Baseline predictors of resistant hypertension in the Anglo- Scandinavian Cardiac Outcome Trial (ASCOT): a risk score to identify those at high-risk

a , on behalf of the ASCOT investigators Background Resistant hypertension is a well recognized clinical entity, which has been inadequately researched to date. Methods A multivariable Cox model was developed to identify baseline predictors of developing resistant hypertension among 3666 previously untreated AngloScandinavian Cardiac Outcome Trial (ASCOT) patients and construct a risk score to identify those at high risk. Secondary analyses included evaluations among all 19 257 randomized patients. Results One-third (1258) of previously untreated, and onehalf Conclusion Baseline SBP and choice of subsequent antihypertensive therapy were the two most important determinants of resistant hypertension in the ASCOT population. Individuals at high risk of developing resistant hypertension can be easily identified using an integerbased risk score

Techniques for aout-of-0ffice blood pressure measurement: comparison of diagnostic value of home versu 24-hour ambulatory blood pressure monitoring

Background: Several studies with relatively small size, different design andendpoints have investigated the diagnostic ability of home blood pressure (HBP)monitoring. The objective of this study was to investigate the usefulness of HBPcompared to ambulatory monitoring (ABP) in diagnosing sustained hypertension,white coat phenomenon (WCP) and masked hypertension (MH) in a large sample ofuntreated and treated subjects using a blood pressure (BP) monitoring protocolaccording to current guidelines. The diagnostic ability of HBP was also tested insubjects with resistant hypertension (RH), whereas morning hypertension detectedby HBP or ABP, a novel field in hypertension was also investigated.Method: A total of 613 subjects attending a hypertension clinic (mean age 53±12.4[SD] years, men 57%, untreated 59%) had measurements of clinic BP (3 visits,triplicate measurements per visit), HBP (6 days, duplicate morning and eveningmeasurements) and awake ABP (20 min intervals) within 6 weeks. Among subjectson stable treatment with ≥3 antihypertensive drugs, clinic RH was defined aselevated clinic BP and true RH as elevated awake ABP. The diagnostic value of HBPwas assessed by taking ABP as reference method. Threshold for hypertensiondiagnosis was ≥135/85 mmHg for HBP and awake ABP and ≥140/90 mmHg for clinicBP. Morning HBP (6 days, duplicate morning readings) was compared with mοrningABP (first 1, 2 or 3 h after arising). Morning hypertensives' were defined asindividuals with morning HBP or ABP ≥135/85 mmHg.Results: Sustained hypertension was diagnosed in 50% of the participants by ABPand HBP (agreement 89%, kappa 0.79), WCP in 14% and 15% respectively(agreement 89%, kappa 0.56) and MH in 16% and 15% (agreement 88%, kappa0.52). The sensitivity, specificity, positive and negative predictive value of HBP indetecting sustained hypertension were 90%, 89%, 89% and 90% respectively, WCP61%, 94%, 64% and 94% and MH 60%, 93%, 60% and 93%. These findings did notchange when treated or untreated subjects were analysed separately. Among 73subjects on ≥3 antihypertensive drugs, 44 (60%) had clinic RH and 40 (55%) trueRH. There was agreement between ABP and HBP in diagnosing clinic RH in 82% ofthe cases (kappa 0.59). Regarding the diagnosis of true RH, there was agreementbetween ABP and HBP in 74% of the cases (kappa 0.46).The sensitivity, specificityand positive and negative predictive values of HBP in detecting clinic RH were 93%, 63% and 81% and 83%, respectively and true RH were 90%, 55% and 71% and82%, respectively. Morning ABP (2 h) was the closest to morning HBP (meandifference 0.4±14.0/1.2±8.6 mmHg, p=NS/<0.01, systolic/diastolic) and was stronglycorrelated with morning ABP (r=0.60/0.68, p< 0.001). There was moderateagreement between morning HBP and morning ABP in detecting morninghypertensives (agreement 72%, kappa 0.44, for systolic BP and 75%, kappa 0.51, fordiastolic). These findings did not change when morning ABP of 1 or 3 h after arisingwere used.Conclusions: HBP appears to be a reliable alternative to ABP in the diagnosis ofhypertension and the detection of WCP and MH in both untreated and treatedsubjects. HBP retains the same diagnostic ability in patients with RH and mighttherefore, be a useful tool in both uncontrolled and controlled subjects on tripletherapy to detect the WCP and also masked RH. Despite their methodologicaldifferences, there seems to be considerable similarity between morning HBP andmorning ABP, suggesting that these methods are interchangeable for theassessment of morning hypertension.