The evolution of systolic blood pressure as a strong predictor of cardiovascular risk and the effectiveness of fixed-dose ARB/CCB combinations in lowering levels of this preferential target

Elevated blood pressure is an important cardiovascular risk factor. Although targets for both diastolic blood pressure (DBP) and systolic blood pressure (SBP) are defined by current guidelines, DBP has historically taken precedence in hypertension management. However, there is strong evidence that SBP is superior to DBP as a predictor of cardiovascular events. Moreover, achieving control of SBP is assuming greater importance amongst an aging population. In spite of the growing recognition of the importance of SBP in reducing cardiovascular risk and the emphasis by current guidelines on SBP control, a substantial proportion of patients still fail to achieve SBP targets, and SBP control is achieved much less frequently than DBP control. Thus, new approaches to the management of hypertension are required in order to control SBP and minimize cardiovascular risk. Fixed-dose combination (FDC) therapy is an approach that offers the advantages of multiple drug administration and a reduction in regimen complexity that favors compliance. We have reviewed the latest evidence demonstrating the efficacy in targeting SBP of the most recent FDC products; combinations of the calcium channel blocker (CCB), amlodipine, with angiotensin receptor blockers (ARBs), valsartan or olmesartan. In addition, results from studies with new classes of agent are outlined

Application in the STRATHE trial of a score system to compare the efficacy and the tolerability of different therapeutic strategies in the management of hypertension

A score system integrating the evolution of efficacy and tolerability over time was applied to a subpopulation of the STRATHE trial, a trial performed according to a parallel group design, with a double-blind, random allocation to either a fixed-dose combination strategy (perindopril/indapamide 2 mg/0.625 mg, with the possibility to increase the dose to 3 mg/0.935 mg, and 4 mg/1.250 mg if needed, n = 118), a sequential monotherapy approach (atenolol 50 mg, followed by losartan 50 mg and amlodipine 5 mg if needed, n = 108), or a stepped-care strategy (valsartan 40 mg, followed by valsartan 80 mg and valsartan 80 mg+ hydrochlorothiazide 12.5 mg if needed, n = 103). The aim was to lower blood pressure below 140/90 mmHg within a 9-month period. The treatment could be adjusted after 3 and 6 months. Only patients in whom the study protocol was strictly applied were included in this analysis. At completion of the trial the total score averaged 13.1 ± 70.5 (mean ± SD) using the fixed-dose combination strategy, compared with −7.2 ± 81.0 using the sequential monotherapy approach and −17.5 ± 76.4 using the stepped-care strategy. In conclusion, the use of a score system allows the comparison of antihypertensive therapeutic strategies, taking into account at the same time efficacy and tolerability. In the STRATHE trial the best results were observed with the fixed-dose combination containing low doses of an angiotensin enzyme converting inhibitor (perindopril) and a diuretic (indapamide)

Blood pressure normalization by fixed perindopril/indapamide combination in hypertensive patients with or without associate metabolic syndrome: results of the OPTIMAX 2 study

The aim of the observational pharmaco-epidemiological study Optimax II was to seek whether the pre-existence of a metabolic syndrome (MS) defined by the NCEP-ATP III criteria impacts blood pressure (BP) control in hypertensive patients receiving a fixed perindopril/indapamide combination therapy. The primary objective of the study was to compare in patients with and without MS the rate of BP control defined as a systolic BP ≤140 mmHg and a diastolic BP ≤90 mmHg. Patients were prospectively included and the follow-up lasted 6 months. The study population consisted of 24,069 hypertensive patients (56% men; mean age 62 ± 11 years; 18% diabetics; mean BP at inclusion 162 ± 13/93 ± 9 mmHg). MS was found in 30.4% of the patients (n = 7322): 35.2% women and 20.1% men. Three therapeutic subgroups were constituted: Group A, previously untreated, received the combination therapy as initial treatment; Group B, previously treated but with unsatisfactory results and/or treatment intolerance, had its previous treatment switched to perindopril/indapamide; and Group C, previously treated, with good treatment tolerance but uncontrolled BP, received the study treatment in adjunction to the previous one. The normalization rate was 70.3% in group A, 68.4% in Group B, and 64.1% in Group C (p < 0.0001). The pre-existence of MS did not show any significant influence on these rates since BP lowering was −22.7 ± 13.7 (SBP) and −12.0 ± 10.0 mmHg (DBP) in patients without MS and −22.6 ± 13.3 (SBP) and −12.1 ± 9.7 (DBP) in those with MS. The results of this study show a significant effect of perindopril/indapamide treatment on systolic BP lowering, whatever the treatment status: initiation, switch, or adjunctive therapy, and independently from the presence or not of MS. This effect may be related to the specific vascular effect of the perindopril/indapamide combination, which has recently demonstrated in the ADVANCE trial its ability to reduce mortality, and cardiovascular and renal complications in diabetic patients

