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Rise in albuminuria and blood pressure in patients who progressed to diabetic nephropathy in the Diabetes Control and Complications Trial.

The Diabetes Control and Complications Trial (DCCT) enrolled 1441 participants to address the role of intensive therapy for type 1 diabetes mellitus on the onset and progression of microvascular complications. To examine the timing of elevated systolic BP (SBP) and diastolic BP (DBP) and increased albumin excretion rate (AER) in the progression to clinical diabetic nephropathy (AER > 300 mg/24 h on two consecutive visits from a baseline of <100 mg/24 h) and, importantly, to control for initial values of hemoglobin A(1c), a retrospective case-control study was assembled from the records of the publicly released DCCT data. Participants who progressed to clinical diabetic nephropathy-progressors-were matched with participants of the same gender and treatment group who had similar baseline values for DBP, SBP, AER AER and hemoglobin A(1c), but who did not progress to clinical diabetic nephropathy-matched controls. In the conventional treatment group, the 21 progressors exhibited a significant rise in mean AER (above their own baseline levels and above values in the matched controls) at year 2 of the DCCT. In contrast, the progressors' mean DBP and SBP were not significantly higher than baseline until year 3 (DBP) or year 4 (SBP) and not significantly higher than the matched controls until year 4 (both DBP and SBP). On the individual level, 19 of 21 (90%) progressors reached clinical diabetic nephropathy before the diagnosis of hypertension (140/90 mmHg). In the intensive treatment group, however, the rise in DBP preceded the rise in AER by 1 to 2 yr among the six progressors. Both intensively treated progressors who experienced hypertension reached this before AER > 300 mg/24 h. These results underline the early and prognostic rise in AER in diabetic patients, but only in those who received conventional treatment. The evolution of diabetic renal disease may follow a different course in patients who receive intensive diabetic treatment.

Adult↗

Blood pressure in young adulthood and the risk of type 2 diabetes in middle age.

OBJECTIVE: Hypertension is known to accompany type 2 diabetes in middle age, but it is unknown how early in life blood pressure (BP) begins to rise among individuals who later develop diabetes. The objective of this study was to evaluate elevated BP as a long-term predictor of type 2 diabetes. RESEARCH DESIGN AND METHODS: We conducted a prospective cohort study of 1,152 white male medical students in The Johns Hopkins Precursors Study to longitudinally assess systolic BP (SBP) and diastolic BP (DBP) from young adulthood through middle age in men who went on to develop diabetes. Incident diabetes was identified by self-report through mailed questionnaires verified by medical record review. RESULTS: During a median follow-up of 38 years, 77 cases of incident diabetes occurred. The mean age of diabetes diagnosis was 58 years. As early as age 30 years, mean SBP and DBP were significantly higher in men who developed diabetes during follow-up than in those who remained nondiabetic (SBP 122 vs. 119 mmHg, P = 0.009; DBP 78 vs. 75 mmHg, P = 0.0005). The rate of increase in SBP and DBP over time in men who developed diabetes was greater than the rate of increase in men who did not develop diabetes (SBP 0.49 vs. 0.27 mmHg/year, P < 0.00003; DBP 0.24 vs. 0.17 mmHg/year; P = 0.09). After adjustment for BMI and other risk factors for diabetes, SBP and DBP at age 30 years remained significantly higher in individuals who developed diabetes than in their nondiabetic counterparts; however, the difference in the rate of increase in SBP was no longer significant following multivariate adjustment. CONCLUSIONS: BP elevations precede the development of type 2 diabetes in middle age by 20-25 years. Higher BP in the prediabetic state might contribute to the presence of vascular disease at the time of diagnosis of type 2 diabetes.

Adult↗

Hypocaloric diet and antihypertensive drug treatment. A randomized controlled clinical trial.

OBJECTIVE: To compare the amount of drug quantified by a score needed to control blood pressure in two groups of overweight hypertensive patients, receiving or not receiving a hypocaloric diet. DESIGN: Randomized controlled clinical trial. SETTING: Two hospital outpatient hypertension clinics. PATIENTS: Fifty-four subjects with a DBP between 95 and 110 mmHg and a weight > or = 110% of the ideal weight. INTERVENTION: Allocation to either drug treatment (DT) or hypocaloric diet (HD). In the HD group, after 2 months, an antihypertensive drug was administered to the subjects with a DBP > or = 90 mmHg, following the same scheme protocol as in the DT group. Subjects were followed during 10 months by a clinician only in the DT group and by a clinician and a dietician in the HD group. MAIN OUTCOME MEASURES: Score of treatment: hydrochlorothiazide 25 mg [score = 1] with, as needed to obtain a DBP < 90 mmHg, the addiction of enalapril 10 mg [score = 2], 20 mg [score = 3], and nifedipine 40 mg [score = 4]. RESULTS: At the end of the trial, 5 subjects were lost to follow-up in the HD group and 1 in the DT group (p > 0.05). Mean weight loss was 5.9 kg (sd = 1.2) in the HD and 2.3 kg (sd = 0.7) in the DT group (p = 0.02). Mean decrease in DBP was 18 mmHg (sd = 7) and 15 mmHg (sd = 8) in HD and DT groups respectively (p = 0.36). Mean DBP was 84 mmHg (sd = 7.8) in the HD group and 85 mmHg (sd = 7.2) in the DT group. In the HD group, 8 (38.1%) subjects had a DBP < 90 mmHg without any drug treatment. The mean drug treatment score was 0.86 (sd = 0.91) in the HD and 1.52 (0.70) in the DT group (p = 0.01). CONCLUSION: This study shows that in overweight hypertensives, the quantity of drug needed to achieve an acceptable level of BP is nearly reduced by 50% when an efficient hypocaloric diet is prescribed simultaneously.

Adult↗

Ketanserin in the treatment of essential hypertension. A double blind trial against metoprolol followed by one-year open treatment.

