Relationship between blood pressure measurements recorded on patients' charts in family physicians' offices and subsequent 24 hour ambulatory blood pressure monitoring.

Godwin M, Delva D, Seguin R, Casson I, MacDonald S, Birtwhistle R, Lam M.

Centre for Studies in Primary Care and the Department of Family Medicine, Queen's University, 220 Bagot Street, Kingston, Ontario, Canada, K7L 5E9. godwinm post.queensu.ca

BACKGROUND: In most western countries 20% of adults have hypertension. Reports in the literature suggest that from 31 to 86% of treated patients are not at recommended target levels. However it is important to consider how we are determining whether targets are unmet and the degree to which they are unmet. Our underlying hypothesis is that white coat effect is partially responsible for the reported low rates of control of hypertension by primary care practitioners. METHODS: The study population consists of 1142 patients who are being assessed for enrollment in two community-based randomized controlled trials. Patients must have essential hypertension, be on antihypertensive medication, and must not have met their blood pressure targets. We are reporting on the proportion of patients who have not achieved target, and the degree to which they have not achieved their target. We also report on the mean daytime blood pressures on 24 hour ABPM and compare these to mean blood pressures found on the patients' charts. RESULTS: We identified 3284 patient charts of patients with hypertension. Of these, 1142 were determined to be "out of control" (did not achieve target) and 436 agreed to undergo 24 hour ABPM for final determination of eligibility. Overwhelmingly (95.8% of the time) it was the systolic blood pressure that was not under control. However, most of the patients who had not achieved target according to our criteria were within 10 mmHg of the recommended targets. Isolated systolic blood pressure was the best predictor of elevated mean daytime blood pressure on 24 hour ABPM. CONCLUSIONS: At least 35% of patients had not achieved target blood pressure levels and this is primarily due to lack of control of systolic blood pressure. The best predictor of continuing hypertension on 24 hour ABPM was the mean systolic blood pressure on the patients chart. However, only 69% of patients who were uncontrolled according blood pressures recorded in the chart were uncontrolled according to 24 hour ABPM criteria. This suggests that the white coat effect makes blood pressure measurements in the doctor's offices, at least as currently done, not sufficiently accurate for determining treatment endpoint.

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The evaluation of the changes in blood pressure and pulse rate of hypertensive patients during tooth extraction.

Gungormus M, Buyukkurt MC.

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk University, 25240 Erzurum, Turkey. gungormusm yahoo.com

The purpose of this investigation was to evaluate the changes in blood pressure and the pulse rate of hypertensive patients having dental extraction under a local anesthetic containing a vasopressor. The study included 64 patients (42 female and 22 male), 38 to 78 years of age. Twenty-six of the patients were normotensive, 38 were hypertensive patients. The hypertensive patients were identified as those patients who had histories of medically diagnosed high blood pressure and baseline recordings of blood pressures higher than 140/90 mm Hg. Articain HCl with 0.012 mg epinephrine hydrochloride, was used as the local anesthetic for all patients and one tooth was extracted from each patient. Blood pressure and pulse rate measurements were recorded immediately prior to anesthesia, just before extraction and 5 minutes after extraction. The data were analyzed by a two-way ANOVA with repeated measures. Analysis of the data indicated no statistically significant changes in the systolic and diastolic blood pressures and pulse rate for all interval measurements in both normotensive and hypertensive patients (P > 0.05). In this study, it was determined that there were no significant changes in the blood pressures and the pulse rate of hypertensive patients during surgical procedure, and one cartridge local anesthetic with articain HCl containing 0.012 mg pinephrine may be used safely in hypertensive patients with blood pressure equal or smaller than 154/99 mm Hg.

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High sodium intake strengthens the association between angiotensinogen T174M polymorphism and blood pressure levels among lean men and women: a community-based study.

Yamagishi K, Iso H, Tanigawa T, Cui R, Kudo M, Shimamoto T.

Department of Public Health Medicine, Institute of Community Medicine, University of Tsukuba, Tsukuba, Japan.

