Impact of Endometriosis Surgery on In Vitro Fertilization/Intracytoplasmic Sperm Injection Outcomes: a Systematic Review and Meta-analysis.

Endometriosis-related infertility remains a therapeutic challenge. A burning issue in this field of research is determining whether pre-assisted reproductive technology (ART) surgery may be of some benefit in terms of reproductive outcomes. This systematic review and meta-analysis aimed at comparing ongoing pregnancy rates (OPR) and/or live birth rates (LBR) in patients who underwent endometriosis surgery before ART (IVF/ICSI) in comparison with patients who underwent first-line ART (IVF/ICSI). Searches were conducted from January 1990 to June 2021 on PubMed, Embase, and Cochrane Library using the following search terms: endometriosis, surgery, reproductive outcomes, and IVF/ICSI. The primary outcomes were OPR or LBR. A total of 19 studies were included in the meta-analysis. No statistically significant differences in LBR [0.91[0.63, 1.30]; I2 = 66%; n = 11], OPR [1.28[0.66, 2.49]; I2 = 60%; n = 3], and early pregnancy loss rate [0.88[0.62, 1.25]; I2 = 0%; n = 7] per cycle were found when comparing patients who underwent endometriosis surgery before IVF/ICSI and those who did not. After the exclusion of the studies with high risks of bias, the LBR per cycle was significantly reduced in the case of surgical treatment before IVF/ICSI [0.53[0.33, 0.86]; I2 = 30%; n = 4]. These data urge the clinician to carefully weigh the pros and cons before referring infertile patients with endometriosis to surgery before IVF, highlighting the key role of multidisciplinary referral centers.

[Factors associated with medication non-adherence in uncontrolled hypertensive males and females: ODACE study]. / Facteurs associés à la non-observance chez les hommes et chez les femmes hypertendus non contrôlés : étude ODACE.

OBJECTIVES: The aim of this study was (1) to measure adherence in males and females with uncontrolled hypertension, and (2) to identify factors associated with non-adherence to antihypertensive medication. PATIENTS AND METHODS: Each general practitioner (GP) should include the first two male and the first two female patients with uncontrolled treated hypertension. Adherence to antihypertensive treatment was estimated by the GP and using the French League Against High blood pressure (FLAH) self-administered questionnaire. A stepwise logistic regression analysis was used to identify factors associated with non-adherence on the FLAH scale, independently in males and in females. RESULTS: A total of 1630 males and 1612 females were included in the analysis. Adherence to treatment was significantly better in females or when estimated by the GP. Lack of motivation was the first factor associated with poor adherence in both sexes. Considering hypertension as a simple anomaly and not a disease that can lead to cardiac or cerebral disorders was the second common parameter in both sexes. Other common factors were: having monthly periods of financial difficulties in facing his/her needs and absence of regular screening for colon cancer. CONCLUSION: Adherence to treatment is better in uncontrolled hypertensive females. Poor adherence is mainly associated with non-clinical factors. The lack of motivation is the most important element.

Pharmacogenomics in cardiovascular clinical trials.

Genomics - having quickly emerged as the central discipline in basic science and biomedical research - is poised to take the center stage in clinical medicine as well over the next few decades. Although there is no specific regulatory guideline on the application of pharmacogenetics to drug development, some recommendations are already included in several published guidelines on drug development. The patients more likely to provide the most valuable information on the specific contribution of a given gene or its variant are those who fail to respond to a drug ('therapeutic failures') and those who develop toxicity to the drug. However, before drawing definite conclusions on subgroups following pharmacogenomic analyses, one must be aware of disease classification, data collection, and how much is known about the disease process. It seems reasonable to collect genomic DNA from all patients enrolled in clinical drug trials (along with appropriate consent to permit pharmacogenetic studies) for the purpose of post hoc analyses. One exception to post hoc genomic analysis is when patients with a specific genotype are excluded from randomization into a clinical trial. Physicians will need to understand the concept of genetic variability, its interactions with the environment (e.g. drug-drug or drug-disease interactions), and its implication for patient care.