The present study was designed to compare the antihypertensive potencies of ketanserin and metoprolol in a double-blind trial and to study ketanserin long-term efficacy in a one-year open trial, plain or combined with metoprolol, according to diastolic blood pressure (DBP) normalization. Thirty-four patients were randomly assigned to two groups, one (n = 17) received ketanserin, 80 mg/day, and the other, (n = 17) metoprolol, 200 mg/day. After 3 mo. double blind treatment, all patients received plain ketanserin, or combined with metoprolol if ketanserin failed to normalize DBP. A significant effect was demonstrated after 3 mo. double blind treatment, for both drugs, in both standing and supine DBP (p less than 0.001). In the one-year follow-up, all patients received ketanserin and were divided in: I (n = 15) previously treated with the same drug; II (n = 2) plus metoprolol, in whom ketanserin had failed to decrease DBP; and III (n = 15) previously treated with metoprolol. In group I the blood pressure lowering effect of ketanserin remained constant during the one-year follow-up. In group II a trend in the decrease of parameters was observed. In group III, supine DBP diminished from 92.5 +/- 2 mmHg during treatment with metoprolol to 86.0 +/- 2 at 12 mo., after treatment with ketanserin (p less than 0.05). In groups I and III, 24/30 of patients normalized their DBP during one-year ketanserin open treatment. Ketanserin appears as a new alternative in the treatment of mild and moderate essential hypertension.

Adult↗

The effects of antihypertensive drug treatment on the incidence of stroke and of coronary heart disease.

The effects of differences in usual diastolic blood pressure (DBP) on the risks of stroke and of coronary heart disease (CHD) were estimated from nine major prospective observational studies involving about 420,000 men and women, followed up over intervals of 6 to 25 years. The results indicated that a prolonged difference in usual DBP of approximately 6 mmHg was associated with about 36% (+/- 2) fewer strokes and 22% (+/- 1) fewer CHD deaths and non-fatal myocardial infarctions. The effects of equivalent reductions in DBP produced by antihypertensive drug treatment but maintained for just a few years, have been estimated in several overviews of randomised controlled trials, involving totals of between 30,000 and 40,000 hypertensive patients. The results of the overviews indicated that antihypertensive treatment reduced the risk of stroke by about 40%, suggesting that all of the long-term potential benefit for stroke of lower DBP was achieved within about 3 years of beginning treatment. The risk of CHD may have been reduced by about 10% among patients allocated active treatment, but the 95% confidence limits for the difference ranged from about zero to about 20%. Whatever the true effect of treatment on CHD, it would appear to be somewhat less than the difference in risk estimated from the prospective observational studies for a prolonged difference in DBP of the same size. This apparent shortfall may reflect chronic pathophysiological processes in the relationship between DBP and CHD, and/or possible cardiotoxic side-effects of the principal trial treatments.

Antihypertensive Agents↗

Comparison of monotherapy with irbesartan 150 mg or amlodipine 5 mg for treatment of mild-to-moderate hypertension.

OBJECTIVE: The primary objective of this study was to compare the antihypertensive efficacy of the angiotensin II receptor blocker irbesartan 150 mg and the calcium channel blocker amlodipine 5 mg in the treatment of patients with seated diastolic blood pressure (DBP) 95-110 mmHg. DESIGN: Multicentre, randomised, double-blind, comparative pilot study. METHODS: Subjects were 18-65 years of age, with DBP 95-110 mmHg, and of non-African American origin. Following a three week, single-blind, placebo lead-in period, 181 subjects were randomised in a 1:1 ratio to receive once-daily irbesartan 150 mg (n=89) or amlodipine 5 mg (n=92) for four weeks. Trough (24+/-3 hours post-dosing) BP measurements were obtained at baseline and at Weeks 2 and 4 under standardised, controlled conditions. Response was defined as DBP <90 mmHg or a reduction from baseline of 10 mmHg. RESULTS: After four weeks of treatment, the mean (+/-SE) decrease from baseline in DBP was 9.4+/-0.6 mmHg in the irbesartan group vs. 9.6+/-0.6 mmHg in the amlodipine group (p=0.806). The mean decrease from baseline in seated systolic BP was 12.2+/-1.0 mmHg in the irbesartan group vs. 12.0+/-1.0 mmHg in the amlodipine group (p=0.885). Overall, 62% of subjects in the irbesartan group and 63% in the amlodipine group had a response (p=0.609), and 54% and 56% of patients (p=0.596), respectively, had their DBP normalised (<90 mmHg). Adverse events were reported by 21.3% of patients receiving irbesartan and 20.7% receiving amlodipine. Conclusions. Irbesartan 150 mg demonstrated comparable efficacy to amlodipine 5 mg, thereby confirming its value as an antihypertensive treatment option in non-African American patients with DBP 95-110 mmHg.

Adolescent↗

Serologic responses to recombinant Plasmodium vivax Duffy binding protein in a Colombian village.

The Plasmodium vivax Duffy binding protein (DBP) is essential during merozoite invasion into human erythrocytes. Because of its biological importance, the DBP is also seen to have potential use as a malaria blood-stage vaccine. We have used a soluble recombinant DBP (rDBP) containing the functional ligand domain to assess the natural immunogenicity of DBP in a low-endemic vivax malaria region. Human sera from adult residents from a Colombian village with unstable vivax malaria transmission reacted specifically with the rDBP as determined by ELISA. There was a significant positive correlation between increased antibody response (average, median, and percent positives) and age of patients, although the level of responses did vary considerably in their reactivity to the rDBP from negative to very high level within each age group. These data confirm previous findings on the serologic reactivity of the DBP in exposed populations and that immunologic boosting to the DBP occurs in malaria-endemic regions even with low-level transmission.

Adolescent↗

A comparison of the efficacies and duration of action of the angiotensin II receptor blockers telmisartan and amlodipine.