Evidence on the effect of salt intake on the interaction between angiotensinogen (AGT) T174M polymorphism and high blood pressure is sparse. We therefore conducted a large population-based cross-sectional study of 2,823 men and women aged 30-74 in a Japanese farming community to examine associations between AGT polymorphism and blood pressure levels stratified by age (30-64 and 65-74), body mass index (BMI; median), and salt intake (median) estimated by 24-h urine collection and dietary questionnaire. Our a priori hypothesis is that individuals, particularly younger and non-overweight individuals, with the 174M allele have elevated blood pressure levels in response to higher sodium intake, and thus the association between T174M polymorphism and blood pressure is more evident among individuals with higher sodium intake than those with lower sodium intake. There were no differences in systolic or diastolic blood pressure levels (SBP or DBP) between the TT and TM+MM genotype groups overall. However, the mean difference in DBP between the TM+MM and TT groups was +1.0 mmHg in subjects of younger age (p=0.06), +1.7 mmHg in non-overweight subjects (BMI<23.5 kg/m2, p=0.01), and +2.3 mmHg in younger and non-overweight subjects (p = 0.002). Furthermore, among younger and non-overweight subjects, blood pressure differences were larger for those with higher urinary sodium excretion (+3.1 mmHg, p = 0.03), those with a higher sodium/potassium excretion ratio (+4.1 mmHg, p=0.007), those with higher present sodium intake score (+3.0 mmHg, p=0.003), and those with higher past sodium intake score (+3.4 mmHg, p<0.001). In conclusion, AGT T174M polymorphism was associated with higher DBP levels in younger and non-overweight Japanese. This association was more evident among subjects with higher sodium intake.

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Stent-supported angioplasty of severe atherosclerotic renal artery stenosis preserves renal function and improves blood pressure control: long-term results from a prospective registry of 456 lesions.

Zeller T, Frank U, Muller C, Burgelin K, Sinn L, Horn B, Flugel PC, Schwarzwalder U, Roskamm H, Neumann FJ.

Department of Angiology, Bad Krozingen Heart Center, Sudring 15, D-79189 Bad Krozingen, Germany. thomas.zeller herzzentrum.de

PURPOSE: To report a prospective study evaluating the long-term impact of stent-supported angioplasty on renal function and blood pressure control. METHODS: In a 6-year period, 456 hemodynamically significant de novo renal artery stenoses > or =70% were treated in 340 consecutive hypertensive patients (223 men; mean age 66+/-10 years, range 44-84) with or without impaired renal function. Baseline data on serum creatinine (sCr), intrarenal resistance index, ambulatory 24-hour blood pressure monitoring, and documentation of the number and dose of antihypertensive drugs were compared to values obtained during follow-up. The primary endpoint was a 10% decrease in sCr; the glomerular filtration rate and changes in blood pressure control were additional outcome measures. RESULTS: During a mean follow-up of 34+/-20 months, sCr decreased significantly from 1.45+/-0.87 to 1.39+/-0.73 mg/dL (p=0.048). In 34% of the patients, sCr decreased >10%, 39% were unchanged, and 27% had an increase >10%. Glomerular filtration rate increased from 59+/-26 to 62+/-26 mL/min/1.73 m(2) (p=0.6). Systolic, diastolic, and mean blood pressure measurements significantly improved immediately after the intervention (132/72/93 versus 144/79/102 mmHg at baseline, p<0.0001) and remained improved during follow-up (p<0.0001). Blood pressure control was improved in 46%, unchanged in 43%, and deteriorated in 11%. Baseline sCr, bilateral intervention, percent diameter stenosis, and 3-vessel coronary disease were independent predictors of improved renal function during follow-up; the number of antihypertensive drugs taken before the intervention predicted improved blood pressure control. CONCLUSIONS: Stent-supported angioplasty of renal artery stenoses preserves renal function and improves blood pressure control in a broader spectrum of patients than previously thought.

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Blood pressure and alpha-vascular reactivity in hypertensive rats treated with amlodipine and dietary Ca.

Civantos B, Aleixandre A.

Departamento de Farmacologia, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain.