[Comparison of central pulse pressure estimated from pulse wave propagation velocity and carotid pulse pressure measured by applantation tonometry]. / Comparaison de la pression pulsée centrale estimée à partir des vitesses de propagation de l'onde du pouls et de la pression pulsée carotidienne mesurée par tonométrie d'aplanation.

BACKGROUND: Pulse pressure (PP) corresponds to the difference between arterial systolic blood pressure and diastolic blood pressure. Central PP seems to be a stronger coronary risk marker than brachial PP. Central PP can be estimated by aortic PP measured non invasively by aplanation tonometry of the carotid artery. The aim of this study was to compare 2 methods of estimation of aortic PP: estimation from Pulse Wave Velocities (PWV) and by aplanation tonometry of the carotid artery. Estimation from PWV is based on the non uniform transmission of the PP i.e. the amplification of PP from the aorta to brachial artery, through arteries of increasing impedance. METHODS: One hundred and fifty one subjects were included, 111 hemodialysis patients and 40 subjects free of cardiovascular treatment or cardiovascular organ damage, recruited in a preventive medicine setting. Central PP was measured by aplanation tonometry of the carotid artery. The following formula was used for the relationship between PP and PWV in the two arterial segments considered for pulse wave travel (waterhammer formula): [formula: see text] Where measurement of brachial PP (PPBr) and PWV at aortic (PWVAo) and brachial (PWVBr) gives an estimation of aortic PP (PPAo estimated). Carotid-femoral PWV was used for PWVAo and carotid-radial PWV was used for PWVBr. The two methods were compared by t-test and according to Bland and Altman's method. RESULTS: In the hemodialysis group (73 males, 44 +/- 12 years old), brachial PP was 56 +/- 15 mm Hg and central PP as measured at the carotid level was 47 +/- 15 mmHg. In the healthy group (29 males, 46 +/- 11 years old), these values were 46 +/- 10 mmHg and 35 +/- 10 mmHg respectively. Compared to carotid artery aplanation tonometry, PPAo estimated was larger than central PP by 2.9 +/- 6.3 mmHg in hemodialysis patients and by 5.4 +/- 6.6 mmHg in the healthy group. The difference was significantly larger in healthy subjects than in hemodialysis patients (p = 0.031). CONCLUSION: The PWV estimated PP is larger than the central PP measured at the carotid level by aplanation tonometry. The difference is larger in cardiovascular event free subjects than in patients on hemodialysis.

[Green study: quality of blood pressure measurement by general practitioners]. / Green study: qualité de la mesure tensionnelle chez l'hypertendu en médecine générale.

BACKGROUND: Diagnosis and management of hypertension is based on blood pressure (BP), as measured by auscultatory method. However, the devices are rarely checked making the quality of the measures doubtful. OBJECTIVE: To compare BP measured according to the WHO recommendations using 2 different devices: the mercury or aneroid sphygmomanometer used by the physician and a SECURUS manometer that has been calibrated just before the implementation of the study. METHOD: This is a randomised study performed with 1,336 French general practitioners (GP). Each GP received a calibrated SECURUS before the start of the study and was asked to include 2 treated hypertensive patients and one newly diagnosed patient. BP was measured 3 times with each device at 2 different visits. The devices were used in a random order: the order, at the 1st visit, was always the same for all the patients for a given GP. At the second visit the order of the devices was reversed. Patients were classified as normal (BP < 140/90 mm Hg) or high BP with each device at each visit. RESULTS: 3,992 patients were included in the study (2,751 treated hypertensive patients). SECURUS BP measures were rounded up to 0 or 5 by 69% of the GPs and BPs with their own device by 77% of the GPs. A difference between the 2 devices > 5 mmHg was observed in nearly 10% of the GPs for SBP and 4% of the GPs for DBP. At the second visit, 13% of the treated hypertensive patients and 12% of the newly diagnosed patients and in whom no antihypertensive drug treatment has been introduced were not classified as having normal or high BP value in the same way by the 2 devices. CONCLUSIONS: This study confirms the results of a previous pilot study and emphasises the need of BP measurements respecting the guidelines in clinical practice, because of the possible impact on patient care and related costs.

