[Impact of the ExSel(®) test administration on the excessive salt consumption in hypertensive patients followed in general practice]. / Conséquences de la réalisation du test ExSel(®) sur la consommation excessive de sel chez des patients hypertendus suivis en médecine générale.

OBJECTIVE: To evaluate the impact of the Exsel(®) test administration on salt intake in hypertensive subjects followed in general practice. METHOD: In a group practice of general practitioners in the Île-de-France, the ExSel(®) test http://www.comitehta.org/testez-vous/consommez-vous-du-sel-en-exces-test-exsel/ was administered to 329 outpatients. The questionnaire was filled in the waiting room and then commented by the doctor. In patients treated for hypertension, 24hours urinary Na was prescribed after the consultation. Excessive salt consumption (ESC) was defined as a urinary Na≥200mmol/day. RESULTS: The population included subjects aged on average 57 years with 43 % of hypertensive patients. According Exsel(®), an ESC was suspected in 36 % of patients and was more common in treated hypertensive patients (44 %; [36-52]) in hypertensive men (57 %; [46-68]) than among non-hypertensive (31 %; [24-38]) and non hypertensive women (18 % [11-25]). Urinary Na has been finally performed by 63 % of subjects and 24hours excretion was 157±56mmol in men and 123±39mmol in women. After this 24hours urinary sodium evaluation, subsequent to ExSel(®) test, ESC frequency was lower among men (19 %) and very low among women (5 %). CONCLUSION: To estimate the ESC, the ExSel(®) test is easily performed in general practice while 24hours urinary sodium is more difficult to obtain. Achieving an ExSel(®) test was accompanied by a decrease in the frequency of excessive salt consumers with a greater effect in women.

Management of resistant hypertension: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology.

To improve the management of resistant hypertension, the French Society of Hypertension, an affiliate of the French Society of Cardiology, has published a set of eleven recommendations. The primary objective is to provide the most up-to-date information based on the strongest scientific rationale and that is easily applicable to daily clinical practice. Resistant hypertension is defined as uncontrolled blood pressure on office measurements and confirmed by out-of-office measurements despite a therapeutic strategy comprising appropriate lifestyle and dietary measures and the concurrent use of three antihypertensive agents including a thiazide diuretic, a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, for at least 4 weeks, at optimal doses. Treatment compliance must be closely monitored, as must factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression, drug interactions and vasopressor drugs). If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for potential target organ damage and secondary causes of hypertension. The recommended treatment regimen is a combination therapy comprising four treatment classes, including spironolactone (12.5-25 mg per day). In the event of a contraindication or a non-response to spironolactone, or if adverse effects occur, a ß-blocker, an α-blocker, or a centrally acting antihypertensive drug should be prescribed. Because renal denervation is still undergoing assessment for the treatment of hypertension, this technique should only be prescribed by a specialist hypertension clinic.

[Development and evaluation of ExSel Test to screen for excess salt intake in hypertensive subjects]. / Mise au point et évaluation de l'ExSel Test pour dépister une consommation excessive de sel chez les patients hypertendus.

OBJECTIVE: Development of a test to screen excess salt intake (ESI) in hypertensive patients. METHODS: Hypertensive subjects living in Paris area have been included. A 24-hour urinary sodium collection has been performed the day before the visit for a day hospital. A food diary was completed on the day of the urine collection and validated after an interview with a dietetician. An ESI was defined by a urinary sodium ≥ 200mmol/d. Clinical or food characteristics associated to an ESI were retained for the ExSel Test variables. A ROC curve was performed to determine the optimal score for the ExSel Test in detection of ESI in hypertensive patients. RESULTS: One hundred and forty-eight hypertensive patients have been included living in the Île-de-France area. ESI was observed in 19% with a higher frequency in men. Seven major determinants of ESI have been identified and are the questions that constitute the ExSel Test. A positive response assigns points: man (1); BMI > 30 (2); bread 4 or 5 pieces per day (1) or more than 6 pieces; cheese at least 1 time per day (2); charcuterie at least 2 times per week (2); use of processed broth or pilaf (1); food rich in hidden salt (pizza, cheeseburger, quiche, shrimp, potato chips, smoked fish, olive) at least 2 times per week (1). The ROC curve analysis shows that a score of 5 or more has the best Youden index with a sensitivity of 0.63, specificity of 0.95, PPV of 0.75, NPV of 0.92. CONCLUSIONS: In hypertensive subjects, an excessive salt intake can be detected by the realization of the ExSel Test based only on a simple food-questionnaire and some clinical parameters. For a clinical use of the ExSel Test, an electronic version is available on http://www.comitehta.org.

[An abdominal CT scan in first-line is an efficient investigation of uncontrolled hypertensives suspected to have an adrenal cause]. / Évaluation de l'efficience diagnostique de la tomodensitométrie abdominale de première intention chez l'hypertendu non contrôlé

UNLABELLED: The prevalence of hypertension resistant to treatment to indicate for renal denervation. OBJECTIVE: To evaluate the efficiency for imaging the adrenal glands with an abdominal CT scan in first-line in subjects with resistant hypertension suspected to have an adrenal cause. METHODS: On 75 hypertensive patients uncontrolled by at least a combination therapy, but suspected to have secondary hypertension due to adrenal cause, an abdominal CT scan was performed in first intention. In all subjects, an exploration of the renin-aldosteron axis in standardized conditions, a 24-hour urinary cortisol and a WHO recommended biological analysis were also performed. RESULTS: An abnormal morphology of adrenal was found by abdominal CT in 64% of patients. The abnormalities observed were: bilateral hyperplasia (27%), unilateral adenoma (15%), unilateral hyperplasia (15%), bilateral adenoma (7%). Abnormal biological and/or hormonal tests for adrenal disease were found in 29% of patients, with a primary aldosteronism (A/R corrected>23) in 11% or K less than 3.5mmol/L in 20%. According to the assessment conducted in first-line, indication to spironolactone is selected in 48% of patients investigated with CT as first-line and in 17% of patients investigated with biological tests (P<0.01) while the indication to adrenal surgery would be held in 15% and 11% of patients respectively. CONCLUSION: In a population of subjects with uncontrolled hypertension in which an adrenal cause is suspected, achieving a first-line abdominal CT leads to adrenal abnormality observed in 64% of patients while a specific biological abnormality is noted in 29% of subjects. This study shows that assessment that starts with an abdominal CT scan allows to indicate treatment with spironolactone more frequently than when the first assessment is limited to a biological investigation.