OBJECTIVES: To compare the antihypertensive effects and duration of action of the angiotensin II receptor antagonist, telmisartan, amlodipine, and placebo in patients with mild-to-moderate hypertension using both conventional clinic blood pressures and ambulatory blood pressure monitoring (ABPM). METHODS: After a 4-week single-blind, placebo run-in period, qualifying patients were randomly allocated in double-blind manner to be administered 40 mg telmisartan (n = 73; increased to 80 and 120 mg as necessary for patients whose diastolic blood pressure (DBP) remained > 90 mmHg); 5 mg amlodipine (n = 78; titrated to 5 mg and titrated to 10 mg for patients whose DBP remained > 90 mmHg); or placebo (n = 81). ABPM was performed at the end of the baseline period and again at the end of 12 weeks of double-blind treatment. RESULTS: Telmisartan and amlodipine treatments significantly decreased trough supine systolic blood pressure and DBP (P < 0.001, measured conventionally) to a similar extent (by 13.1/7.1 and 14.0/7.1 mmHg, respectively, at the end of 12 weeks' treatment) compared with placebo. Both drugs also significantly reduced 24 h mean systolic blood pressures and DBP compared with placebo (P < 0.0001), measured using ABPM, maintaining control of blood pressure throughout the dosing period. Reductions in DBP with telmisartan were greater (P < 0.05) than those with amlodipine during the night-time interval and the last 4 h of the dosing period. Twenty-four-hour mean ABPM DBP < 85 mmHg were observed in 71% of telmisartan patients and in 55% of patients administered amlodipine. In addition, heart rates in patients treated with telmisartan were lower than heart rates in those treated with amlodipine during the final 4 h of the dosing period (P = 0.0003) and during the morning interval (P = 0.005). Generally, both telmisartan and amlodipine were well tolerated, however, drug-related edema occurred significantly more commonly (P < 0.05) among the patients administered amlodipine than it did among patients administered either telmisartan or placebo. CONCLUSIONS: Clinic blood pressure measurements detected no difference between the antihypertensive effects and durations of action of telmisartan and amlodipine, both agents producing statistically significant reductions compared with placebo. ABPM measurements, however, revealed differences between the efficacies at specific time points within the dosing periods. These findings highlight the potential importance of the use of ABPM for evaluating and comparing efficacies of antihypertensive agents.

Journal Article↗

Validation of the SpaceLabs 90207 automatic non-invasive blood pressure monitor in elderly subjects.

OBJECTIVE: To validate the SpaceLabs 90207 ambulatory blood pressure monitor in the elderly. METHODS: Eighty-five subjects aged 60-90 years were recruited from hospital inpatients. Using the same-arm sequential measurement technique two observers recorded blood pressure with a mercury sphygmomanometer first and then by using the SpaceLabs 90207 ambulatory monitor. This set of blood pressure readings was performed three times with all 85 subjects supine, sitting and standing. Data were analysed according to the British Hypertension Society protocol. RESULTS: Over the blood pressure range tested the SpaceLabs 90207 device recorded diastolic blood pressure (DBP) satisfactorily, achieving grade A in all body postures, but not systolic blood pressure (SBP; supine D, standing C, sitting C). However, at SBP </= 160 mmHg, satisfactory performance was achieved in sitting (B) and standing (B) patients, but not in supine patients (C). With higher blood pressure there was increasing underestimation by the SpaceLabs 90207 device of SBP and DBP compared with those recorded by the mercury sphygmomanometer (supine SBP r = -0.42, P < 0.001; DBP r = -0.21, P = 0.05; sitting SBP r = -0.43, P < 0.001; DBP r = -0.5, P < 0.001; standing SBP r = -0.34, P = 0.002; DBP r = -0.24, P = 0.003). CONCLUSION: The SpaceLabs 90207 blood pressure monitor appears satisfactory for clinical use in elderly subjects over a wide range of DBP levels, but with increasing SBP its performance diminishes, particularly in the very high SBP range.

Journal Article↗

Twenty-four-hour blood pressure profiles following stroke.

OBJECTIVES: To investigate 24 h blood pressure profiles after stroke and determine their relationship to outcome. DESIGN: This was a prospective observational study. SUBJECTS: Fifty-five conscious subjects (median age 77 years) admitted to hospital within 24 h of hemiparetic stroke were enrolled; 42 completed the study. METHODS: Stroke patients underwent non-invasive 24 h blood pressure monitoring on days 1 and 7 of hospital admission, and were followed up for between 2 and 6 years. RESULTS: Twenty-four-hour systolic and diastolic blood pressure (SBP and DBP) decreased significantly by 7 mmHg [95% confidence interval (CI): 2 to 13 mmHg, P = 0.01] and 3 mmHg (95% CI 0 to 6 mmHg, P = 0.03), respectively, from day 1 to day 7 (148+/-20/84 +/- 13 mmHg to 141 +/- 20/81 +/- 13 mmHg, respectively). Day-night blood pressure differences on days 1 and 7 were 0.4 +/-10.2/2.1 +/- 6.1 mmHg and -0.7 +/- 12.0/2.5 +/- 8.8 mmHg, respectively. Survival analysis revealed a significantly increased chance of dying for patients with an increasing nocturnal-above-daytime blood pressure on day 7 both for SBP (P = 0.02) and for DBP (P = 0.003). The group of patients dying within 2 years (n = 16) or surviving (n = 26) had similar day*ndash;night SBP and DBP differences on day 1 (0.6 +/- 11.4 compared with 0.3 +/- 9.5 mmHg and 0.6 +/- 6.9 compared with 3.1 +/- 5.4 mmHg, respectively). However, by day 7 nocturnal SBP and DBP were significantly higher than day SBP and DBP in those dying within 2 years, but not in those surviving after this time (SBP difference: -7.0 +/- 11.6 compared with 3.2 +/- 10.9, P = 0.018; DBP difference: -2.6 +/- 8.3 compared with 5.7 +/- 7.6 mmHg, P = 0.004, respectively). CONCLUSION: In those stroke patients with a poor outcome, there was a reversal of the usual 24 h blood pressure profile, such patients having a higher night-time than daytime blood pressure.

Journal Article↗

The Hypertension Optimal Treatment study and the importance of lowering blood pressure.