[Self monitoring versus ambulatory blood pressure monitoring]. / Automesure versus mesure ambulatoire de la pression artérielle.

Blood pressure is a variable parameter for which the isolated determination cannot be considered as a characteristic of the subject. Therefore, the clinical measurement of blood pressure constitutes the method of reference but presents limits and causes of errors which pose a problem for its validity in evaluating the average blood pressure level in certain patients. In order to overcome the limits of occasional measurement, different methods of blood pressure measurement have been proposed. Among these methods, self monitoring of blood pressure by the patient and 24 hour ambulatory blood pressure monitoring (ABPM) are the most used. Each of these methods presents advantages and disadvantages, indications and limits of use. The information obtained by each of them is of a different nature: these methods are not substitutes but are complementary. Self monitoring and ABPM seem to evaluate the pressure load better than clinical monitoring and are better correlated to the organic effects of hypertension and thus the cardiovascular morbidity and mortality, ABPM in particular. However, it remains to be clarified whether the use of these methods in the evaluation of cardiovascular risk and the therapeutic management of the hypertensive can improve the long term cardiovascular prognosis.

[Quality of blood pressure measurement in the management of arterial hypertension. Pilot study]. / Qualité de la mesure de la PA dans la prise en charge de l'hypertension artérielle. Etude pilote.

UNLABELLED: In clinical practice, diagnosis and follow-up of hypertension is based on blood pressure (BP) as measured by auscultatory method. BP is usually measured using a stethoscope to auscultate the Korotkoff sounds and mercury or an aneroid sphygmomanometer. However due to the lack of regulatory rules, the devices are rarely checked making the quality of the measures doubtful. OBJECTIVE: To compare BP measured following the WHO recommendations, using 2 different devices: the mercury or aneroid sphygmomanometer used by the physician and a SECURUS manometer that has been calibrated just before the implementation of the study. METHOD: The study was performed with 1694 French general practitioners. Every physician included 2 ambulatory patients: a newly diagnosed non-treated hypertensive patient and a treated hypertensive patient. The physician was asked to include the first patient of each category attending his office. BP was measured sequentially with the 2 devices in a random order. Collected data were socio-demographic parameters, cardiovascular risk factors, hypertension related diseases, drug treatment for hypertension and BP levels. RESULTS: Mean BPs differ by less than 1 mmHg between the 2 devices. However 10% of the treated hypertensive patients are not classified as having normalised BP values (BP < 140/90 mmHg) or high BP values, in the same way by the 2 devices. Mean absolute difference between the 2 devices is > 5 mmHg in 22% and 13% of the physicians for SBP and DBP respectively. CONCLUSION: This pilot study emphasises the need of BP measurements of good quality in clinical practice, because of the possible impact on the care of the patients and the related costs. Regulatory rules on the control of the devices might improve the quality of BP measurements.

Comparison of sympathetic modulation induced by single oral doses of mibefradil, amlodipine, and nifedipine in healthy volunteers.

