Understanding of blood pressure by people with type 2 diabetes: a primary care focus group study.

Stewart J, Brown K, Kendrick D, Dyas J.

research fellow, Nottingham Primary Care Research Partnership, University of Nottingham, Nottingham.

BACKGROUND: For many people with type 2 diabetes most care is provided in primary care. While people with both diabetes and hypertension are at increased risk of complications, little is known about their understanding of blood pressure.AIM: To explore the understanding and beliefs about the importance of blood pressure held by people with type 2 diabetes.Design of study: Framework analysis of qualitative research using focus groups.SETTING: Thirty-two participants were recruited from four general practices and a religious meeting group in Nottingham. Discussions took place in five community centres providing familiar surroundings for participants.METHOD: In order to get views expressed fully, white, Asian, and African-Caribbean participants met in five separate groups. Facilitators were fluent in the appropriate language and one member of the research team was present at all focus groups.RESULTS: Some participants, including those with raised blood pressure, were not aware of the increased importance of achieving good blood pressure control. No participants mentioned the increased risk of eye or kidney disease as a result of the combination of diabetes and raised blood pressure. Participants' perceptions regarding the control of blood sugar and blood pressure were different: blood sugar control was seen as their responsibility but blood pressure control was seen as the responsibility of the doctor. There was scepticism regarding the diagnosis of raised blood pressure, of targets and the management of blood pressure. There was also scepticism about the advice and education about diabetes given in primary care.CONCLUSIONS: People with type 2 diabetes require more knowledge of the increased risks they have from raised blood pressure, although this alone is unlikely to improve blood-pressure control. Strategies to increase the degree of control over and responsibility taken for the control of blood pressure need development and may require the specific development of participatory and negotiating skills among people with type 2 diabetes. Increasing the participation of these people in their own care will require doctors and nurses to work in a different way.

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Influence of Elevated Renin Substrate on Angiotensin II and Arterial Blood Pressure in Conscious Mice.

Cholewa BC, Mattson DL.

Medical College of Wisconsin.

The present experiments were performed to determine the influence of intravenous administration of renin substrate on plasma angiotensin II and mean arterial blood pressure in conscious C57BL/6J mice. Mice with chronic indwelling femoral arterial and venous catheters were acutely or chronically administered intravenous doses of a synthetic peptide corresponding to the 14 amino acids on the N-terminal of angiotensinogen. A dose-dependent increase in arterial blood pressure was observed as the intravenous bolus dose of the renin substrate was increased from 0.18 to 180 nmol/kg with a maximal increase in pressure of 40+/-3 mmHg achieved following administration of the 18 nmol/kg bolus (n=11). Additional experiments demonstrated that a sustained intravenous infusion of the renin substrate led to a long-term increase in arterial blood pressure. The continuous infusion of renin substrate at 0.05 nmol/kg/min for three days did not alter arterial blood pressure from the control level of 119+/-5 mmHg (n=5); however, arterial blood pressure significantly increased to 129+/-6 mmHg with an infusion rate of 0.5 nmol/kg/min and further increased to 141+/-3 mmHg when the renin substrate infusion was increased to 5.0 nmol/kg/min. Finally, the infusion of renin substrate at 5.0 nmol/kg/min resulted in a significant increase in plasma angiotensin II from 34+/-6 in vehicle-infused mice to 288+/-109 pg/ml. These results demonstrate that modulation of the circulating level of angiotensinogen can alter plasma angiotensin II and arterial blood pressure in normal animals.

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Influence of short stature on the change in pulse pressure, systolic and diastolic blood pressure from age 36 to 53 years: an analysis using multilevel models.

Langenberg C, Hardy R, Breeze E, Kuh D, Wadsworth ME.

Department of Epidemiology and Public Health, University College London Medical School, 1-19 Torrington Place, London WC1E 6BT, UK; Department of Family and Preventive Medicine, University of California San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA.

BACKGROUND: Previous cross-sectional analyses of this cohort have shown that short height and leg length are associated with higher pulse pressure and systolic blood pressure in middle age. It is unclear how these adult measures of childhood growth influence the change in blood pressure as it increases with age. METHODS: Multilevel models were fitted to investigate associations between components of height and the change in blood pressure between 36, 43, and 53 years in a prospective national cohort of 1472 men and 1563 women followed-up since birth in 1946. RESULTS: Shorter height and leg length, but not trunk length, were associated with higher blood pressure, similarly in men and women. Longitudinal analyses showed that the effects of both height and leg length on pulse pressure and systolic blood pressure became significantly stronger with age. For example, the change in systolic blood pressure was found to be -0.021 mm Hg (95% confidence interval -0.029 to -0.013) per year lower for every centimetre increase in leg length (P </= 0.001). In other words, the increase in systolic blood pressure over a 10 year period of a participant whose legs were 10 centimetres shorter was 2.1 mm Hg higher (P </= 0.001), compared with a taller participant. Associations were independent of a number of potential confounders. CONCLUSIONS: These results support the hypothesis that short people may be more susceptible to the effects of ageing on the arterial tree. Childhood growth may contribute to the tracking of cardiovascular risk throughout life.

