There is a persistent need for the development of new antihypertensive drugs, because the control of blood pressure is still not achievable in a significant proportion of hypertensive patients. Since ...the approval in 2007 of aliskiren, no other new antihypertensive based on new mechanism(s) of action have been approved. In fact, the development of promising novel drugs has been stopped for safety, efficacy or marketing reasons. Despite these difficulties, the pipeline is not dry and different new antihypertensive strategies targeting the renin-angiotensin-aldosterone pathway, are in clinical development stage. The dual angiotensin II receptor-neprilysin inhibitor LCZ696, a single molecule synthetized by cocrystallisation of valsartan and the neprilysin inhibitor prodrug AHU377 is in development for resistant hypertension and for heart failure. Daglutril is a dual neprylisin-endothelin converting enzyme inhibitor which was shown to decrease BP in patients with type 2 diabetic nephropathy. Aldosterone synthase inhibitors and the third and fourth generation non-steroidal dihydropyridine based mineralocorticoid receptors blockers are new ways to target the multiple noxious effects of aldosterone in the kidney, vessels and heart. Centrally acting aminopeptidase A inhibitors block brain angiotensin III formation, one of the main effector peptides of the brain renin angiotensin system. However, a long time will be still necessary to evaluate extensively the efficacy and safety of these new approaches. In the mean time, using appropriate and personalized daily doses of available drugs, decreasing physician inertia, improving treatment adherence, improving access to healthcare and reducing treatment costs remain major objectives to reduce the incidence of resistant hypertension.
Sex differences in antihypertensive treatment have often been highlighted, but whether there is truly a difference or whether this difference is mediated by confounding factors has yet to be ...deciphered.
We performed a cross-sectional study on the first consultation in the Georges Pompidou Hospital Tertiary Hypertension Unit between July 2000 and June 2015 to explore sex differences in both patient and treatment characteristics over this period.
A total of 17 856 patients were included. We observed in both women and men an increase in blood pressure control over time despite having more comorbidities. In conjunction, there was an increasing number of treated patients and treatments per patient. The treatments previously selected by the referring physicians strongly differed by sex: women were more frequently treated with loop diuretics odds ratio (OR) = 1.2 (95% confidence interval (CI): 1.05-1.37), thiazide diuretics OR = 1.13 (95% CI: 1.03-1.23), aldosterone-receptor blockers OR = 1.41 (95% CI: 1.24-1.61), and beta blockers OR = 1.53 (95% CI: 1.41-1.66) but less frequently with angiotensin-converting enzyme inhibitors OR = 0.77 (95% CI: 0.70-0.84), angiotensin II-receptor blockers OR = 0.93 (95% CI: 0.86-1.0), and calcium channel blockers OR = 0.72 (95% CI: 0.67-0.78) than men after adjusting for various patient-related confounding factors.
Blood pressure control has greatly improved over the last 15 years in both men and women. Although the treatment choice remained strongly dependent on sex, this is not justified by a sex-related difference in cardiovascular benefit from antihypertensive treatment.
Context:
The role of vasopressin (AVP) in the pathophysiology of primary aldosteronism (PA) remains unclear.
Objectives:
The primary aim of this study was to investigate AVP secretion in PA by ...measuring the plasma concentration of copeptin (PCop), the C-terminal portion of provasopressin. The secondary aim was to assess renal sensitivity to AVP.
Design and Setting:
This was a cross-sectional study in a tertiary-care hospital.
Protocol:
We recruited 115 patients with PA, 48 patients with essential hypertension (EH), and 108 normotensive healthy subjects (HS). Blood was sampled for biochemical and hormonal evaluations in fasting condition after 1-h rest in supine position. Osmolality was determined in 24-h urine. PCop was determined by immunoassay.
Main Outcome Measure:
The main outcome measure was adjusted difference in PCop between groups.