OBJECTIVE: Our objective was to compare the sympathetic modulation induced by oral administration of a single dose of 20 mg of standard nifedipine, of 10 mg of amlodipine, and of 100 mg of mibefradil. METHODS: Sixteen healthy male volunteers participated in this double-blind, randomized, placebo-controlled, crossover four-period study. The sympathetic modulation induced by treatments was evaluated during 24 hours after drug administration by neurohormonal dosages, hemodynamic parameter measurements, and spectral analysis of heart rate and blood pressure. RESULTS: We observed a significant (P <.05) decrease in diastolic blood pressure 1 hour after the administration of nifedipine (62 +/- 9 to 59 +/- 5 mm Hg) with concomitant increases in heart rate (59 +/- 5 to 74 +/- 8 bpm) and neurohormones (53 +/- 18 to 83 +/- 50 pg/mL for aldosterone, 157 +/- 56 to 282 +/- 119 pg/mL for norepinephrine, and 9.8 +/- 5.5 to 40.2 +/- 97.1 pg/mL for active renin). No significant modification of these parameters was observed with amlodipine and mibefradil, except an isolated increase of norepinephrine plasma level 2 hours after the administration of mibefradil (133.1 +/- 67.1 to 210.9 +/- 92.5 pg/mL). The spectral analysis over 24 hours of Mayer waves of systolic blood pressure did not show any significant change over time in the different groups. When the analysis was performed during the first 4 hours after treatment administration, we observed a decrease of Mayer waves of systolic blood pressure with nifedipine (2.21 +/- 1.45 mm Hg(2) versus 3.53 +/- 1.85 mm Hg(2) with placebo). These results indicate that oral single doses of mibefradil and amlodipine do not induce baroreflex-mediated clinical changes in healthy volunteers. The single oral dose of nifedipine resulted in a marked increase in sympathetic tone and a decrease in systolic blood pressure variability early after oral administration. CONCLUSION: Mibefradil, the nondihydropyridine calcium antagonist, exerts much less sympathetic stimulation than nifedipine.

Assessment of outcomes other than systolic and diastolic blood pressure: pulse pressure, arterial stiffness and heart rate.

In recent years, studies have shown that parameters derived from the arterial pressure wave other than systolic and diastolic blood pressure provide important information on cardiovascular status. Among these parameters, pulse pressure, arterial stiffness and heart rate have emerged as independent markers of cardiovascular risk in different populations. Although a number of studies have used casual measurements of these parameters in a clinic setting, others have focused on their assessment under ambulatory conditions. The pulse pressure represents the amplitude of the pressure wave signal (systolic minus diastolic blood pressure), higher pulse pressure values having been reported in patients possessing cardiovascular risk factors. Close associations between a high pulse pressure and several surrogate end-points have been described. Furthermore, epidemiological studies have shown that a high pulse pressure is an independent predictor of hard end-points in several populations. Arterial stiffness represents one of the major haemodynamic factors determining pulse pressure. Pulse wave velocity, measured from the initial upstroke of the pressure wave, constitutes an established index of arterial stiffness. Studies have reported stiffer arteries in patients with cardiovascular pathology even at an early stage of disease. Close correlations between arterial stiffness and several surrogate markers have been reported, and arterial stiffness and its changes have recently been shown to be an independent predictor of hard end-points in patients with a high cardiovascular risk. Methods to evaluate arterial stiffness under ambulatory conditions are emerging. Heart rate represents the frequency of the cyclical strain of the arterial wall, clinical studies having shown that ambulatory heart rate is correlated to several surrogate markers. A few epidemiological studies have analysed the value of ambulatory heart rate as an independent predictor of hard end-points, but their positive findings need to be confirmed. The analysis of the pressure wave thus allows the determination of several haemodynamic indices other than systolic and diastolic blood pressure. Pulse pressure, arterial stiffness and heart rate constitute other outcomes that may be useful as additional factors in risk assessment for future therapeutic decision-making.

Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group.

