: Ambulatory blood pressure (BP) monitoring is encouraged by all international guidelines for the management of hypertension. Home BP monitoring is the preferred method of the patients. Automated BP ...devices with remote data transmission have been repeatedly shown to be useful in improving hypertension control in the frame of clinical trials on telemedicine. Recently, new technologies have created a new context. Despite the important number of smartphone apps devoted to BP developed these last 10 years, only two BP monitoring apps refer to the European Society of Hypertension (ESH) Guidelines and have been published in peer-reviewed journals: Hy-Result and ESH CARE. At present, the absence of close collaboration between start-up engineers and healthcare professionals is a risk for patient safety. Therefore, health professionals must become actors in the so-called digital health revolution.
The purpose of this research was to review the literature on masked hypertension. Studies, reviews and editorials on masked hypertension were identified by PubMed, Pascal BioMed and Cochrane ...literature systematic searches. Then, we carried out a meta-analysis of the six cohort studies reporting quantitative data for masked hypertension prognosis. There is still no clear consensus definition of masked hypertension and the reproducibility of the phenomenon is unknown. Nevertheless, the prevalence of masked hypertension seems to lie between 8 and 20%, and can be up to 50% in treated hypertensive patients. Subjects with masked hypertension have a higher risk of cardiovascular accidents hazard ratios: 1.92 (1.51-2.44) than normotensive subjects. This is due to a possible failure to recognize and appropriately manage this particular form of hypertension, the frequent association with other risk factors and coexisting target organ damage. The remaining unresolved questions are as follows: is masked hypertension a clinical entity that requires identification and characterization or a statistical phenomenon linked to the variability of blood pressure measurements?; because screening of the entire population is not feasible, how to identify individuals with masked hypertension?; and, in the absence of randomized trial, how to treat masked hypertension?
Bartter syndrome type 3 is a clinically heterogeneous hereditary salt-losing tubulopathy caused by mutations of the chloride voltage-gated channel Kb gene (
), which encodes the ClC-Kb chloride ...channel involved in NaCl reabsorption in the renal tubule. To study phenotype/genotype correlations, we performed genetic analyses by direct sequencing and multiplex ligation-dependent probe amplification and retrospectively analyzed medical charts for 115 patients with
mutations. Functional analyses were performed in
oocytes for eight missense and two nonsense mutations. We detected 60 mutations, including 27 previously unreported mutations. Among patients, 29.5% had a phenotype of ante/neonatal Bartter syndrome (polyhydramnios or diagnosis in the first month of life), 44.5% had classic Bartter syndrome (diagnosis during childhood, hypercalciuria, and/or polyuria), and 26.0% had Gitelman-like syndrome (fortuitous discovery of hypokalemia with hypomagnesemia and/or hypocalciuria in childhood or adulthood). Nine of the ten mutations expressed
decreased or abolished chloride conductance. Severe (large deletions, frameshift, nonsense, and essential splicing) and missense mutations resulting in poor residual conductance were associated with younger age at diagnosis. Electrolyte supplements and indomethacin were used frequently to induce catch-up growth, with few adverse effects. After a median follow-up of 8 (range, 1-41) years in 77 patients, chronic renal failure was detected in 19 patients (25%): one required hemodialysis and four underwent renal transplant. In summary, we report a genotype/phenotype correlation for Bartter syndrome type 3: complete loss-of-function mutations associated with younger age at diagnosis, and CKD was observed in all phenotypes.
To compare two drug regimens to treat resistant hypertension.
In a prospective, randomized, open blinded endpoint study, 167 patients with mean baseline daytime ambulatory blood pressure 135 mmHg or ...more and/or 85 mmHg or more, despite 4 weeks' treatment with irbesartan 300 mg/day, hydrochlorothiazide 12.5 mg/day and amlodipine 5 mg/day, were randomized to sequential nephron blockade (group 1, n = 85) or sequential renin-angiotensin system blockade (group 2, n = 82). First, spironolactone 25 mg/day in group 1 or ramipril 5 mg/day in group 2 were added for 4 weeks. Treatment was increased at weeks 4, 8 or 10 if home blood pressure was 135 mmHg or more and/or 85 mmHg or more by sequentially administering furosemide 20 mg/day, furosemide 40 mg/day and amiloride 5 mg/day in group 1, or ramipril 10 mg/day, bisoprolol 5 mg/day and bisoprolol 10 mg/day in group 2. The primary endpoint was change in systolic daytime ambulatory blood pressure at week 12.