OBJECTIVES: The Hypertension Optimal Treatment (HOT) Study had two objectives: (1) to define the optimal target blood pressure when treating hypertensive patients (i.e. the level of blood pressure associated with the lowest incidence of major cardiovascular events such as fatal and non-fatal stroke and myocardial infarction and other cardiovascular mortality); and (2) to assess the effect of a low dose of acetylsalicylic acid (aspirin) compared with placebo on major cardiovascular events. METHODS: The HOT study recruited 18 790 hypertensive subjects aged 50 to 80 years with diastolic blood pressure (DBP) between 100 and 115 mmHg (mean DBP 105 mmHg). Subjects were randomly assigned to be treated with the goal of reaching one of three target DBPs: < or = 90 mmHg (n = 6264), < or = 85 mmHg (n = 6264), or < or = 80 mmHg (n = 6262) using felodipine as initial therapy with the addition of other agents according to a 5-step regimen. In addition, subjects were randomly assigned to receive either 75 mg/day aspirin (n = 9399) or placebo (n = 9391). RESULTS: DBP was reduced by 20.3, 22.3, and 24.3 mmHg in the < or = 90, < or = 85, and < or = 80 mmHg target groups, respectively. The incidence of all major cardiovascular events (fatal and non-fatal stroke, myocardial infarction, and other cardiovascular mortality) decreased, although not significantly, in relation to the randomized target blood pressure. There were 84, 64, and 61 fatal and non-fatal myocardial infarctions in the < or = 90 mmHg, < or = 85 mmHg, and < or = 80 mmHg groups, respectively (P = 0.05). The overall effect of aspirin on cardiovascular events was positive, most noticeably on fatal and non-fatal myocardial infarctions; aspirin reduced events by 36%. There were seven fatal episodes of bleeding (two cerebral) in the aspirin group compared with eight (three cerebral) in the placebo group, and 129 versus 70 non-fatal major episodes of bleeding in the two groups, respectively. The lowest incidence of all major cardiovascular events combined was found at an achieved DBP of 82.6 mmHg and at an achieved systolic blood pressure (SBP) of 138.5 mmHg. In the subgroup with diabetes mellitus at baseline (n = 1501), the effect of intensive lowering of blood pressure was especially noticeable. CONCLUSIONS: Most cardiovascular end-points showed a declining frequency in relation to target blood pressure. The optimal protection against combined major cardiovascular end-points was observed in the range 80-85 mmHg for DBP and in the range 130-140 mmHg for SBP. It is worth noting that 92% of all subjects reached a DBP of < or = 90 mmHg and that side-effects gradually declined from 16.9% at 3 months to 2.2% at the end of the study. A substudy showed that quality of life was linked to the level of blood pressure obtained: the lower the blood pressure, the better the quality of life.

Adrenergic beta-Antagonists↗

[Evaluation of the activity of the autonomic nervous system in "dipper" and "non dipper" essential hypertensives. Gender differences].

OBJECTIVES: 1) To compare the autonomic nervous system activity parameters obtained from a photoplethysmographic recording in dipper and non dipper hypertensive. 2) To look for an interaction between dipper/non dipper status and gender. METHODS: Prospective study involving 245 untreated hypertensives (51 +/- 13 years, 146 men, 99 women). All of the patients underwent a 24-hour ambulatory blood pressure measurement (ABPM) as well as an echocardiography for left ventricular mass index determination (LVMI) and a photoplethysmographic recording of blood pressure (BP). Nondippers were defined as those whose nocturnal decrease in systolic BP (SBP) and/or diastolic BP (DBP) was < 10% of daytime BP. Spectral powers were obtained from the photoplethysmographic recording using a fast Fourier transform over the low frequency band (LF) and the high frequency band (HF). Baroreflex sensitivity (BRS) was evaluated by the sequences method. RESULTS: Of the 245 patients, 159 were dippers (98 men, 61 women) and 86 were non dippers (48 men and 38 women). Clinic BP was significantly higher in non dippers than in dippers (168/101 vs 161/98 mmHg; p < 0.01 for SBP and p < 0.05 for DBP) whereas daytime ABPM and LVMI were not different, whatever the gender. LF spectral powers were significantly lower in non dippers than in dippers for SBP (respectively 25 +/- 11% vs 30 +/- 13%; p < 0.01) for DBP (respectively 35 +/- 14% vs 41 +/- 15%; p < 0.01) and for HR (respectively 34 +/- 15% vs 38 +/- 15%; p = 0.03). They showed a positive correlation with the nocturnal SBP fall (r = 0.21, p < 0.001 for SBP and DBP spectral powers, r = 0.19; p < 0.005 for HR spectral power) and with the nocturnal DBP fall, too (r = 0.19; p < 0.005 for SBP spectral power, r = 0.20; p < 0.002 for DBP spectral power, r = 0.19; p < 0.005 for HR spectral power). HF spectral powers tended to be higher in non dippers than in dippers but in a non significative way. BRS was roughly the same in dippers and non dippers (7.5 +/- 2.7 vs 7.0 +/- 3.1 ms/mmHg, NS). The interaction between non dipper/dipper status and sex was non significant whatever the LF spectral power. CONCLUSIONS: 1) The greater the nocturnal BP fall, the higher the sympathetic activity indexes. 2) This relationship was found both in males and females.

Ambulatory Care↗

Ageing and hypertension: the assessment of blood pressure indices in predicting coronary heart disease.

OBJECTIVE: To determine whether pulse pressure (PP), diastolic blood pressure (DBP), systolic blood pressure (SBP), or mean arterial pressure (MAP) is the superior haemodynamic predictor for the risk of coronary heart disease (CHD). METHODS: Age-related changes of blood pressure in normotensive and untreated hypertensive subjects in a population-based cohort from the Framingham Heart Study were characterized. The relationship between these blood pressure indices and risk of CH D over a 20-year follow-up period were then evaluated. RESULTS: There was a parallel linear rise in SBP, DBP and MAP from age 30-49 years, suggesting increased peripheral vascular resistance (PVR) in this age group. After age 50-60 years, DBP declined, PP rose steeply, and MAP levelled off, while SBP continued to show a linear increase, suggesting increasing predominance of large artery stiffness (LAS) in this middle-aged and elderly group. After adjusting for age, sex and other risk factors, MAP and DBP consistently underestimated PVR and risk of CHD. Systolic blood pressure fully represented PVR but frequently underestimated LAS and risk of CHD. Pulse pressure was superior to SBP as a surrogate marker for LAS and predictor of CHD risk in the presence of discordantly low DBP, but PP frequently underestimated PVR. CONCLUSIONS: In middle-aged and older subjects, at any given level of SBP > or = 120 mmHg, the risk of CHD rose with discordantly lower DBP, suggesting that the wider PP was driving the risk for CHD. These results suggest that total haemodynamic load, defined as the sum of pulsatile load (LAS) and steady-state load (PVR), is a major determinant of CHD risk.