Data for the effects on blood pressure of renal artery balloon angioplasty are mostly from uncontrolled studies. The aim of this study was to document the efficacy and safety of angioplasty for lowering blood pressure in patients with atherosclerotic renal artery stenosis. Patients were randomly assigned antihypertensive drug treatment (control group, n = 26) or angioplasty (n = 23). Twenty-four-hour ambulatory blood pressure, the primary end point, was measured at baseline and at termination. Termination took place 6 months after randomization or earlier in patients who developed refractory hypertension. In those allocated angioplasty, antihypertensive treatment was discontinued after the procedure but was subsequently resumed if hypertension persisted. Secondary end points were the treatment score and the incidence of complications. Two patients in the control group and 6 in the angioplasty group suffered procedural complications (relative risk, 3.4; 95% confidence interval, 0.8 to 15.1). Early termination was required for refractory hypertension in 7 patients in the control group. Antihypertensive treatment was resumed in 17 patients in the angioplasty group. Mean ambulatory blood pressure at termination did not differ between control (141+/-15/84+/-11 mm Hg) and angioplasty (140+/-15/81+/-9 mm Hg) groups. Angioplasty reduced by 60% the probability of having a treatment score of 2 or more at termination (relative risk, 0.4; 95% confidence interval, 0.2 to 0.7). There was 1 case of dissection with segmental renal infarction and 3 of restenosis in the angioplasty group. No patient suffered renal artery thrombosis. In unilateral atherosclerotic renal artery stenosis, angioplasty is a drug-sparing procedure that involves some morbidity. Previous uncontrolled and unblinded assessments of angioplasty overestimated its potential for lowering blood pressure.

Improving hypertension control among excessive alcohol drinkers: a randomised controlled trial in France. The WALPA Group.

OBJECTIVES: To improve blood pressure control among hypertensive ( > 140/90 mmHg) excessive alcohol drinkers. DESIGN: Fourteen worksite physicians were randomised onto an intervention group and a control group. The intervention was based on training the worksite physicians and follow up of those hypertensive subjects defined as excessive drinkers. Follow up was based on self monitoring of alcohol consumption by the subject, in view of the results of their gamma glutamyl transferase (GGT) activity determination. SETTING: Fourteen workplaces in France - mainly in the industrial sector. SUBJECTS: Altogether 15 301 subjects were screened by the 14 physicians: 129 of these were included in the study. MAIN OUTCOME MEASURES: This was the difference between the initial systolic blood pressure (SBP) and the SBP one year later (delta BP). Secondary criteria were the difference between the initial and final diastolic blood pressure (delta DBP) and delta BP at two years; antihypertensive treatment; state alcohol consumption (delta AC); delta GGT; and body mass index (delta BMI). RESULTS: The decrease in SBP levels was significantly larger in the intervention group than in the control group: at one year, delta SBP values were -11.9 (15.6) mmHg and -4.6 (13.8) respectively (p < 0.05). This benefit was still observed after two years of follow up (-13.8 (17.4) mmHg v -7.5 (14.2) mmHg (p < 0.05)). No difference was observed in DBP. The percentage of treated subjects did not differ between groups. At one year, delta AC was larger in the intervention group (-2.8 (5.2) U/d) than in the control group (-1.6 (3.4) (p < 0.1)). delta GGT and delta BMI did not differ between the two groups. A weak positive correlation was observed between delta AC and delta SBP (r = 0.16). CONCLUSION: An intervention aimed at the hypertensive excessive drinkers in a working population was found to be effective in reducing SBP on a long term basis (two years). The mechanisms of reduction in alcohol consumption and improved drug compliance cannot be ascertained in this pragmatic study. From a public health point of view, reducing the excess cardiovascular risk among a "hard to reach" population seems feasible with a strategy specifically designed for this high risk group.

Predicting common bile duct lithiasis: determination and prospective validation of a model predicting low risk.