High Power Very Low Voltage Electric Motor for Electric Vehicle

Electric vehicles are often designed in the same way as their conventional counterparts based on the internal combustion engine, they are heavy machines for comfort and safety reasons, and increasingly powerful. Under these conditions, in order to simplify the motor electrical supply system by reducing the current levels, the voltage chosen for the battery is very high and can go up to 700 V. However, for many applications where the power is relatively low (< 30 kW per motor), it can be more beneficial to size the system at very low voltage (< 60 V). This approach allows to overcome many constraining safety requirements and also to use off-the-shelf components (motor controllers, connectors, etc.) that are more easily available on the market in this voltage range. There are also many regulatory provisions that may require to stay within this voltage limit. This article presents a variety of very low voltage motorisation solutions with a required power up to 100kW. They use two complementary approaches. The first is to implement an original permanent magnet synchronous machine technology with an optimised armature winding for low voltage operation. The second is based on power splitting where the electrical machine being designed to be driven by multiple controllers. Many examples of low-voltage motorised vehicles (sporty vehicle, tractor, re-motorised automobile, etc.) are illustrated in this article

Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

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Impact différentiel des pressions systolique et diastolique sur la sévérité de l'hypertension artérielle (classification d'une population en médecine générale)

Les dernières recommandations officielles (OMS, ANAES, JNC VI), classifient l'HTA selon des stades, en se basant sur le niveau de PAS et/ou de PAD ; quand une différence existe entre le niveau de PAS et de PAD, les patients sont classés dans le stade le plus haut d'HTA. L'objectif principal de l'étude a été d'évaluer l'impact de la pression artérielle systolique par rapport à celui de la pression artérielle diastolique sur la classification de l'hypertension artérielle au sein d'un large échantillon d'une population d'hypertendus, traités ou non, suivis en médecine générale. 18 273 sujets hypertendus (PAS > ou = 140 mmHg et/ou PAD > ou = 90 mmHg), inclus de mars à décembre 1999, ont été classés selon les critères de l'OMS et selon le niveau de PAS ou de PAD pris isolément. Cette population avait un âge moyen de 62 +/- 12 ans, 53 % étaient des hommes et 72 % étaient traités, la PA était de 163 +/- 13/93 +/- 9 mmHg et 26 % avaient une HTA systolique isolée. La distribution des patients dans les grades d'HTA sur la base de la PAS seule, était plus proche de la classification de l'OMS qua celle basée sur la PAD seule, avec un taux de concordance de 88 %, 100 %, respectivement pour les grades 1, 2, 3 d'HTA, alors qu'il n'était, avec la PAD, que de 40 %, 80 % et 100 %. Dans cette étude, 59 % des sujets avaient un stade différent de PAS et de PAD ; parmi eux, 54 % avaient un niveau de PAS supérieur à celui de la PAD, alors que seulement 5 % avaient un niveau de PAD supérieur à celui de la PAS. La PAS seule, permettait une classification correct de l'HTA (par rapport à celle de l'OMS) dans 95 % (41 % + 54 %), contre seulement 46 % (41 % + 5 %) pour la PAD. Pour les sujets hypertendus âgés de plus de 60 ans, la considération isolée de la PAD méconnaissait le diagnostic d'HTA chez 23 % des sujets, alors que cette sous-estimation ne concernait que 3,2 % des sujets si la PAS était le seul paramètre pris en compte. Pour les sujets hypertendus traités, l'importance diagnostique de la PAS était accentuée par la normalisation plus fréquente de la PAD sous traitement, avec 28,9 % de PAD normale chez les sujets traités contre 18 % chez les non traités. La PAD joue donc un rôle prédominant par rapport à la PAD dans la détermination du grade tensionnel. Dans la mesure où cette stratification influence les décisions thérapeutiques, des recommandations insistant sur le rôle prépondérant de la PAS sur la PAD dans la définition de l'HTA, dans le calcul du risque cardio-vasculaire, dans la décision de traiter et dans l'évaluation du bénéfice attendu des thérapeutiques anti-hypertensives semblent nécessaires.PARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Inertie thérapeutique dans le traitement de l'hypertension artérielle (étude qualitative auprès des médecins généralistes)

PARIS6-Bibl. St Antoine CHU (751122104) / SudocSudocFranceF