It has been suggested that the combination of dietary Ca and Ca2+ channel antagonists could have a synergic antihypertensive effect. In this study, 3-week-old male spontaneously hypertensive rats (SHR) were randomized into four groups of animals. Two of these groups were fed on a normal Ca diet (Ca 1%) and the other two groups were fed on a Ca-enriched diet (Ca 2.5%). One of the groups fed on each diet also received amlodipine (1 mg/kg/day) in their drinking water. Systolic and diastolic arterial blood pressure were measured weekly in the rats, from the 6th week of life until the 25th week of life, by the tail-cuff method, and we also calculated the corresponding pulse pressure values (systolic blood pressure-diastolic blood pressure). Determination of plasma Ca levels by colourimetric methods, and measurement in pithed rats of the pressor responses to the alpha-adrenoceptor agonists methoxamine and B-HT 920 (5-allyl-2-amino-5,6,7,8-tetrahydro-4H-thiazolo-(4,5-d)-acepin-dihydrochloride, talixepole) were also performed using 16- and 23-week-old animals from the different groups. The Ca-enriched diet decreased systolic and diastolic blood pressure in SHR. Almodipine also decreased systolic and diastolic blood pressure in SHR, and this drug intensified the antihypertensive effect of the Ca 2.5% diet in the SHR between weeks 13 and 18. Nevertheless, in the 19- to 25-week-old SHR amlodipine antagonized the effect of dietary Ca on arterial blood pressure. A decrease in the pulse pressure was seen only in the 15- to 20-week-old SHR which had been simultaneously treated with dietary Ca and amlodipine. All the treatments used increased calcaemia, and the highest plasma Ca levels were obtained in the animals which had received the combined treatment with Ca and amlodipine. The responses to methoxamine and to B-HT 920 in the pithed 16-week-old SHR were similar in the four groups of animals. The responses to these agonists in the pithed 23-week-old SHR fed on the Ca-enriched diet were smaller than the corresponding responses in 23-week-old SHR of the untreated group. By contrast, the responses to these agonists were slightly higher in the pithed 23-week-old SHR which were treated with amlodipine than in the pithed 23-week-old SHR in the untreated group. Moreover, amlodipine partially reversed the effect of dietary Ca on alpha-vascular reactivity. According to our results, it would seem inadvisable to use dietary Ca with a Ca2+ channel antagonist with the aim of controlling arterial blood pressure.

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The usefulness of glycosuria and the influence of maternal blood pressure in screening for gestational diabetes.

Buhling KJ, Elze L, Henrich W, Starr E, Stein U, Siebert G, Dudenhausen JW.

Clinic of Obstetrics, Charite Campus Virchow-Klinikum, Humboldt University, Augustenburger Platz 1, D-13353 Berlin, Germany. kai.beuhling charite.de

OBJECTIVE: Although gestational diabetes is among the most common diseases arising during pregnancy, glucose stix is the only screening test to date in Germany. Our goal was to evaluate the sensitivity of the glucose-stix for diabetes screening and the possible influence of other parameters. METHODS: 1001 patients who underwent the 50 g glucose screening test between June 1, 1997 and January 5, 2000 as part of prenatal care were asked to participate. In accordance with the guidelines of the American Diabetes Association, patients with a screening test result >/= 140 mg/dl underwent a oral glucose tolerance test (Carpenter/Coustan criteria). A urine sample was collected prior to the test. The glucose content of the urine was semiquantitatively analyzed using a test strip (Multistix 10 SG Bayer), Munich, Germany). Blood pressure was measured in 349 consecutive cases according to the criteria of the National Institute of Health. RESULTS: The overall frequency of gestational diabetes was 4.1% (37/912). 8.2% of the women presented with glycosuria (82/1001, 36 before screening, 46 based on the pregnancy medical records booklet). 30/82 (37%) of these patients had a pathological screening test (P = 0.029). 7.1% (52/729) of the healthy patients and 10.8% (4/37) of the gestational diabetics had glycosuria at least once. Therefore, the sensitivity of glycosuria is 10.8%, the positive predictive value is 6.6%. The systolic blood pressure was 116+/- 12 mmHg and the diastolic blood pressure 72 +/- 9 mmHg. Three of 349 (0.9%) patients were documented with preexisting hypertension, 14/349 (4.0%) patients with "pregnancy induced hypertension". Patients with glycosuria were both significantly more advanced in gestational age (34.4 +/- 2.8 versus 33.7 +/- 2.9, P = 0.673) and had higher diastolic blood pressure (79 +/- 9 versus 71 +/- 9, P = 0.005). The 50 g glucose screening test results showed only a tendency to differ (131 +/- 23 versus 127 +/- 24, P = 0.073). A multivariate analysis of these factors showed a significant influence of the diastolic blood pressure (P = 0.016) and the 50 g glucose screening test (P = 0.032), whereas the gestational week had no influence (P = 0.673). CONCLUSIONS: Urine glucose dip stick analysis is not useful in the detection of gestational diabetes because of its low sensitivity and negative predictive value. Our study suggests that glycosuria is not only dependent on the blood glucose level, but highly influenced by diastolic blood pressure. The results clearly underscore the need for standardized, routine testing of every pregnant woman.