Aging↗

Blood pressure control in treated hypertensive patients: clinical performance of general practitioners.

BACKGROUND: The blood pressure of many treated hypertensive patients remains above recommended target levels. This discrepancy may be related to general practitioners' (GPs') actions. AIM: To assess clinical performance of GPs in blood pressure control in treated hypertensive patients and to explore the influence of patient and GP characteristics on clinical performance. DESIGN OF STUDY: Cross-sectional study conducted on 195 GPs with invitations to participate made via bulletins and by letter. SETTING: One hundred and thirty-two practices in the southern half of The Netherlands from November 1996 to April 1997. METHOD: Performance criteria were selected from Dutch national hypertension guidelines for general practice. GPs completed self-report forms immediately after follow-up visits of hypertensive patients treated with antihypertensive medication. RESULTS: The GPs recorded 3526 follow-up visits. In 63% of these consultations the diastolic blood pressure (DBP) was 90 mmHg or above. The median performance rates of the GPs were less than 51% for most of the recommended actions, even at a DBP of > or = 100 mmHg. Performance of non-pharmacological actions increased gradually with increasing DBP; prescribing an increase in antihypertensive medication and making a follow-up appointment scheduled within six weeks rose steeply at a DBP of > or = 100 mmHg. Patient and GP characteristics contributed little to clinical performance. Action performance rates varied considerably between GPs. CONCLUSION: GPs seem to target their actions at a DBP of below 100 mmHg, whereas guidelines recommend targeting at a DBP of below 90 mmHg.

Adolescent↗

Blood pressure patterns in pregnant patients on oral ketanserin.

BACKGROUND: Ketanserin, a selective serotonin-2 receptor antagonist, decreases systolic blood pressure (SBP) and diastolic blood pressure (DBP) in non-pregnant patients with hypertension, but not in normotensive subjects. Its effect on longitudinal blood pressure (BP) patterns in pregnant women has not been documented. OBJECTIVES: To assess how ketanserin, given orally, influences maternal BP during pregnancy. DESIGN: A double-blind randomised controlled trial where patients with DBP > or =80 mmHg between 12 and 20 weeks' gestation received either ketanserin or placebo. SETTING: Tygerberg Hospital, a tertiary referral unit in the Western Cape. SUBJECTS: One hundred and two patients who received their study drug for at least 140 days during pregnancy. Patients requiring additional antihypertensive medication were excluded from the analysis. OUTCOME MEASURES: Changes in SBP and DBP in relation to gestational age and days since entering the study. RESULTS: The mean DBP over the total period was significantly lower in the ketanserin group (77 +/- 8.7 mmHg v. 80.8 +/- 9.1 mmHg). The decline in DBP was 9.2 mmHg in the ketanserin group and 5.3 mmHg in the placebo group. These differences were detected from within 7 days of therapy and persisted for most of the pregnancy. The mean SBP did not differ at any stage, although the mean fall in SBP was significantly greater in the ketanserin group (8.6 +/- 16.7 v. 4.1 +/- 17.1 mmHg). CONCLUSIONS: Ketanserin decreased DBP during pregnancy significantly more than placebo.

Administration, Oral↗

An assessment of the toxicity of phthalate esters to freshwater benthos. 2. Sediment exposures.

Seven phthalate esters were evaluated for their 10-d toxicity to the freshwater invertebrates Hyalella azteca and Chironomus tentans in sediment. The esters were diethyl phthalate (DEP), di-n-butyl phthalate (DBP), di-n-hexyl phthalate (DHP), di-(2-ethylhexyl) phthalate (DEHP), diisononyl phthalate (DINP), diisodecyl phthalate (DIDP), and a commercial mixture of C7, C9, and C11 isophthalate esters (711P). All seven esters were tested in a sediment containing 4.80% total organic carbon (TOC), and DBP alone was tested in two additional sediments with 2.45 and 14.1% TOC. Sediment spiking concentrations for DEP and DBP were based on LC50 (lethal concentration for 50% of the population) values from water-only toxicity tests, sediment organic carbon concentration, and equilibrium partitioning (EqP) theory. The five higher molecular weight phthalate esters (DHP, DEHP, DINP, DIDP, 711P), two of which were tested and found to be nontoxic in water-only tests (i.e., DHP and DEHP), were tested at single concentrations between 2,100 and 3,200 mg/kg dry weight. Preliminary spiking studies were performed to assess phthalate ester stability under test conditions. The five higher molecular weight phthalate esters in sediment had no effect on survival or growth of either C. tentans or H. azteca, consistent with predictions based on water-only tests and EqP theory. The 10-d LC50 values for DBP and H. azteca were >17,400, >29,500, and >71,900 mg/kg dry weight for the low, medium, and high TOC sediments, respectively. These values are more than 30x greater than predicted by EqP theory and may reflect the fact that H. azteca is an epibenthic species and not an obligative burrower. The 10-d LC50 values for DBP and C. tentans were 826, 1,664, and 4.730 mg/kg dry weight for the low, medium, and high TOC sediments, respectively. These values are within a factor of two of the values predicted by EqP theory. Pore-water 10-d LC50 values for DBP (dissolved fraction) and C. tentans in the three sediments were 0.65, 0.89, and 0.66 of the water-only LC50 value of 2.64 mg/L, thereby agreeing with EqP theory predictions to within a factor of 1.5. The LC50 value for DEP and C. tentans was >3,100 mg/kg dry weight, which is approximately 10x that predicted by EqP theory. It is postulated that test chemical loss and reduced organism exposure to pore water may have accounted for the observed discrepancies with EqP calculations for DEP

Animals↗

[Blood pressures values during evaluation of 24-h ambulatory blood pressure monitoring and left ventricular hypertrophy in patients with chronic renal failure treated with hemodialysis (HD)].