At week 12, the mean between-group difference in daytime ambulatory blood pressure was 10/4 mmHg (95% confidence interval: 7-14/2-7; P < 0.001/P = 0.0014) in favour of the group 1. The blood pressure goal (daytime ambulatory blood pressure <135/85 mmHg) was achieved in 58% in the group 1 and 20% in the group 2 (P < 0.0001). Discontinuation for drug-related adverse events was low (group 1, n = 7; group 2, n = 6).
In patients with resistant hypertension, sequential nephron blockade induces a large and well tolerated reduction in blood pressure via a progressive increase in sodium depletion, and is more effective than sequential renin-angiotensin system blockade.
...the large discrepancy between ambulatory and office blood pressure reduction in the Symplicity studies could be attributed to a less controlled office blood pressure measurement setting. The ...antihypertensive treatment was adapted on the results of 7 days of home blood pressure measurements before each visit.1 Home blood pressure measurements are known to have moderate diagnostic agreement with ambulatory blood pressure measurements.5 Moreover, even though patients were trained to adequately measure their blood pressure at home, home blood pressure measurements displayed larger standard deviation (systolic blood pressure: 21·4 mm Hg) than ambulatory blood pressure measurements (daytime systolic blood pressure: 17·9 mm Hg).1 Finally, home blood pressure levels were slightly, but not significantly, higher at baseline in the denervation group (154·7 SD 19·5/94·1 SD 14·2 mm Hg) than in the control group (153·3 SD 19·0/93·0 SD 10·5 mm Hg; Article1 table 1). ...as pointed out by Mircheva and colleagues, this was the first time that drug adherence had been reported in a renal denervation trial.
We assessed the influence of medication adherence on blood pressure (BP) control and target organ damage in a pre-specified analysis of a published trial comparing sequential nephron blockade (SNB) ...or sequential renin-angiotensin system blockade (SRASB) in patients with resistant hypertension.
Patients were randomized to SNB (n = 82) or SRASB (n = 82) and studied at baseline and after 12 weeks. BP was measured by ambulatory blood pressure monitoring. Carotid-femoral pulse wave velocity (PWV) was measured by applanation tonometry and left ventricular mass (LVM) by echocardiography. Low medication adherence was assessed through plasma irbesartan concentration below 20 ng/ml; urinary N-acetyl-seryl-aspartyl-lysyl-proline/creatinine ratio below 4 nmol/mmol; last medication intake before visit greater than 24 h and pill counting below 80% of theoretical intake. Medication adherence score (sum of items, max = 4) is defined as low (medication adherence score <2) or acceptable (medication adherence score ≥2).
Among 164 patients, 134 (81.7%) had acceptable medication adherence and 30 (18.3%) low medication adherence, with similar proportions in the SNB and SRASB arms. After 12 weeks, in patients with acceptable medication adherence, BP was more frequently controlled in those treated with SNB (64%), than SRASB (18%; P < 0.001). The difference in daytime SBP was -11.5 mmHg 95% confidence interval (CI) -15.4 to -7.5, P < 0.0001 in patients with acceptable medication adherence. In contrast, in patients with low medication adherence, the difference between groups was smaller and not significant (-9.4 mmHg, 95% CI -20.4 to 1.7, P = 0.09). Independently of BP changes, PWV and LVM decreased more in the SNB than in the SRASB arm when medication adherence was acceptable (-0.52 m/s, 95% CI -1.3 to -0.007, P = 0.047; and -24 g/m, 95% CI -36 to -12, P = 0.0003), whereas no significant changes were observed in low medication adherence patients.
Medication adherence contributes to BP-lowering and regression of target organ damage. The differential effects of SNB and SRASB is observed in patients with acceptable medication adherence, and not in patients with low medication adherence.