Results:
After adjustment for sex, body mass index, systolic blood pressure, natremia, and kalemia, PCop was significantly higher in patients with PA than in HS (geometric mean ratio, 1.61; 95% confidence interval CI, 1.26–2.06; P < .0001) and patients with EH (1.40; 95% CI, 1.08–1.82; P = .0070) PCop was positively correlated with natremia (P = .0094). Urine osmolality was significantly lower in patients with PA than in HS (0.82; 95% CI, 0.74–0.92; P = .0002) and 24-h urinary output was significantly higher in patients with PA than in HS (1.32; 95% CI, 1.11–1.56; P = .0005). The relationship between urine osmolality and PCop was shifted downward in patients with PA but was similar in patients with EH and HS, indicating peripheral resistance to AVP.
Conclusion:
PCop increases in patients with PA in response to an increase in natremia and a renal resistance phenomenon, indicating that AVP release is chronically stimulated in PA.
La dysplasie fibromusculaire désigne un groupe de maladies non athéroscléreuses et non inflammatoires des artères de moyen calibre entraînant des sténoses segmentaires, et parfois des anévrysmes ...et/ou des dissections. L’atteinte des artères rénales est soit asymptomatique, soit révélée par une hypertension artérielle, rarement une complication aiguë (infarctus/hémorragie). L’imagerie en coupes ou par angiographie permet de différencier les dysplasies fibromusculaires multifocales (aspect en collier de perles) des dysplasies fibromusculaires focales (sténose tubulaire). Il convient d’évoquer plusieurs diagnostics différentiels, et de rechercher une atteinte des vaisseaux du cou. Il faut encourager le sevrage tabagique et discuter du bénéfice éventuel d’une revascularisation rénale. Les meilleures indications sont l’hypertension artérielle récente ou résistante, et l’atrophie rénale progressive. L’angioplastie sans endoprothèse est la technique de revascularisation de choix des formes purement sténosantes.
Fibromuscular dysplasia is non-atherosclerotic, non-inflammatory disease of the medium caliber arteries causing segmental stenosis, and sometimes aneurysm and/or dissection. Renal involvement is either asymptomatic or revealed by hypertension, rarely acute complications (renal infarction/hemorrhage). Cross-sectional imaging or angiography differentiates multifocal fibromuscular dysplasia (pearl necklace appearance) and focal fibromuscular dysplasia (tubular stenosis). Several differential diagnoses are to be mentioned. Carotid and vertebral involvement are possible. Smoking cessation must be encouraged. Selected patients benefit from renal revascularization. The best indications are recent or resistant hypertension, and progressive renal atrophy. Angioplasty without stent revascularization is the technique of choice in purely stenotic forms.
To evaluate a patient questionnaire (HY-QUEST) to be completed at home before consulting in a hypertension clinic for the first time.
HY-QUEST is a questionnaire translated into patient language of ...the items from a standardized computerized medical record used since 1975 and regularly updated. This questionnaire contains 97 closed and seven free-text questions designed to evaluate cardiovascular risk and possible secondary hypertension, and to guide therapeutic strategy. One hundred and thirty-three new patients were asked to complete it at home and to bring it with them to their first visit in the hypertension clinic. The primary end-point was completeness of the answers. Other end-points were legibility and correctness of the answers.
Questionnaires were available for 128 out of 133 patients (96%). More than 80% of the 97 closed questions were answered in 121 out of 128 questionnaires 94.6%; 95% confidence interval (CI) 90.7-98.5 and no question had a response rate less than 85%. The answers were legible in 85% of the closed questions and the concordance rate with the physician's assessment was 94%. Among the 101 treated patients, 72 (71.3%; 95% CI 62.5-80.1) were able to provide the correct names, doses and schedule of their antihypertensive treatments.
The HY-QUEST questionnaire can be completed by most patients with few missing or incorrect answers. It is well accepted by patients and provides useful information to orient the first consultation in a hypertension clinic. Whether the same approach is feasible and useful in primary care remains to be investigated.
To assess the causes and frequency of kidney infarction associated with hypertension, and the blood pressure and renal function outcomes.
We analyzed the records of patients with kidney infarction ...documented by angiography and referred to a hypertension unit.