Left ventricular hypertrophy (LVH) is common and important predictor of risk of death in end-stage renal failure. In the present study we have analysed the relationship between 24-h ambulatory blood pressure (BP) profile and LVH. The effect of parathyroid hormone (PTH) on was also assessed. From a cohort of 85 patients with crf we selected for analysis 59 stable patients. Ambulatory BP 24-h monitoring, echocardiography (ECHO), body mass index (BMI), serum creatinine, hemoglobin, total protein, albumin, electrolytes and PTH concentrations were assessed in all patients. Concentric LVH was detected by ECHO in 46 patients, in 13 patients excentric LVH was observed. Mean 24-h ambulatory sBP, dBP, mean 24-h ambulatory day sBP, dBP as well as night sBP and dBP were significantly higher than in a control group 60 healthy subjects. It was a correlation between mean 24-h ambulatory sBP and left ventricular mas (LVM) r = 0.606 (p < 0.0001), between mean dBP and (LVM) r = 0.498 (p < 0.001), between mean day sBP and (LVM) r = 0.591 (p < 0.0001), between mean day dBP and (LVM) r = 0.479 (p < 0.001), between mean night dBP and (LVM) r = 0.548 (p < 0.0001), between left ventricular mass index (LVMI) and mean sBP r = 0.428 (p < 0.05), between LVMI and mean day sBP r = 0.442 (p < 0.05). The loss in physiological night-time BP was observed in all patients. It was also correlations between PTH and (LVM) r = 0.704 (p < 0.001), and between BMI and LVMI r = -0.451 (p < 0.05). LVH is common in crf patients. These results confirmed that strong correlations between BP values and LVH and between serum PTH concentrations and LVH indicate that both hypertension and hyperparathyroidism play an important role in the LVH development.

Blood Pressure↗

NTP technical report on the toxicity studies of Dibutyl Phthalate (CAS No. 84-74-2) Administered in Feed to F344/N Rats and B6C3F1 Mice.