BACKGROUND: The aim of this two-part prospective study was: (1) to identify simple, noninvasive, preoperative factors associated with low or very low risk of common bile duct lithiasis (CBDL); and (2) to test the validity of the statistical model obtained during Part One by the postcholecystectomy follow-up of patients classified into a low-risk group. PATIENTS AND METHODS: In Part One of the study, preoperative clinical, biologic, and ultrasonographic data, and intraoperative cholangiographic findings were collected from 503 consecutive patients undergoing cholecystectomy for symptomatic lithiasis from 1985 to 1989. Using the data obtained in Part One, a linear logistic model was used prospectively in Part Two to determine the prediction of absence of CBDL in 279 consecutive patients. No jaundice, normal transaminase levels, common bile duct (CBD) diameter < 8 mm, and no intrahepatic duct enlargement defined the low-risk group of CBDL. RESULTS: In Part One, CBDL was present in 84 (17%) of all patients. Five parameters were used to classify 73% of all patients as low risk of CBDL and 27% as high risk. In the low-risk groups, CBDL was present in 1% of 116 cases with acute gallbladder complications, and 5% of 250 cases with no acute gallbladder complications. In Part Two, 171 (61%) patients were classified in the low-risk group (Group 1), and CBD stones were not sought by any additional preoperative investigations or intraoperative cholangiography (IOC). One hundred eight patients (39%) were considered at risk of CBDL (Group 2). Mean follow-up was 20.6 months (median 19); 2 patients (1%) in the low-risk group presented a symptomatic retained stone. CONCLUSIONS: This study validated this simple model for predicting risk of CBDL and avoiding invasive preoperative investigations--as well as IOC--in more than 60% of symptomatic cholelithiases. In addition, this model seemed useful for defining patients in whom further exploration for CBDL was justified, since 42 (39%) of the 108 Group 2 patients were proved to have CBDL.

Hypocaloric diet and antihypertensive drug treatment. A randomized controlled clinical trial.

OBJECTIVE: To compare the amount of drug quantified by a score needed to control blood pressure in two groups of overweight hypertensive patients, receiving or not receiving a hypocaloric diet. DESIGN: Randomized controlled clinical trial. SETTING: Two hospital outpatient hypertension clinics. PATIENTS: Fifty-four subjects with a DBP between 95 and 110 mmHg and a weight > or = 110% of the ideal weight. INTERVENTION: Allocation to either drug treatment (DT) or hypocaloric diet (HD). In the HD group, after 2 months, an antihypertensive drug was administered to the subjects with a DBP > or = 90 mmHg, following the same scheme protocol as in the DT group. Subjects were followed during 10 months by a clinician only in the DT group and by a clinician and a dietician in the HD group. MAIN OUTCOME MEASURES: Score of treatment: hydrochlorothiazide 25 mg [score = 1] with, as needed to obtain a DBP < 90 mmHg, the addiction of enalapril 10 mg [score = 2], 20 mg [score = 3], and nifedipine 40 mg [score = 4]. RESULTS: At the end of the trial, 5 subjects were lost to follow-up in the HD group and 1 in the DT group (p > 0.05). Mean weight loss was 5.9 kg (sd = 1.2) in the HD and 2.3 kg (sd = 0.7) in the DT group (p = 0.02). Mean decrease in DBP was 18 mmHg (sd = 7) and 15 mmHg (sd = 8) in HD and DT groups respectively (p = 0.36). Mean DBP was 84 mmHg (sd = 7.8) in the HD group and 85 mmHg (sd = 7.2) in the DT group. In the HD group, 8 (38.1%) subjects had a DBP < 90 mmHg without any drug treatment. The mean drug treatment score was 0.86 (sd = 0.91) in the HD and 1.52 (0.70) in the DT group (p = 0.01). CONCLUSION: This study shows that in overweight hypertensives, the quantity of drug needed to achieve an acceptable level of BP is nearly reduced by 50% when an efficient hypocaloric diet is prescribed simultaneously.

Abdominal body mass distribution and elevated blood pressure are associated with increased risk of death from cardiovascular diseases and cancer in middle-aged men. The results of a 15- to 20-year follow-up in the Paris prospective study I.