Σκοπός: H αρτηριακή πίεση (ΑΠ) εκτός ιατρείου αποτελεί απαραίτητο εργαλείο γιατην αξιολόγηση της αρτηριακής υπέρτασης και κατ’ επέκταση του καρδιαγγειακούκινδύνου. Εν τούτοις, μόνο μικρές μελέτες έχουν προσδιορίσει τη διαγνωστική αξίατης ΑΠ στο σπίτι συγκριτικά με την 24ωρη ΑΠ (μέθοδο αναφοράς για την αξιολόγησητης ΑΠ εκτός ιατρείου). Σκοπός της παρούσας μελέτης είναι η διερεύνηση τηςχρησιμότητας της ΑΠ στο σπίτι συγκριτικά με την 24ωρη ΑΠ στη διάγνωση τηςεμμένουσας υπέρτασης, του φαινομένου της υπέρτασης λευκής μπλούζας και τηςσυγκαλυμμένης υπέρτασης σε υπερτασικούς υπό ή χωρίς αγωγή με βάση τοπροτεινόμενο από τις διεθνείς οδηγίες πρωτόκολλο μετρήσεων της ΑΠ στο σπίτι. Ηδιαγνωστική αξία της ΑΠ στο σπίτι ελέγχθηκε επιπλέον σε ομάδα ασθενών μεανθεκτική υπέρταση, ενώ αξιολογήθηκε με τις δύο τεχνικές η πρωινή ΑΠ, μια νέαπαράμετρος, με επιπρόσθετη προγνωστική αξία για τα καρδιαγγειακά συμβάματα.Μέθοδος: Συμπεριλήφθησαν 613 ασθενείς με αυξημένη ΑΠ (μέση ηλικία 53±12.4[SD] έτη, άρρενες 57%, χωρίς αντιυπερτασική αγωγή 59%). Αξιολογήθηκαν με ΑΠστο ιατρείο (3 επισκέψεις, τριπλές μετρήσεις/επίσκεψη), στο σπίτι (6 ημέρες, διπλέςπρωινές και απογευματινές μετρήσεις) και 24ωρη καταγραφή (20 min μεσοδιάστημα)εντός 6 εβδομάδων. Στην υποομάδα των ασθενών υπό ≥3 αντιυπερτασικά φάρμακαορίστηκε ως ανθεκτική υπέρταση ιατρείου η παθολογική ΑΠ ιατρείου και ως αληθήςανθεκτική υπέρταση, η αυξημένη 24ωρη ΑΠ ημέρας. Η διαγνωστική αξία της ΑΠ στοσπίτι αξιολογήθηκε συγκριτικά με την 24ωρη ΑΠ ημέρας (μέθοδος αναφοράς), ενώ ταδιαγνωστικά όρια της υπέρτασης ήταν ≥135/85 mmHg για την ΑΠ στο σπίτι και την24ωρη ημέρας και ≥140/90 mmHg για τις μετρήσεις στο ιατρείο. Η πρωινή AΠ στοσπίτι (6 ημέρες, διπλές πρωινές μετρήσεις) συγκρίθηκε με την πρωινή 24ωρη ΑΠ (3ορισμοί: μέσος όρος 1ης ώρας, 1ης και 2ης και 1ης, 2ης και 3ης ώρας μετά την έγερσηαπό το κρεβάτι). Ως ασθενείς με πρωινή υπέρταση ορίστηκαν αυτοί με πρωινή ΑΠ≥135/85 mmHg (στο σπίτι και/ή στην 24ωρη καταγραφή).Αποτελέσματα: Εμμένουσα υπέρταση διεγνώσθη στο 50% των ασθενών με 24ωρηΑΠ και με ΑΠ στο σπίτι (συμφωνία 89%, kappa 0.79), υπέρταση λευκής μπλούζαςστο 14% και 15% αντίστοιχα (συμφωνία 89%, kappa 0.56) και συγκαλυμμένηυπέρταση στο 16% και 15% (συμφωνία 88%, kappa 0.52). Η ευαισθησία, ηειδικότητα, η θετική και η αρνητική προγνωστική αξία της ΑΠ στο σπίτι για τηδιάγνωση της εμμένουσας υπέρτασης ήταν 90%, 89%, 89% και 90%, της υπέρτασης λευκής μπλούζας 61%, 94%, 64% και 94% και της συγκαλυμμένης υπέρτασης 60%,93%, 60% και 93%. Μεταξύ των 73 ασθενών υπό ≥3 αντιυπερτασικά, 44 (60%) είχανανθεκτική υπέρταση ιατρείου και 40 (55%) αληθή ανθεκτική υπέρταση. Ηδιαγνωστική συμφωνία των δυο τεχνικών ως προς την ανθεκτική υπέρταση ιατρείουήταν 82% (kappa 0.59), η ευαισθησία, ειδικότητα, θετική και αρνητική προγνωστικήαξία 93%, 63%, 81% και 83% και για την αληθή ανθεκτική υπέρταση 74% (kappa0.46) και 90%, 55%, 71% και 82% αντίστοιχα. Η πρωινή 24ωρη ΑΠ (2 πρώτες ώρεςαπό την έγερση) ήταν παρόμοια με την πρωινή ΑΠ στο σπίτι (μέση διαφορά0.4±14/1.2±8.6 mmHg, p=NS/<0.01, συστολική/διαστολική; συσχέτιση, r=0.60/0.68,p<0.001). Mέτρια διαγνωστική συμφωνία διαπιστώθηκε μεταξύ της πρωινής ΑΠ στοσπίτι και της 24ωρης (2 πρώτες ώρες) για τη διάγνωση ασθενών με πρωινήυπέρταση (συμφωνία 72/75 %, kappa 0.44/0.51, συστολική/διαστολική). Ανάλογαήταν τα αποτελέσματα όταν συγκρίθηκαν η πρωινή ΑΠ στο σπίτι με την 24ωρη ΑΠτης 1ης ή των 3 πρώτων ωρών από την πρωινή έγερση.Συμπεράσματα: Η ΑΠ στο σπίτι είναι αξιόπιστη εναλλακτική τεχνική της 24ωρης ΑΠγια τη διαγνωστική προσπέλαση της εμμένουσας υπέρτασης και των φαινόμενωνυπέρτασης λευκής μπλούζας και συγκαλυμμένης υπέρτασης. Η διαγνωστική της αξίαεπιβεβαιώθηκε και σε ασθενείς με ανθεκτική υπέρταση ιατρείου οπότε η χρήση τηςαποκτά ιδιαίτερο ενδιαφέρον και σε ασθενείς υπό πολλαπλή αντιυπερτασική αγωγήγια τον έλεγχο της επαρκούς ρύθμισης και τον αποκλεισμό της συγκαλυμμένηςυπέρτασης. Παρά τις μεθοδολογικές διαφορές, διαπιστώθηκε σημαντική συμφωνίαμεταξύ της ΑΠ στο σπίτι και 24ωρης ΑΠ στον προσδιορισμό της πρωινής πίεσης καιτη διάγνωση της πρωινής υπέρτασης