L’European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)/European Society of Hypertension (ESH) préconise les mesures hors centre de la pression artérielle, automesure ...tensionnelle ou mesure ambulatoire de la pression artérielle, chez les patients dialysés. La faisabilité des mesures hors centre de la pression artérielle en soins courants n’est toutefois pas connue. L’objectif de notre étude a été de la quantifier tant « a priori », c’est-à-dire le pourcentage d’hémodialysés à qui les mesures hors centre de la pression artérielle peuvent être proposées et qui l’acceptent, qu’« a posteriori », c’est-à-dire le pourcentage de mesures hors centre de la pression artérielle faites et valides. Un programme de mesures hors centre de la pression artérielle systématiques a été mis en place d’avril à octobre 2019 dans nos structures d’hémodialyse chronique. Il a été proposé à chaque hémodialysé de réaliser, après éducation, une automesure tensionnelle (Omron M3®), de 2 mesures, à 1 à 2minutes d’intervalle, le matin et le soir de 6jours sans dialyse (validité : ≥15mesures). En dehors des patients arythmiques, il a été proposé une mesure ambulatoire de la pression artérielle (Microlife WatchBP 03®) à tous les patients « non éligibles » à l’automesure tensionnelle (malvoyants, hémiplégiques, troubles neuropsychologiques, barrière de langage), sur 44heures séparant 2 séances d’hémodialyse. Ces mesures étaient réalisées toutes les 15min de 7 à 22heures et toutes les 30mn de 22 à 7heures (validité : >40mesures/jour et >14/nuit). Il s’agit d’une étude d’évaluation de pratiques recommandées en soins courants chez des hémodialysés >18ans, ayant donné leur consentement au recueil et l’analyse des données. Cent-vingt-neuf patients ont été traités par hémodialyse chronique dans nos structures pendant la campagne de mesures hors centre de la pression artérielle. Ces mesures n’ont pu être faites chez 21 patients (4 décédés, 2 greffés et 4 absents avant évaluation ; 7 arythmiques ; 3 refus et 1 polyhandicapé). Parmi les 108 patients (sex ratio 1,25 ; 69,3±13,5ans), 23 étaient non éligibles pour l’automesure tensionnelle (mal- ou non-voyants, troubles neuro- et/ou psychologiques, barrière de langage). En raison de 4 échecs d’automesure tensionnelle, la faisabilité de l’automesure tensionnelle (n = 81/129) est de 62,8 % (IC 95 % : 54,2–70,7). Parmi les 24 mesures ambulatoires de pression artérielle réalisées (23 chez les non-éligibles pour l’automesure tensionnelle et 1 chez un patient ayant un échec d’automesure tensionnelle), 19 étaient valides. La faisabilité des mesures hors centre de la pression artérielle (n=100/129) est de 77,5 % (IC 95 % : 69,6–83,4). La faisabilité des mesures hors centre de la pression artérielle chez les hémodialysés est bonne, rendant l’application des recommandations envisageable.
The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)/European Society of Hypertension (ESH) recommends out-of-center blood pressure measurements, self-blood pressure measurement or ambulatory blood pressure measurement in dialysis patients. However, the feasibility of out-of-center blood pressure measurements in routine care is not known. The objective of our study was to quantify it as “a priori” i.e. the percentage of hemodialysis to whom out-of-center blood pressure measurements can be proposed and who accept it, as “a posteriori”, i.e. the percentage of out-of-center blood pressure measurements made and valid. A systematic out-of-center blood pressure measurements program was implemented from April to October 2019 in our chronic hemodialysis structures. It was proposed to each dialysis patient to carry out after education, an self-blood pressure measurement (Omron M3®), from 2 measurements, to 1 to 2minutes interval, mornings and evenings of 6days without dialysis (validity: 15 measures). Apart from arrhythmic patients, to all patients “not eligible” for self-blood pressure measurement (visually impaired, hemiplegic, neuropsychological disorders, language barrier), a 44-hour ambulatory blood pressure measurement (Microlife WatchBP 03®) was proposed separating 2 hemodialysis sessions; measures every 15minutes from 7 a.m. to 10 p.m. and 30minutes from 10 p.m. to 7 a.m. (validity: 40 measurements/day and 14/night). This is a study evaluating practices recommended for routine care in 18-year-old hemodialysis, having given their consent to the collection and analysis of the data. One hundred twenty nine patients were treated with chronic hemodialysis in our structures during the out-of-center blood pressure measurements campaign. Out-of-center blood pressure measurements could not be done in 21 patients (4 deceased, 2 transplanted and 4 absent before evaluation; 7 arrhythmics; 3 refusals and 1 multiple-disabled). Of these 108 patients (sex ratio 1.25; 69.3±13.5 years), 23 were ineligible for self-blood pressure measurement (visually impaired, neuro- and/or psychological disorders, language barrier). Due to 4 self-blood pressure measurement failures, the feasibility of the self-blood pressure measurement (n=81/129) is 62.8 % (CI95% 54.2–70.7). Of the 24 ambulatory blood pressure measurements performed (23 among those not eligible for self-blood pressure measurement and 1 failure of self-blood pressure measurement), 19 were valid. The “a posteriori” feasibility of out-of-center blood pressure measurements (n=100/129) is 77.5 % (CI95% 69.6–83.4). The feasibility of out-of-center blood pressure measurements in hemodialysis patients is good, making the application of the recommendations possible.