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Stress-induced increases in interleukin-6 and fibrinogen predict ambulatory blood pressure at 3-year follow-up.

Brydon L, Steptoe A.

The Psychobiology Group, Department of Epidemiology and Public Health, University College London, UK.

BACKGROUND: The biological mechanisms underlying the association between psychological stress and hypertension are poorly understood. Increased plasma concentrations of the inflammatory proteins interleukin-6 and fibrinogen are commonly reported both in hypertensive patients and in people subject to chronic psychological stress. Recent laboratory studies have also shown that acute psychological stress increases plasma interleukin-6 and fibrinogen concentrations in healthy individuals. OBJECTIVE: To investigate the relationship between stress-induced inflammatory responses and blood pressure using a longitudinal design. METHODS: Participants were 153 individuals from the Whitehall II cohort. Blood pressure, plasma interleukin-6 and fibrinogen were assessed in response to an acute laboratory stressor, and ambulatory blood pressure was monitored on a separate day. Three years later, a follow-up day of ambulatory blood pressure monitoring was carried out. RESULTS: Individual differences in systolic pressure, fibrinogen and interleukin-6 stress responses predicted ambulatory blood pressure at the 3-year follow-up. Larger increases in ambulatory systolic pressure over the 3-year period were predicted by larger acute fibrinogen and interleukin-6 stress responses, independently of previous ambulatory blood pressure, acute blood pressure stress responses, age, sex, body mass and smoking. CONCLUSION: Given the important roles of interleukin-6 and fibrinogen in hypertensive pathophysiology, these results indicate that psychological stress could promote hypertension through stimulating these inflammatory proteins.

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Nocturnal blood pressure decrease is associated with increased regional cerebral blood flow in patients with a history of ischemic stroke.

Fujiwara N, Osanai T, Baba Y, Okuguchi T, Metoki N, Maeda N, Konta Y, Okumura K.

aDepartment of Internal Medicine, Reimeikyo Rehabilitation Hospital, Ikarigaseki bSecond Department of Internal Medicine, Hirosaki University School of Medicine, Hirosaki, Japan.

BACKGROUND: It remains controversial whether there is a J-shaped relationship between blood pressure and recurrent stroke among patients with a recent history of ischemic stroke. OBJECTIVE: To investigate the relationship between regional cerebral blood flow (rCBF) and the dipping of nocturnal blood pressure in patients receiving antihypertensive treatment after ischemic stroke. METHODS AND RESULTS: Forty-seven patients with a previous history of ischemic stroke and 37 patients with a history of non-ischemic stroke underwent 24-h ambulatory blood pressure monitoring and rCBF measurement with single photon emission computed tomography. Of the 47 patients with ischemic stroke, 30 were diagnosed as having suffered atheromatous or embolic stroke, and 37 had an ischemic lesion in the territory of the carotid artery. Systolic and diastolic blood pressures during daytime and night-time were controlled at less than 140/90 mmHg by a low-salt diet or long-acting antihypertensive agents, or both. In patients with ischemic stroke, there were significant negative correlations between the percentage change in nocturnal blood pressure and rCBFs in the thalamus (r = -0.33, P = 0.02), putamen (r = -0.34, P = 0.02) and cerebral cortex (r = -0.31, P = 0.03). Multivariate analysis revealed that only the percentage change in nocturnal blood pressure was related to rCBF. There was a significant positive correlation between rCBFs in the thalamus and the cerebral cortex (r = 0.74, P < 0.05). In patients with non-ischemic stroke, there was no significant correlation between the percentage change in nocturnal blood pressure and rCBFs. CONCLUSIONS: These findings indicate that the decrease in nocturnal blood pressure is associated with the increase in rCBF in patients with a history of ischemic stroke in the territory of the carotid artery.

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[New guidelines for treatment of hypertension.]

[Article in German]

Haller H.

Abteilung Nephrologie, Zentrum Innere Medizin der Medizinischen Hochschulen Hannover, .