The optimal home blood pressure monitoring schedule based on the Didima outcome study

This study investigated the optimal schedule for home blood pressure (HBP) monitoring that has the greatest prognostic ability and provides the most reliable assessment of HBP. The Didima study assessed the value of HBP (duplicate morning and evening measurements, 3 days) in predicting cardiovascular events in the general population (662 adults, 8.2±0.2 years follow-up). Criteria for the optimal monitoring schedule were stabilization of mean HBP, its variability (standard deviation (s.d.)) and hazard ratios (HRs) of cardiovascular events per 1 mm Hg HBP increase. By averaging more readings (1-12), there was a progressive decline in average HBP and its s.d. and increase in HR, with most of these benefits achieved on the second day (8 readings) and little additional benefit obtained on the third day (12 readings). The first day gave higher and more unstable HBP values (higher s.d.) with less prognostic ability (lower HR). The first HBP readings per occasion gave higher values but with similar prognostic ability as the second readings taken 1 min later. There was little difference in average HBP between morning and evening readings with no prognostic superiority of morning readings. In conclusion, by averaging more readings the average HBP and its variability are reduced and the prognostic ability improved. Any aspect of HBP monitoring (first or second readings, morning or evening) has similar prognostic ability. The first day gives higher and unstable values with lower prognostic ability and should be better discarded. These data validate the HBP monitoring schedule proposed by the European Society of Hypertension. © 2010 Macmillan Publishers Limited All rights reserved

Do proton pump inhibitors attenuate the effect of aspirin on platelet aggregation? A randomized crossover study

It is common practice to coadminister proton pump inhibitors with aspirin to diminish the risk of upper gastrointestinal bleeding. This is the first study that investigated the potential impact of a proton pump inhibitor on aspirin effects on platelet aggregation. Twenty-four hypertensive subjects eligible for treatment with low-dose enteric-coated aspirin (LDECA) for primary prevention of cardiovascular disease were randomized to receive 100 mg LDECA or 100 mg LDECA plus 30 mg lansoprazole for 4 weeks. Then, participants were crossed over to the alternative regimen for another 4 weeks. Salicylic, gastrin, and pepsinogen I blood level counting were used to ensure adherence to treatment. Platelet aggregation was evaluated by light transmittance aggregometry and PFA100. The LDECA administration reduced arachidonic acid (P &lt; 0.001), collagen (P &lt; 0.01), and epinephrine (P &lt; 0.001) tests. These changes paralleled an increase in collagen/epinephrine duration (P &lt; 0.001) but not in collagen/ adenosine diphosphate duration and platelet count. No significant difference was found in any of these platelets&apos; function tests with LDECA alone versus LDECA plus lansoprazole. A significant increase in salicylic levels was observed in patients on LDECA as well as in those on LDECA plus lansoprazole, whereas gastrin and pepsinogen I levels were increased only when lansoprazole was added. These data suggest that the concomitant use of the lansoprazole at 30-mg daily does not influence the long-term effect of LDECA on platelet aggregation. Furthermore, they might imply that an interaction of LDECA with other proton pump inhibitors on platelet aggregation is unlikely. Copyright © 2009 by Lippincott Williams &amp; Wilkins

