95th percentile interval, 85-258 days), more ABP than CBP patients had stopped antihypertensive drug treatment (26.3% vs 7.3%; P<.001), and fewer ABP patients had progressed to sustained multiple-drug treatment (27.2% vs 42.7%; P<.001). The final CBP and 24-hour ABP averaged 144.1/89.9 mm Hg and 129.4/79.5 mm Hg in the ABP group and 140.3/89.6 mm Hg and 128.0/79.1 mm Hg in the CBP group. Left ventricular mass and reported symptoms were similar in the 2 groups. The potential savings in the ABP group in terms of less intensive drug treatment and fewer physician visits were offset by the costs of ABP monitoring. CONCLUSIONS: Adjustment of antihypertensive treatment based on ABP monitoring instead of CBP measurement led to less intensive drug treatment with preservation of blood pressure control, general well-being, and inhibition of left ventricular enlargement but did not reduce the overall costs of antihypertensive treatment.
Adult↗
Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators.
BACKGROUND: Isolated systolic hypertension occurs in about 15% of people aged 60 years or older. In 1989, the European Working Party on High Blood Pressure in the Elderly investigated whether active treatment could reduce cardiovascular complications of isolated systolic hypertension. Fatal and non-fatal stroke combined was the primary endpoint. METHODS: All patients (> 60 years) were initially started on masked placebo. At three run-in visits 1 month apart, their average sitting systolic blood pressure was 160-219 mm Hg with a diastolic blood pressure lower than 95 mm Hg. After stratification for centre, sex, and previous cardiovascular complications, 4695 patients were randomly assigned to nitrendipine 10-40 mg daily, with the possible addition of enalapril 5-20 mg daily and hydrochlorothiazide 12.5-25.0 mg daily, or matching placebos. Patients withdrawing from double-blind treatment were still followed up. We compared occurrence of major endpoints by intention to treat. FINDINGS: At a median of 2 years' follow-up, sitting systolic and diastolic blood pressures had fallen by 13 mm Hg and 2 mm Hg in the placebo group (n = 2297) and by 23 mm Hg and 7 mm Hg in the active treatment group (n = 2398). The between-group differences were systolic 10.1 mm Hg (95% CI 8.8-11.4) and diastolic, 4.5 mm Hg (3.9-5.1). Active treatment reduced the total rate of stroke from 13.7 to 7.9 endpoints per 1000 patient-years (42% reduction; p = 0.003). Non-fatal stroke decreased by 44% (p = 0.007). In the active treatment group, all fatal and non-fatal cardiac endpoints, including sudden death, declined by 26% (p = 0.03). Non-fatal cardiac endpoints decreased by 33% (p = 0.03) and all fatal and non-fatal cardiovascular endpoints by 31% (p < 0.001). Cardiovascular mortality was slightly lower on active treatment (-27%, p = 0.07), but all-cause mortality was not influenced (-14%; p = 0.22). INTERPRETATION: Among elderly patients with isolated systolic hypertension, antihypertensive drug treatment starting with nitrendipine reduces the rate of cardiovascular complications. Treatment of 1000 patients for 5 years with this type of regimen may prevent 29 strokes or 53 major cardiovascular endpoints.
Aged↗