Treatment of high blood pressure is a central element in prevention of cardiovascular diseases. The new classification of hypertension takes into consideration the close association between blood pressure level and cardiovascular risk and designates blood pressure between 140/90 and 130/80 mmHg as high-normal so that blood pressure <140/90 mmHg should always be the goal. The targeted blood pressure levels are also defined by the extent of end-organ damage already present. The therapeutic objective in patients with diabetes mellitus is a blood pressure level of 130/80 mmHg and in patients with kidney disease and proteinuria 125/75 mmHg. The five substance groups of diuretics, beta-blockers, calcium antagonists, ACE inhibitors, and angiotensin receptor blockers are recommended for primary treatment. In addition to the antihypertensive properties, substance-specific effects of ACE inhibitors and angiotensin receptor blockers have been described. Primarily, instead of monotherapy low-dose combination therapy can also be judicious.

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Decline of renal function is associated with proteinuria and systolic blood pressure in the morning in diabetic nephropathy.

Suzuki H, Kanno Y, Nakamoto H, Okada H, Sugahara S.

Department of Nephrology, Saitama Medical School, Saitama, Japan. iromichi saitama-med.ac.jp

The aim of this study was to investigate a significance of increased proteinuria in the morning and the effects of antihypertensive treatment on proteinuria and arterial blood pressure in the progression of chronic renal insufficiency in type 2 diabetic patients with hypertension and nephropathy. In three 24-hr urine samples and blood pressure monitoring, separated into a night-and daytime and spot urine in the morning, variation in protein-creatinine ratio (g/g) and blood pressure were assessed in 24 (58 +/- 3 years old; M/F: 17/7) diabetic patients with hypertension and nephropathy. Furthermore, the effects of antihypertensive therapy of combinations of angiotensin converting enzyme (ACE) inhibitor, calcium antagonists, diuretics, and alpha1 blocker were evaluated in 3 years. Home blood pressure measurement was carried out every month and 24-hr urine was collected every 2 months. The baseline urine excretion of protein-creatinine ratio and blood pressure were (1.22 +/- 0.13 g/g creatinine: 154/96 +/- 6/5 mmHg) in daytime and (1.39 +/- 0.13: 168/88 +/- 15/7) in the morning. At the end of the study, significant associations among a decline of 24-hr creatinine clearance and both of the urine excretion of protein-creatinine ratio (r = 0.47, p < .01) and the levels of systolic blood pressure (r = 0.46, p < .01) and between the levels of systolic blood pressure and the urine excretion of protein-creatinine ratio in the morning (r = 0.57, p < .001) were demonstrated. However, there were no significant associations among other variables. Analysis of patients who had systolic blood pressure in the morning less than 140 mmHg revealed that 65% of these patients received doxazosin-averaged doses of 4.8 +/- 1.5 mg daily. The levels of both blood pressure and proteinuria-creatinine ratio in the morning mainly associate with progression of renal function in diabetic patients with hypertension and nephropathy.

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Muscle Fiber-Type Distribution as a Predictor of Blood Pressure. A 19-Year Follow-Up Study.

Hernelahti M, Tikkanen HO, Karjalainen J, Kujala UM.

Unit for Sports and Exercise Medicine, Institute of Clinical Medicine, University of Helsinki, Finland; Central Military Hospital, Helsinki, Finland; and the Department of Health Sciences, Faculty of Sport and Health Sciences, University of Jyvaskyla, Finland.

The known association between physical activity and low blood pressure may be influenced by inherited characteristics. Skeletal muscle consists of type I (slow-twitch) and type II (fast-twitch) muscle fibers, with proportions highly variable between individuals and mostly determined by genetic factors. A high percentage of type I fibers (type I%) has been associated with low blood pressure in cross-sectional studies. We investigated whether type I percentage predicts future blood pressure levels and explains part of the association between physical activity and blood pressure. At baseline, in 1984, muscle fiber-type distribution, physical activity, and body mass index (BMI) were determined in 64 healthy men (age, 32 to 58 years). At follow-up, in 2003, blood pressure, physical activity, and BMI were determined in these men. In subjects without antihypertensive medication (n=43), type I percentage accounted for 5%/18% of the variation in systolic/diastolic blood pressure. A high type I percentage predicted, independent of both baseline (in 1984) and follow-up (in 2003), physical activity, BMI, and low systolic and diastolic blood pressure. Adjusted for all baseline covariates, a 20-unit higher type I percentage predicted a 11.6-mm Hg lower systolic blood pressure (P=0.018) and a 5.0-mm Hg lower diastolic blood pressure (P=0.018). High levels of physical activity in 1984 predicted low diastolic blood pressure, but this association was lost when type I percentage was included into the model. A high proportion of type I fibers in skeletal muscle is an independent predictor of low blood pressure and explains part of the known association between high levels of physical activity and low blood pressure.

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