Albuminuria in Association with Cognitive Function and Dementia: A Systematic Review and Meta-Analysis

Objectives: Cerebral microvascular disease is considered to contribute to cognitive dysfunction. We opted to explore whether albuminuria, a marker of systemic microangiopathy, is associated with cognitive impairment, dementia, and cognitive function. Design: Systematic review; independent reviewers screened 2359 articles, derived through the search strategy, for identification of observational studies quantifying an association of albuminuria with the outcomes of interest, abstracted data on study characteristics and results and evaluated studies on quality using the Newcastle-Ottawa scale. Setting: Community. Participants: Adults. Mesurements: Cognitive impairment and dementia, defined by validated neuropsychological tests or clinical guidelines, respectively, and cognitive function, assessed by validated instruments. Results: Thirty-two eligible studies were identified. Albuminuria was associated with cognitive impairment (Odds Ratio (OR): 1.35, 95% Confidence Interval (CI): 1.19–1.53; 7,852 cases), dementia (OR: 1.35, 95% CI: 1.10–1.65; 5,758 cases), clinical Alzheimer&apos;s disease (OR: 1.37, 95% CI: 1.11–1.69; 629 cases) and vascular dementia (OR: 1.96, 95% CI: 1.16–3.31; 186 cases); the effect remained significant among longitudinal, population-based and high quality studies. Time-to-event analysis on prospective studies of non-demented at baseline individuals also showed a significant association with incident dementia (Risk Ratio: 1.52, 95% CI: 1.16–1.99; 971 cases). Worse global cognitive performance (Hedge&apos;s g: −0.13, 95% CI: −0.18, −0.09; 68,348 subjects) and accelerated cognitive decline (g: −0.20, 95% CI: −0.34, −0.07; 31,792 subjects) were noted among subjects with albuminuria, who also scored lower in executive function, processing speed, verbal fluency, and verbal memory. Conclusions: Albuminuria was independently associated with cognitive impairment, dementia and cognitive decline. The stronger effects for vascular dementia and cognitive performance in domains primarily affected by microvascular disease support that the association could be mediated by shared microvascular pathology in the kidney and the brain. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Societ

Long-term reproducibility of home vs. office blood pressure in children and adolescents: the Arsakeion school study

This study compared the long-term reproducibility of home blood pressure (BP) in comparison with office BP in children and adolescents. Forty-eight subjects (27 boys, mean age 11.3 +/- 3.1 (s.d.) years) recruited from the Arsakeion school study because of elevated office and/or home BP were assessed with office (1 visit, mercury sphygmomanometer) and home BP measurements (3 days, electronic devices) in two assessments 17 +/- 4.9 months apart (range 10-26 months). Home and office BP were compared on the basis of the following criteria: (a) s.d. of mean BP; (b) s.d. of differences; (c) variation coefficient (CV); (d) concordance correlation coefficient (CCC); (e) test-retest correlations; (f) correlation with ambulatory BP. (a) The s.d. of mean home BP was lower than that of office BP in both the initial (home BP 9.1/7.1 mm Hg, systolic/diastolic; office BP 13.1/8.0 mm Hg) and the second assessment (9.2/6.0 and 14.9/11.5 respectively). (b) The s.d. of differences was lower for home BP (8.3/6.5 mm Hg, systolic/diastolic) than for office BP (13.9/10.7 mm Hg). (c) The CV of home BP (5.3/6.6, systolic/diastolic) was lower than that of office BP (8.2/10.9). (d) The CCC of home BP (0.54/0.50, systolic/diastolic) was higher than that of office BP (0.51/0.41). (e) Test-retest correlations were closer for home BP (r=0.58/0.52, systolic/diastolic) than for office BP (0.51/0.44). (f) Awake ambulatory BP was more closely associated with home (r=0.77/0.40, systolic/diastolic) than with office BP (0.65/0.24). These data suggest that in children and adolescents the long-term reproducibility of home BP is superior to that of office measurements