The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)/European Society of Hypertension (ESH) recommends out-of-center blood pressure measurements, self-blood pressure ...measurement or ambulatory blood pressure measurement in dialysis patients. However, the feasibility of out-of-center blood pressure measurements in routine care is not known. The objective of our study was to quantify it as "a priori" i.e. the percentage of hemodialysis to whom out-of-center blood pressure measurements can be proposed and who accept it, as "a posteriori", i.e. the percentage of out-of-center blood pressure measurements made and valid. A systematic out-of-center blood pressure measurements program was implemented from April to October 2019 in our chronic hemodialysis structures. It was proposed to each dialysis patient to carry out after education, an self-blood pressure measurement (Omron M3®), from 2 measurements, to 1 to 2minutes interval, mornings and evenings of 6days without dialysis (validity: 15 measures). Apart from arrhythmic patients, to all patients "not eligible" for self-blood pressure measurement (visually impaired, hemiplegic, neuropsychological disorders, language barrier), a 44-hour ambulatory blood pressure measurement (Microlife WatchBP 03®) was proposed separating 2 hemodialysis sessions; measures every 15minutes from 7 a.m. to 10 p.m. and 30minutes from 10 p.m. to 7 a.m. (validity: 40 measurements/day and 14/night). This is a study evaluating practices recommended for routine care in 18-year-old hemodialysis, having given their consent to the collection and analysis of the data. One hundred twenty nine patients were treated with chronic hemodialysis in our structures during the out-of-center blood pressure measurements campaign. Out-of-center blood pressure measurements could not be done in 21 patients (4 deceased, 2 transplanted and 4 absent before evaluation; 7 arrhythmics; 3 refusals and 1 multiple-disabled). Of these 108 patients (sex ratio 1.25; 69.3±13.5 years), 23 were ineligible for self-blood pressure measurement (visually impaired, neuro- and/or psychological disorders, language barrier). Due to 4 self-blood pressure measurement failures, the feasibility of the self-blood pressure measurement (n=81/129) is 62.8 % (CI95% 54.2-70.7). Of the 24 ambulatory blood pressure measurements performed (23 among those not eligible for self-blood pressure measurement and 1 failure of self-blood pressure measurement), 19 were valid. The "a posteriori" feasibility of out-of-center blood pressure measurements (n=100/129) is 77.5 % (CI95% 69.6-83.4). The feasibility of out-of-center blood pressure measurements in hemodialysis patients is good, making the application of the recommendations possible.
The development of mobile telephones has made it possible to design blood pressure (BP) monitors with data transmission via cellular lines, contributing to the emergence of "e-health". Today, the ...direct-to-consumer marketing of devices create a new context allowing an algorithmic processing of information for remote decision-making either by the patient or by a healthcare professional. The home BP telemonitoring (HBPT) is the remote transmission of BP values, measured at home and transmitted to the doctor's office or hospital, by means of telehealth strategies. In this context, randomized controlled trials (RCTs) studies have demonstrated HBPT ability in improving patients' compliance and adherence to treatment and in accomplishing better hypertension control rates. The level of evidence for the drop in BP is "moderate" and the place of HBPT is not clearly established in current practice. Digital interventions have the potential to support patient in self-management. This approach presupposes the prior acquisition of skills, the level of which must be adapted to the level of health literacy of each patient. Few of medical applications (mobile apps or web-apps) for hypertension can be regarded as accurate and safe for clinical use and to date, we do not have high quality evidence to determine the overall effect of the use smartphone apps on BP control.
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