The associations of blood pressure (BP), body mass index (BMI) and iliac-to-thigh circumference index (CI) with total, cardiovascular and cancer mortality were investigated in 7312 middle-aged men, initially free of coronary heart disease, known cancer and not treated for hypertension, who have been followed for 15 to 20 years in the Paris prospective study I. Using Cox survival regression analysis, total mortality (1208 deaths) was found to be highest in relatively lean men (BMI < 24.4 kg/m2) with elevated blood pressure (mean BP > or = 96 mmHg) and central pattern of body mass distribution (CI > 1.82). Cancer causes accounted for a large proportion of the increased mortality risk. In parallel, mortality from cardiovascular diseases increased independently with blood pressure and iliac-to-thigh circumference index, but increased with body mass index only in men with low blood pressure (mean BP < 96 mmHg). Taking into account serum cholesterol and cigarette smoking levels as covariates and excluding deaths occurring 5 to 10 years after the examination only slightly attenuated the intensity of this pattern of association.

Restenosis after a first percutaneous transluminal renal angioplasty.

The incidence of restenosis after a first successful percutaneous transluminal angioplasty of a native renal artery and the clinical and angiographic variables that may influence its occurrence were studied in 104 hypertensive patients. Angiograms obtained immediately before and after angioplasty and, in 92 patients, 8.8 +/- 6.0 months after angioplasty were interpreted separately by two observers. Stenosis severity was classified into five grades, and restenosis was defined by a stenosis one grade or more higher at follow-up than immediately after angioplasty. Interobserver concordance for etiology, stenosis grade, and other angiographic items yielded kappa coefficients in the range of 0.328-0.942. Sessions were organized to reach a consensus in each case. Ostial stenoses were more frequent in patients with atheromatous stenoses, and branch stenoses were more frequent in those with fibromuscular dysplasia. There was no significant difference between the 15 patients (16%) with restenosis and those without concerning sex distribution, mean age, mean blood pressure, plasma creatinine level, and etiology distribution. Truncal stenoses were less prone to restenosis than ostial or branch stenoses (12% versus 35%, respectively; 95% confidence interval of difference, -0.6% to 47%). In patients with atheromatous stenoses, aortitis or aortic ectasia were associated with a high restenosis incidence (35% when present versus 8% when absent; 95% confidence interval of difference, 5% to 48%). In conclusion, restenosis was observed in one sixth of patients after a first successful renal angioplasty; its incidence was low in patients with truncal stenoses and high in those with severe aortic atheroma. Automated renal artery stenosis quantification methods are needed to standardize stenosis description.

Converting enzyme inhibition: dissociation between antihypertensive and arterial effects.

In this study the dose-response curves reflecting the arterial and the antihypertensive effects of converting enzyme inhibition were analysed. The BP measurement (using a random zero sphygmomanometer) and its decrease following converting enzyme inhibition were used as a marker of the arteriolar effect of the drug. The effect on conduit arteries was evaluated through determination of carotid-femoral pulse wave velocity used as an index of arterial distensibility. We compared the dose-response curves of these two parameters in a double-blind study carried out in 24 patients with essential hypertension, who were randomised between placebo and 2, 4 and 8 mg of the converting enzyme inhibitor trandolapril given for 8 days. The antihypertensive effect was observed from 2 mg, at which dose the plateau of BP reduction was already achieved. No significant correlation was found between dose and BP reduction (r = -0.34), whereas the dose was significantly related to the change in pulse wave velocity (r = -0.56, P < 0.01). No significant correlation was found between changes in BP and change of pulse wave velocity. The study provides evidence that the effect on the conduit artery was obtained for higher doses than the BP effect in patients treated for hypertension by the converting enzyme inhibitor trandolapril.

[Renovascular hypertension: diagnostic and therapeutic strategy]. / Hypertension artérielle rénovasculaire: stratégie diagnostique et thérapeutique.