Spontaneous kidney infarction was documented in 55 of 18,287 patients and was associated with renal artery disease in 41 cases. Twenty-five patients had a longstanding history of hypertension at referral, and 30 patients presented with acute hypertension. Patients with acute hypertension were more likely to report a history of lumbar pain and to develop malignant hypertension than patients with longstanding hypertension; they also had higher plasma renin concentrations. Data for long-term follow-up after referral were available for 36 patients, including 15 patients who underwent surgery or renal artery angioplasty. From referral to most recent follow-up, the blood pressure decreased from 176/111 to 143/89 mmHg in patients with longstanding hypertension, and from 183/111 to 127/80 mmHg in those with acute hypertension (P = 0.007/0.041 for between-group differences). Three patients with acute hypertension had normal blood pressure without treatment at follow-up. Patients with long-term follow-up displayed no change in the glomerular filtration rate.
Kidney infarction is a rare cause of hypertension, usually associated with renal artery lesions. In cases of kidney infarction with acute hypertension, the blood pressure outcome is favorable following intervention and/or medication, and hypertension may resolve spontaneously.
Hy-Result is the first software for self-interpretation of home blood pressure measurement results, taking into account both the recommended thresholds for normal values and patient characteristics. ...We compare the software-generated classification with the physician's evaluation.
The primary assessment criterion was whether algorithm classification of the blood pressure (BP) status concurred with the physician's advice (blinded to the software's results) following a consultation (n=195 patients). Secondary assessment was the reliability of text messages.
In the 58 untreated patients, the agreement between classification of the BP status generated by the software and the physician's classification was 87.9%. In the 137 treated patients, the agreement was 91.9%. The κ-test applied for all the patients was 0.81 (95% confidence interval: 0.73-0.89). After correction of errors identified in the algorithm during the study, agreement increased to 95.4% κ=0.9 (95% confidence interval: 0.84-0.97). For 100% of the patients with comorbidities (n=46), specific text messages were generated, indicating that a physician might recommend a target BP lower than 135/85 mmHg. Specific text messages were also generated for 100% of the patients for whom global cardiovascular risks markedly exceeded norms.
Classification by Hy-Result is at least as accurate as that of a specialist in current practice (http://www.hy-result.com).
Purpose
To classify the renal artery (RA) anatomy based on specific requirements for endovascular renal artery denervation (RDN) in patients with drug-resistant hypertension (RH).
Materials and ...Methods
The RA anatomy of 122 consecutive RH patients was evaluated by computed tomography angiography and classified as two types: A (main RA ≥20 mm in length and ≥4.0 mm in diameter) or B (main RA <20 mm in length or main RA <4.0 mm in diameter). The A type included three subtypes: A1 (without accessory RAs), A2 (with accessory RAs <3.0 mm in diameter), and A3 (with accessory RAs ≥3.0 mm in diameter. A1 and A2 types were eligible for RDN with the Simplicity Flex catheter. Type B included twi subtypes based on the main RA length and diameter. Patients were accordingly classified into three eligibility categories: complete (CE; both RAs were eligible), partial (PE; one eligible RA), and noneligibility (NE; no eligible RA).
Results
Bilateral A1 type was the most prevalent and was observed in 48.4 % of the patients followed by the A1/A2 type (18 %). CE, PE, and NE were observed in 69.7, 22.9, and 7.4 % of patients, respectively. The prevalence of accessory RAs was 41 %.
Conclusions
Of RH patients, 30.3 % were not eligible for bilateral RDN with the current Simplicity Flex catheter. This classification provides the basis for standardized reporting to allow for pooling of results of larger patient cohorts in the future.
Blood pressure is a major determinant of cardiovascular risk. Blood pressure target to reach with antihypertensive therapy, and the population to whom it should apply, remain debatted. Blood pressure ...goals established by scientific societies may be revised after the publication of the US multicenter SPRINT study results (Systolic Blood Pressure Intervention Trial) obtained in 2015. Analysis of the generalizability of the SPRINT results shows that they may not be directly applied to the french population which is at lower risk than the US population and would have major medical and economic implications.
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