Dibutyl phthalate is a phthalate ester with extensive use in industry in such products as plastic (PVC) piping, various varnishes and lacquers, safety glass, nail polishes, paper coatings, dental materials, pharmaceuticals, and plastic food wrap. Concomitant with this extensive worldwide use is the high potential for human exposure to dibutyl phthalate in the workplace and the home environment through direct sources as well as indirectly, through contamination of water, air, and foodstuffs. Because existing toxicity information was considered inadequate, the effects of exposure to dibutyl phthalate were examined in male and female F344/N rats and B6C3F1 mice in 13-week feed studies. Furthermore, due to concern over the potential for pervasive exposure of humans to dibutyl phthalate, additional perinatal studies examined rats and mice exposed as pups in utero, for the 4 weeks of lactation, and for an additional 4 weeks postweaning. Additional studies examined the effects on rats of combining perinatal and adult subchronic exposure. Due to the recognized biologic activity of this and other phthalates, hepatic peroxisome proliferation during the in utero and lactational phases and testicular toxicity during the perinatal period were also examined. Finally, reproductive assessment by continuous breeding (including crossover mating trials and offspring assessment) and genetic toxicity studies were also conducted. In the maximum perinatal exposure (MPE) determination study in rats, dibutyl phthalate was administered in the diet to dams during gestation and lactation, and to the pups postweaning for four additional weeks, at concentrations of 0, 1,250, 2,500, 5,000, 7,500, 10,000, and 20,000 ppm. Decreased weight gains were noted in dams exposed to 20,000 ppm during gestation and to dams exposed to 10,000 ppm during lactation. The gestation index (number of live pups per breeding female) was significantly lower in the 20,000 ppm group than in the controls, and pup mortality in this group was marked (100% by Day 1 of lactation); however, survival was 89% or greater in all other treatment groups. The mean body weight of pups in the 10,000 ppm group at Day 28 of lactation was approximately 90% of the mean weight of control pups. Pups were weaned onto diets containing dibutyl phthalate at the same concentrations fed to dams. After an additional 4 weeks of dietary administration, final mean body weights of pups in the 10,000 ppm groups were 92% of the control value for males and 95% of the control value for females. Hepatomegaly (increased relative liver weight) was observed in males in all exposed groups and in females receiving 2,500 ppm or greater. No gross lesions were observed at necropsy. Moderate hypospermia of the epididymis was diagnosed in all male rats in the 7,500 and 10,000 ppm groups; mild hypospermia of the epididymis was diagnosed in 2 of 10 males in the 5,000 ppm group. No degeneration of the germinal epithelium was detected in the testis of these rats. Thus, although toxicologically important, the epididymal hypospermia was not considered to be life threatening, and 10,000 ppm was recommended as the MPE concentration for male and female rats. In the subsequent subchronic toxicity study of dibutyl phthalate with perinatal exposure, dams were administered diets containing 0 or the MPE concentration (10,000 ppm) during gestation and lactation, and weaned pups were administered the same diets as their dams received for an additional 4 weeks, until the beginning of the 13-week exposure phase. Male and female rats then received diets containing dibutyl phthalate at concentrations of 0, 2,500, 5,000, 10,000, 20,000, and 40,000 ppm for 13 weeks. No mortality or toxicity was observed in dams during the perinatal phase of the study; however, before pups were culled at 4 days postpartum, the percentage of live pups per litter was 86% to 93% that of the controls. Through weaning, litter weights of exposed pups ranged from 89% to 92% of the control values. Ten control and ten exposed pups per sex were examined at the time of trol and ten exposed pups per sex were examined at the time of weaning; hepatomegaly and markedly increased peroxisomal enzyme activities (approximately 9-fold greater than the control values) were observed in exposed pups. Body weights of the perinatally exposed pups remained lower than those of the controls throughout the 4-week period before the 13-week adult exposures began. During the 13-week adult exposure phase, the final mean body weight of males in the MPE: 0 ppm control group (MPE rats, returned to the base diet for 13 weeks), was 95&percnt; that of the controls. The body weight gain of females in the MPE:0 ppm group was greater than that of the unexposed controls, and the final body weights of these two groups were similar. Body weight gains of rats treated with dibutyl phthalate as adults decreased with increasing exposure concentration; for rats that received the MPE concentration followed by 40,000 ppm for 13 weeks, final body weights were 51&percnt; of the control value for males and 74&percnt; of the control value for females. Hepatomegaly apparently regressed in rats in the MPE:0 ppm groups but was observed in male rats receiving 5,000 ppm or greater and in females receiving 2,500 ppm or greater. In males that received 20,000 ppm as adults, testis and epididymal weights were less than in the controls; males in the 40,000 ppm group also had a lower testis weight than the controls. Results of hematologic analyses conducted at the end of the 13-week exposure period suggested a mild anemia in male rats administered 10,000 ppm or greater as adults and female rats administered 40,000 ppm as adults. Hypocholesterolemia and hypotriglyceridemia were observed in male and female rats at the higher exposure concentrations. Hypotriglyceridemia was detected in females receiving 20,000 or 40,000 ppm and in males receiving 10,000 ppm or greater. Elevations in alkaline phosphatase activities and bile acid concentrations in male and female rats receiving 20,000 or 40,000 ppm as adults were indicative of cholestasis. Microscopic examination revealed hepatocellular cytoplasmic alteration, consistent with glycogen depletion, in male and female rats receiving a concentration of 10,000 ppm or greater. In the liver of rats receiving 40,000 ppm, small, fine, eosinophilic granules were also observed in the cytoplasm of hepatocytes. Ultrastructural examination suggested the presence of increased numbers of peroxisomes. Lipofuscin accumulation was detected in rats that received 10,000 ppm or greater. Consistent with the regression of the hepatomegaly in rats in the MPE:0 and MPE:2,500 ppm groups, peroxisomal enzyme activity was not elevated in these groups. Marked elevations of peroxisomal enzyme activity were detected, however, in males receiving 5,000 ppm or greater and in females receiving 10,000 ppm or greater; at the 40,000 ppm concentration, the highest concentration tested, enzyme activities were approximately 20 fold greater than the control values. Histopathologic examination of the testes revealed degeneration of the germinal epithelium, a mild to moderate focal lesion in rats in the 10,000 and 20,000 ppm groups and a marked, diffuse lesion in all males receiving 40,000 ppm; at 40,000 ppm, an almost complete loss of the germinal epithelium resulted. Testicular zinc concentrations were lower in the 40,000 ppm group than in the controls, a finding consistent with the marked loss of germinal epithelium at this exposure concentration. Spermatogenesis was evaluated in rats in the 0, 2,500, 10,000, and 20,000 ppm groups; rats administered 20,000 ppm had fewer spermatid heads per testis than the unexposed controls, and epididymal spermatozoal concentration was less than that in the MPE:0 ppm group. For comparison with the perinatal subchronic study, a standard 13-week evaluation of the toxicity of dibutyl phthalate in male and female rats was also conducted. In this study, rats received dibutyl phthalate at the same dietary concentrations used in the 13-week exposure phase of the study with perinatal exposure: 0, 2,500, 5,000, 10,000, 20,000, and 40,000 ppm. No deaths occurred in the standard study. Markedly reduced final mean body weights were observed in males and females in the 40,000 ppm groups (45&percnt; and 73&percnt; of control body weights, respectively); final mean body weights of males receiving 10,000 ppm or greater and females receiving 20,000 ppm or greater were lower than those of the controls. Hepatomegaly was observed in males that received 5,000 ppm or greater and in females that received 10,000 ppm or greater. Testis and epididymal weights of males in the 20,000 and 40,000 ppm groups were lower than those of the controls. A minimal anemia was detected in male rats receiving 5,000 ppm or greater. Hypocholesterolemia was observed in male and female rats receiving 20,000 or 40,000 ppm, and hypotriglyceridemia was detected in males in all exposed groups