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[Relatively poor regulation of blood pressure in patients with type-2 diabetes mellitus in the primary care setting and specialists' practice in the Netherlands]

[Article in Dutch]

van der Horst-Schrivers AN, Ubink-Veltmaat LJ, van der Horst IC, Bilo HJ, Lambert J.

Afd. Interne Geneeskunde, Isala Klinieken, Zwolle.

OBJECTIVE: To investigate the degree to which the goals for adequate blood-pressure control in patients with type-2 diabetes mellitus (DM) are met in Dutch specialists' practice and in the primary-care setting. DESIGN: Cross sectional. METHOD: Data were collected from all consecutive patients with DM type 2 visiting the outpatient clinic of two physicians specialised in diabetes care, in Zwolle, the Netherlands, in the period 1 November 1999-30 April 2000. The target value for blood pressure was < or = 150/85 mmHg. In addition, baseline data were collected on patients in the primary-care setting who participated in a transmural project in Zwolle in the period 1 February 1997-31 January 1998. In 1998, the target blood pressure in the primary-care setting was < or = 160/90 mmHg. Patients who met the goals for adequate blood-pressure control were compared with patients who did not. RESULTS: A total of 502 patients from specialists' practice and 1084 patients from the primary-care setting were included. The prevalence of hypertension in specialists' practice was 89% (n = 377); of these patients, 140 (37%) had a good regulation of their blood pressure. The patients who had an adequate blood-pressure control and those who did not were comparable. Both groups were prescribed an average of 2.2 kinds of antihypertensive agent per patient. The prevalence of hypertension in the primary care was 69% (n = 733). The goal for adequate blood-pressure control, i.e. a blood pressure of < or = 160/90 mmHg, was achieved in 44% (n = 324). In the primary-care setting, an average of 1.1 kinds of antihypertensive agent was prescribed, 1.6 in patients who achieved the target value and 0.8 in those who did not (p < 0.05). CONCLUSION: Regulation of blood pressure in patients with type 2 DM and hypertension was far from optimal: 37% of patients in specialists' practice and 44% of those in the primary-care setting achieved the target values.

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Ambient pollution and blood pressure in cardiac rehabilitation patients.

Zanobetti A, Canner MJ, Stone PH, Schwartz J, Sher D, Eagan-Bengston E, Gates KA, Hartley LH, Suh H, Gold DR.

Department of Environmental Health, Exposure Epidemiology and Risk Program, Harvard School of Public Health, 401 Park Dr, Landmark Center, Suite 415, PO Box 15698, Boston, Mass 02215, USA. azanobet hsph.harvard.edu

BACKGROUND: Multiple studies have demonstrated a consistent association between ambient particulate air pollution and increased risk of hospital admissions and deaths for cardiovascular causes. We investigated the associations between fine particulate pollution (PM2.5) and blood pressure during 631 repeated visits for cardiac rehabilitation in 62 Boston residents with cardiovascular disease. METHODS AND RESULTS: Blood pressure, cardiac risk factor, and exercise data were abstracted from records of rehabilitation visits between 1999 and 2001. We applied mixed-effect models, controlling for body mass index, age, gender, number of visits, hour of day, and weather variables. For an increase from the 10th to the 90th percentile in mean PM2.5 level during the 5 days before the visit (10.5 microg/m3), there was a 2.8-mm Hg (95% CI, 0.1 to 5.5) increase in resting systolic, a 2.7-mm Hg (95% CI, 1.2 to 4.3) increase in resting diastolic, and a 2.7-mm Hg (95% CI, 1.0 to 4.5) increase in resting mean arterial blood pressure. The mean PM2.5 level during the 2 preceding days (13.9 microg/m3) was associated with a 7.0-mm Hg (95% CI, 2.3 to 12.1) increase in diastolic and a 4.7-mm Hg (95% CI, 0.5 to 9.1) increase in mean arterial blood pressure during exercise in persons with resting heart rate > or =70 bpm, but it was not associated with an increase in blood pressure during exercise in persons with heart rate <70 bpm. CONCLUSIONS: In patients with preexisting cardiac disease, particle pollution may contribute to increased risk of cardiac morbidity and mortality through short-term increases in systemic arterial vascular narrowing, as manifested by increased peripheral blood pressure.

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