Because of poor patient compliance and clinical inertia, hypertension control rates remain poor. Home blood-pressure measurements (HBPM) improve compliance of patients and achievement of blood ...pressure (BP) targets. However, few studies have evaluated self-BP management by patients.
In a multicenter, prospective, single-group, open-label pilot study of 111 patients whose hypertension was uncontrolled despite monotherapy, we studied satisfaction with, and feasibility of, HBPM and self-titration of antihypertensive treatment using telemedicine for compliance, efficacy, and safety. After education (protocol, action plan, and use of the HBPM device), patients performed a sequence of HBPM every 2 weeks for 8 weeks. Following a stepwise approach, treatment was increased by the patient at weeks 4 and 6 if average HBPM values exceeded predefined limits. For each titration, the patient informed the Core Center by telemedicine, but BP values were transferred automatically.
Overall, 80% of patients were satisfied (58%) or very satisfied (23%) with the program (95% confidence interval, 73% to 87%). Regarding compliance, 78% of patients fully complied with self-measurement, and just over 71% titrated their treatment adequately. Physicians were satisfied (52%) or very satisfied (22%) with the program. Between the first and final visits (at week 8), office systolic/diastolic BP (mean +/- SD) decreased significantly from 151 +/- 9/91 +/- 6 to 143 +/- 13/84 +/- 11 mmHg. During the trial, HBPM (mean +/- SD) decreased significantly from 149 +/- 13/86 +/- 12 to 138 +/- 16/81 +/- 10 mmHg. No significant safety issues were reported.
This innovative approach to the management of hypertension, combining self-measurement and self-titration, is feasible, well-accepted by both patients and physicians, and safe.
The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure (BP) lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for ...resistant hypertension at 6 months. We report here the effect of denervation on 24-hour BP and its variability and look for parameters that predicted the BP response. Patients with resistant hypertension were randomly assigned to denervation plus stepped-care treatment or treatment alone (control). Average and standard deviation of 24-hour, daytime, and nighttime BP and the smoothness index were calculated on recordings performed at randomization and 6 months. Responders were defined as a 6-month 24-hour systolic BP reduction ≥20 mm Hg. Analyses were performed on the per-protocol population. The significantly greater BP reduction in the denervation group was associated with a higher smoothness index (
=0.02). Variability of 24-hour, daytime, and nighttime BP did not change significantly from baseline to 6 months in both groups. The number of responders was greater in the denervation (20/44, 44.5%) than in the control group (11/53, 20.8%;
=0.01). In the discriminant analysis, baseline average nighttime systolic BP and standard deviation were significant predictors of the systolic BP response in the denervation group only, allowing adequate responder classification of 70% of the patients. Our results show that denervation lowers ambulatory BP homogeneously over 24 hours in patients with resistant hypertension and suggest that nighttime systolic BP and variability are predictors of the BP response to denervation.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT01570777.
Hy-Result is a validated system designed to help patients complying with the home blood pressure monitoring (HBPM) protocol and understanding their blood pressure (BP) readings. It is available as a ...standalone web application or within a wireless BP monitor app.
The aim of the study was to explore patients' experience with Hy-Result.
Online survey completed by 512 users of the Hy-Result web application or monitor app, and three focus groups with 24 hypertensive patients who monitor their BP at home and use the Hy-Result web application to record their data. We assessed the experience of patients with the functionalities and medical content of Hy-Result, their feelings and expectations, and the impact of Hy-Result on the physician-patient relationship.
(1) Functionalities: Over 90% of survey respondents and all focus group participants found Hy-Result easy to use. The main drawback of the web application is the need to manually enter all BP values at once. (2) Medical content: Hy-Result offers information on arterial hypertension and HBPM that most patients found useful. Users found that Hy-Result triggers appropriate reactions to BP readings, including adequately timed general practitioner visits. (3) Feelings and expectations: Over 90% of survey respondents trust Hy-Result and focus group participants understood that text messages are suggestions, not diagnoses. Hy-Result did not cause anxiety or excessive BP measurements. (4) Physician-patient relationship: Three-quarter of survey respondents agreed that Hy-Result may help when talking with their doctor about their BP values but only one-third of those have shown the report to their physician. For focus group participants, using Hy-Result should ideally be a physician prescription. They were aware that Hy-Result does not replace clinical judgment and that physicians still have a decisive role in BP management.
Most of the users described Hy-Result as an easy-to-use and useful tool. Patients are willing to use it on physician request.
The participation of vasopressin in the mechanisms of resistant hypertension is unclear. We compared plasma copeptin concentration, a surrogate marker for vasopressin secretion, between patients with ...resistant hypertension and those with controlled blood pressure (CBP), in a post hoc analysis of the Prise en charge de l'Hypertension Artérielle RESistante au traitement trial.
After 4-week treatment with irbesartan 300 mg/day, hydrochlorothiazide 12.5 mg/day, and amlodipine 5 mg/day (baseline), 166 patients were classified as having resistant hypertension (n = 140) or CBP (n = 26) by ambulatory BP monitoring. Patients with resistant hypertension were then randomized for 12 weeks of sequential nephron blockade (n = 74) or sequential renin-angiotensin system blockade (n = 66). Plasma copeptin concentration was measured at baseline and week 12 by immunoassay.
Baseline plasma copeptin concentration was positively associated with male sex, plasma osmolality, BP, and negatively with glomerular filtration rate. It was higher in the resistant hypertension than in the CBP group geometric mean 5.7 (confidence interval 95% 5.1-6.4) vs. 2.9 (2.3-3.9) fmol/ml, adjusted P < 0.0001). The relationship between plasma copeptin concentration and urinary osmolality was similar in the two groups. At 12 weeks, plasma copeptin concentration in patients whose BP was controlled by sequential nephron blockade or sequential renin-angiotensin system blockade 6.8 (5.6-8.2) and 4.3 (3.0-5.9) fmol/ml, respectively) remained significantly higher than in patients with CBP at baseline (P < 0.0001 vs. both).