and in females receiving 10,000 ppm or greater. Elevations in alkaline phosphatase activity and bile acid concentration in male and female rats were considered indicative of cholestasis. Morphologic evaluation again confirmed the toxicity of dibutyl phthalate to the liver and testes of rats. Microscopic examination of the liver revealed hepatocellular cytoplasmic alterations, consistent with glycogen depletion, in male and female rats receiving 10,000 ppm or greater. In the liver of rats in the 40,000 ppm groups, small, fine, eosinophilic granules were also observed in the cytoplasm of hepatocytes. Ultrastructural examination suggested the presence of increased numbers of peroxisomes, and peroxisomal enzyme activity was elevated in the livers of male and female rats administered 5,000 ppm or greater; the enzyme activities in the 40,000 ppm groups were approximately 13-fold greater than the control value for males and 32-fold greater than the control value for females. Lipofuscin accumulation was detected in rats receiving 10,000 ppm or greater. Histopathologic examination of the testes revealed degeneration of the germinal epithelium, a mild to marked focal lesion in the 10,000 and 20,000 ppm groups and a marked, diffuse lesion in all males in the 40,000 ppm group; at 40,000 ppm, an almost complete loss of the germinal epithelium resulted. Testicular zinc concentrations were lower in the 20,000 and 40,000 ppm groups than in the controls. Serum testosterone values were also lower at these concentrations than in the controls. Spermatogenesis was evaluated in males in the 0, 2,500, 10,000, and 20,000 ppm groups; at 20,000 ppm, spermatid heads per testis and per gram testis, epididymal spermatozoal motility, and the number of epididymal spermatozoa per gram epididymis were lower than in the controls. All of these findings are consistent with the marked loss of germinal epithelium at these exposure concentrations. In the continuous breeding study, Sprague-Dawley rats received 0, 1,000, 5,000, or 10,000 ppm dibutyl phthalate in feed. Mean body weights of exposed dams at delivery and during lactation generally decreased with increasing exposure concentration. The mean pup weight at birth in the 10,000 ppm group was significantly lower than the control pup weight. The average number of live pups per litter in all exposed groups was lower than in the controls. Crossover mating trials in the F(0) generation revealed no effects on the fertility of male or female rats receiving 10,000 ppm. In contrast to the F(0) rats, mating, pregnancy, and fertility indices of F(1) rats were lower in the 10,000 ppm group than in the controls. Germinal epithelial degeneration of the testes and absence or under development of the epididymides were noted in F(1) males in the 10,000 ppm group. Interstitial cell hyperplasia was noted in 7 of 10 males in the 10,000 ppm group. These effects document the male and female reproductive toxicity of dibutyl phthalate in F(1) rats receiving 10,000 ppm and do not exclude the possibility of developmental toxicity to F2 offspring. In the MPE determination study in mice, dams received 0, 1,250, 2,500, 5,000, 7,500, 10,000, or 20,000 ppm dibutyl phthalate in feed during gestation and lactation; pups were weaned onto the same diets as the dams received and were exposed for an additional 4 weeks. The gestation period was longer in dams that received 2,500 ppm or greater than in the controls, and gestational body weight gain depressions were noted in dams receiving 7,500 ppm or greater. Only 5 of 20 females in the 10,000 ppm group delivered live pups, and none of the 20 females receiving 20,000 ppm delivered live pups. Only one pup in the 10,000 ppm group survived past Lactation Day 1; the number of live pups per litter in the 7,500 ppm group also remained low throughout lactation. No deaths of either male or female pups occurred after weaning. Initial (postweaning) and final body weights of male pups receiving 2,500 ppm or greater were significantly less than those of the control group. The mean body weights of exposed female pups were similar to the control body weight at weaning and remained similar throughout the 4 weeks postweaning. Hepatomegaly was present in male mice in all exposed groups, and the absolute liver weight of males administered 7,500 ppm was greater than that of the controls; although a similar change was apparent in females, no statistical differences between the liver weights of exposed and control females were detected. No treatment-related gross lesions were identified at necropsy, and no histopathologic lesions definitively associated with treatment were observed in male or female mice in the 7,500 ppm groups. The one surviving male pup in the 10,000 ppm group had cytoplasmic alteration in the liver, consistent with peroxisome proliferation. Developmental toxicity and fetal and pup mortality were suggested at concentrations as low as 7,500 ppm. No subchronic toxicity study with prior MPE exposure was conducted with mice, although an MPE concentration of 5,000 ppm was suggested by the data. In a standard 13-week toxicity study, mice received 0, 1,250, 2,500, 5,000, 10,000, or 20,000 ppm dibutyl phthalate in feed. No deaths occurred during this study. Mean body weights and weight gains of male and female mice decreased with increasing exposure concentration, and the decreases were significant for males and females that received 5,000 ppm or greater. Relative liver weights were greater in males and females receiving 5,000 ppm or greater than in the controls. A minimal anemia was suggested in female mice in the 20,000 ppm group. Although no gross lesions were observed at necropsy, microscopic examination revealed hepatocellular cytoplasmic alterations, consistent with glycogen depletion, in male mice receiving 10,000 or 20,000 ppm and female mice receiving 20,000 ppm. Small, fine, eosinophilic granules, consistent with peroxisome proliferation, were also observed in the cytoplasm of hepatocytes in males and females in the 20,000 ppm groups. Lipofuscin accumulation in the liver was detected in mice receiving 10,000 ppm or greater. In a continuous breeding study using Swiss (CD-1&reg;) mice, animals received 0, 300, 3,000, or 10,000 ppm dibutyl phthalate in feed. The fertility index, average number of litters per breeding pair, and average number of live pups per litter in the 10,000 ppm group were lower than in the controls. Crossover mating trials of mice receiving 10,000 ppm revealed effects on dams in the F(0) generation, with a lower fertility index, number of live pups per litter, and pup weight than in the controls. Liver weights were greater in males and females, and the uterine weight was less in exposed dams than in the controls. No other changes were observed at necropsy or on histopathologic examination. These data document the female reproductive toxicity of dibutyl phthalate in F(0) mice. Dibutyl phthalate was not mutagenic in Salmonella typhimurium strain TA98, TA100, TA1535, or TA1537 with or without exogenous metabolic activation but did induce mutations in L5178Y mouse lymphoma cells treated without metabolic activation. In peripheral blood samples obtained from male and female mice at the end of the 13-week study, frequencies of micronucleated normochromatic erythrocytes were similar between exposed and control mice. Together, the studies in rodents suggest that young rodents (in utero and perinatal) respond in a manner qualitatively similar to that of adult rats and mice. Dibutyl phthalate induced toxic effects in rodents as pups in utero and during the lactational phases of development and also affected young adults, as evidenced by fetotoxicity and lethality, body weight gain decrements, increased liver weights, hepatic peroxisome proliferation, testicular toxicity, and female reproductive toxicity. Dibutyl phthalate was lethal to rat fetuses and rat and mouse neonates at dietary concentrations that were not toxic to dams. Otherwise, there was no teratogenic or morphologic evidence that rodent young were uniquely sensitive to the effects of short-term dibutyl phthalate treatment. Synonyms: 1,2-Benzenedicarboxylic acid dibutyl ester; benzene-o-dicarboxylic acid di-n-butyl ester; o-benzenedicarboxylic acid dibutyl ester; butyl phthalate; n-butyl phthalate; DBP; dibutyl 1,2-benzene dicarboxylate; dibutylphthalate; di-n-butylphthalate; di(n-butyl) phthalate; dibutyl-o-phthalate; phthalic acid dibutyl ester. Trade Names: Celluflex DBP; Elaol; Ergoplast FDB; Ersoplast FDA; Genoplast B; Hexaplas M/B; Palatinol C; Polycizer DBP; PX 104; RC Plasticizer DBP; Staflex DBP; Uniflex DBP; Unimoll DB; Witcizer 300; Witicizer 300. (NOTE: These studies were supported in part by funds from the Comprehensive Environmental Response, Compensation, and Liability Act trust fund (Superfund) by an interagency agreement with the Agency for Toxic Substances and Disease Registry, U.S. Public Health Service.)

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