Investigations for renal artery stenosis have been greatly facilitated by advances in imaging techniques. Intravenous digital subtraction angiography is now performed in all patients with progressive, drug-resistant hypertension associated with aorto-iliac lesions or with renal impairment induced by angiotensin-converting enzyme inhibitors. Yet the finding of hypertension with renal artery stenosis is not enough to make the diagnosis of renovascular hypertension, this term being reserved to hypertension reversible by revascularization. The selection of patients who may benefit from revascularization rests on urography to explore the excretory and endocrine functions of the ischaemic kidney, as well as on scintigraphy and measurement of renin levels in renal veins before and after administration of captopril. The functional data are completed by vascular exploration which helps in evaluating the usefulness and safety of revascularization: repercussions of hypertension on target organs and extension of the vascular disease to other territories. Revascularization as first-line treatment consists of percutaneous transluminal dilatation; surgery must be reserved to difficult cases, such as arterial obliteration or failed dilatation.

An indirect evaluation of the effect of the autonomic nervous system following converting enzyme inhibition in hypertension.

Common carotid blood flow and cold pressor test were evaluated in 16 patients with sustained essential hypertension before and after 30 days treatment with the converting enzyme inhibitor Enalapril (20 mg). Enalapril decreased blood pressure and carotid vascular resistance with no significant change in heart rate. After treatment, despite a wide range of the responses, the changes in systolic blood pressure to cold test were significantly attenuated, whereas the heart rate responses were not. Acute random and double blind administration of either Cadralazine or Nitrendipine, two vasodilating drugs which are known to cause an activation of the autonomic nervous system, were performed before and after long term treatment by Enalapril. Whereas the blood pressure and heart rate responses to cold test was unmodified by these compounds before Enalapril treatment, significant changes were observed after converting enzyme inhibition: Cadralazine reduced the heart rate response whereas Nitrendipine increased it significantly. The study provides evidence that converting enzyme inhibition causes sympatho-inhibitory influences which are principally observed in stress conditions, with heterogeneous responses depending on the nature and the type of stimulation.

Lisinopril versus atenolol: decrease in systolic versus diastolic blood pressure with converting enzyme inhibition.

In a multicenter, parallel, double-blind study, lisinopril, a new converting enzyme inhibitor, was compared with atenolol in the treatment of mild to moderate essential hypertension. Four hundred ninety patients were randomized to once-a-day treatment with lisinopril 20 mg or atenolol 50 mg for 4 weeks, and the doses of lisinopril or atenolol were increased at 4-week intervals up to 80 mg or 200 mg, respectively, if sitting diastolic blood pressure (SDBP) was not well controlled. Lisinopril and atenolol reduced SDBP to a similar extent. All reductions from baseline in sitting diastolic and systolic blood pressure were significant (p less than 0.01). Lisinopril produced a significantly greater reduction (p less than 0.01) in sitting systolic blood pressure (SSBP) than atenolol. The predominant reduction in SSBP could not be explained on the basis of age, race, or severity of hypertension. It is suggested that the increase in arterial compliance reported for converting enzyme inhibitors could explain the predominant decrease in systolic blood pressure.

[Antihypertensive efficacy of the combination of captopril 50mg and hydrochlorothiazide 25mg evaluated by ambulatory blood pressure measurement]. / Efficacité antihypertensive de l'association captopril 50 mg et hydrochlorothiazide 25 mg par mesure ambulatoire de la pression artérielle.

The anti-hypertensive effects of the captopril-hydrochlorothiazide combination administered during three months as one single morning dose were evaluated in 51 patients with moderate essential hypertension by means of ambulatory blood pressure recording. At the end of the study, the mean values of arterial blood pressure recorded over 24 hours were significantly lowered: systolic pressure was reduced from 145 +/- 11 to 131 +/- 10 mmHg (P less than 0.001), and diastolic pressure from 88 +/- 5 mmHg to 81 +/- 4 mmHg (P less than 0.001). The same results were recorded during the day (07.00 to 22.00 hours) and during the night (23.00 to 06.00 hours). No change in heart rate was observed.