In patients with resistant hypertension, plasma copeptin concentrations were approximately two-fold higher than those of patients with CBP, after adjustment for plasma osmolality. This difference was not accounted for by renal resistance to vasopressin, suggesting a primary reset of osmostat.
We report the results of an echocardiographic substudy carried out in a trial comparing the effects of two different treatment strategies - mineralocorticoid receptor blockade (MRB) and dual ...renin-angiotensin system blockade (RASB) - in patients with resistant hypertension. Both strategies reduce left ventricular mass index (LVMI), but they have not been compared in patients with resistant hypertension.
After 4-week treatment with 300 mg irbesartan + 12.5 mg hydrochorothiazide + 5 mg amlodipine, 86 patients with resistant hypertension were randomized to the add-on 25 mg spironolactone (MRB group, n = 46) or 5 mg ramipril (RASB group, n = 40) groups for 12 weeks. Treatment intensity was increased at week 4, 8 or 10 if home blood pressure (BP) was equal to or above 135/85 mmHg, by sequentially adding 20-40 mg furosemide and 5 mg amiloride (MRB group), or 10 mg ramipril and 5-10 mg bisoprolol (RASB group). Transthoracic echography was performed at baseline and week 12.
Daytime ambulatory BP decreased by 19 ± 12/11 ± 8 mmHg in the MRB group and by 8 ± 13/7 ± 7 mmHg in the RASB group (P = 0.0003/0.03). LVMI decreased by 8.2 ± 18.9 g/m in the MRB group, whereas it increased by 1.8 ± 19.1 g/m in the RASB group (P = 0.03). The decreases in posterior wall thickness, left ventricular (LV) end-systolic diameter, E/e' ratio and left atrial area were significantly greater with MRB than with RASB. The difference between groups remained significant after adjustment for the decrease in ambulatory BP.
In patients with resistant hypertension, MRB-based treatment decreased both BP and LVMI more efficiently than a strategy based on dual RASB.
Fibrinogen A α-chain amyloidosis (AFib amyloidosis) is a form of amyloidosis resulting from mutations in the fibrinogen A α-chain gene (FGA), causing progressive kidney disease leading to kidney ...failure. Treatment may include kidney transplantation (KT) or liver-kidney transplantation (LKT), but it is not clear what factors should guide this decision. The aim of this study was to characterize the natural history and long-term outcomes of this disease, with and without organ transplantation, among patients with AFib amyloidosis and various FGA variants.
Case series.
32 patients with AFib amyloidosis diagnosed by genetic testing in France between 1983 and 2014, with a median follow-up of 93 (range, 4-192) months, were included.
Median age at diagnosis was 51.5 (range, 12-77) years. Clinical presentation consisted of proteinuria (93%), hypertension (83%), and kidney failure (68%). Manifestations of kidney disease appeared on average at age 57 (range, 36-77) years in patients with the E526V variant, at age 45 (range, 12-59) years in those with the R554L variant (P<0.001), and at age 24.5 (range, 12-31) years in those with frameshift variants (P<0.001). KT was performed in 15 patients and LKT was performed in 4. In KT patients with the E526V variant, recurrence of AFib amyloidosis in the kidney graft was less common than with a non-E526V (R554L or frameshift) variant (22% vs 83%; P=0.03) and led to graft loss less frequently (33% vs 100%). Amyloid recurrence was not observed in patients after LKT.
Analyses were based on clinically available historical data. Small number of patients with non-E526V and frameshift variants.
Our study suggests phenotypic variability in the natural history of AFib amyloidosis, depending on the FGA mutation type. KT appears to be a viable option for patients with the most common E526V variant, whereas LKT may be a preferred option for patients with frameshift variants.
Because of poor patient compliance and clinical inertia, hypertension control rates remain poor. Home blood-pressure measurements (HBPM) improve compliance of patients and achievement of blood ...pressure (BP) targets. However, few studies have evaluated self-BP management by patients.
In a multicenter, prospective, single-group, open-label pilot study of 111 patients whose hypertension was uncontrolled despite monotherapy, we studied satisfaction with, and feasibility of, HBPM and self-titration of antihypertensive treatment using telemedicine for compliance, efficacy, and safety. After education (protocol, action plan, and use of the HBPM device), patients performed a sequence of HBPM every 2 weeks for 8 weeks. Following a stepwise approach, treatment was increased by the patient at weeks 4 and 6 if average HBPM values exceeded predefined limits. For each titration, the patient informed the Core Center by telemedicine, but BP values were transferred automatically.
Overall, 80% of patients were satisfied (58%) or very satisfied (23%) with the program (95% confidence interval, 73% to 87%). Regarding compliance, 78% of patients fully complied with self-measurement, and just over 71% titrated their treatment adequately. Physicians were satisfied (52%) or very satisfied (22%) with the program. Between the first and final visits (at week 8), office systolic/diastolic BP (mean ± SD) decreased significantly from 151 ± 9/91 ± 6 to 143 ± 13/84 ± 11 mmHg. During the trial, HBPM (mean ± SD) decreased significantly from 149 ± 13/86 ± 12 to 138 ± 16/81 ± 10 mmHg. No significant safety issues were reported.
This innovative approach to the management of hypertension, combining self-measurement and self-titration, is feasible, well-accepted by both patients and physicians, and safe.
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