[Influence of blood pressure variability during office visit on the estimation of blood pressure control in treated hypertensive patients]. / Influence de la variabilité de la pression artérielle en consultation sur le diagnostic du contrôle tensionnel chez des hypertendus traités.

OBJECTIVE: To evaluate the variability in blood pressure observed during office visit in treated hypertensive patients and its consequences on the diagnosis of controlled hypertension. METHOD: The medical records of 144 subjects seen consecutively in a hypertension excellence center were extracted from a computerized medical database including hypertension subjects treated and followed-up for at least one year. BP measured with an automatic device (four consecutives measurements at 2min intervals) where compared to BP values of home BP performed in the previous week's visit. Thresholds were 140/90mmHg for office BP and 135/85mmHg for HBP. RESULTS: The population has the following characteristics: age 62 years with 26% over 70 years, treated with a monotherapy (33%), bitherapy (35%), triple therapy (17%), quadri-therapy or more (8%). A white coat effect SBP above 20mmHg was noted in 32% of patients when BP at 2min is taken and in 2% when BP at 8min is taken (P<0.01). After 8min, a masked effect is noted in 16% for SBP above 20mmHg and in 44% for DBP above 10mmHg. White coat hypertension or masked hypertension was noted in 40% or 16% respectively (BP 2min) and in 5% or 29% (BP 8min) in treated hypertensive. CONCLUSION: In treated hypertensive, office BP measured by an automatic device shows significant variability. When the BP is taken with an automatic device, measures taken after 8minutes of rest avoid the misleading effects of white coat effect, but the masked hypertension is present in nearly one third of the subjects. The use of AMT for monitoring hypertensive patients is the best way to monitor treatment efficacy.

[Frequency of hypertension resistant to treatment and indication for renal denervation]. / Fréquence de l'hypertension résistante aux traitements et indication à la dénervation rénale.

OBJECTIVE: To evaluate in hypertensive patients followed in a specialized hypertension unit, the prevalence of subjects uncontrolled despite triple therapy including a diuretic. The aim is to estimate the percentage of hypertensive patients with an indication to renal denervation. METHOD: From a database of computerized medical records of a unit specialized in hypertension, it was extracted 144 consecutive cases of subjects treated and followed for at least 1year and having had a home pressure monitoring (HPM) on treatment, and if necessary a work-up for a secondary hypertension. The blood pressure (BP) was evaluated in office by automated method (after 2 and 8minutes) and with HPM (average of three measurements in the morning and evening for three consecutive days). RESULTS: The population has the following characteristics: age 62 with 26% over 70years, treated dyslipidemia (39%), treated diabetes (11%), adrenal hypertension treated medically (14%), severe renal failure (3%). The means of treatment are: a monotherapy (33%), bitherapy (35%), triple therapy (17%), quadritherapy (7%), pentatherapy or more (1%), spironolactone (45%), thiazide diuretics (49%). The uncontrolled hypertension was observed in 26% if the BP is evaluated with HPM, in 52% if the BP is evaluated at the office after 2minutes of rest and 7% if the BP is evaluated after 8minutes of rest (P<0.01). In patients treated with at least a tritherapy in association with a diuretic, an uncontrolled hypertension was observed in 5% if the BP is evaluated with HPM. Failure to control for the SBP is the cause of 80% of resistant hypertension. CONCLUSION: The frequency of resistant hypertension is 5% of hypertensive patients followed in a specialized hypertension unit when guidelines are applied in the case of uncontrolled hypertension. These results indicate that the indication for renal denervation affects only a small percentage of patients treated for hypertension.

[Diabetes prevention in hypertensive patients]. / Prevention du diabète chez l'hypertendu.

Hypertension and type-2 diabetes are frequently observed concomitantly in a same patient. There are possibilities to delay the onset of type-2 diabetes, especially in patients already managed for hypertension. Trials on renin-angiotensin blockers show that compared to other drug therapies, there is a lower incidence of diabetes in patients treated by an ACE-inhibitor or an Angiotensin 11 antagonist and the benefit can be estimated at 22% (relative risk at 0.78 with a confidence interval from 0.74 to 0.83). A higher risk of occurrence of type-2 diabetes is particularly noted in those under beta-blocking therapy combined to diuretics. In ALLHAT, the comparison of a thiazide diuretic, an ACE-inhibitor and a calcium antagonist showed that the incidence of new cases of diabetes was the highest in the diuretic group and the lowest in the ACE-inhibitor group. Hypertensive patients under calcium antagonists presented an incidence in between the two other groups. According to a recent hypothesis, the insulin-resistance decrease as a consequence of renin-angiotensin system blocking is related to the recruitment of pre-adipocytes. The NAVIGATOR and ONTARGET trials will probably confirm the preliminary results obtained in this topic. Their results are expected within the 2 next years.

[Home blood pressure monitoring in addition to office blood pressure determination is useful in patients with systolic hypertension before their inclusion into a drug trial]. / L'automesure tensionnelle en complément de la mesure de consultation est utile pour l'inclusion dans un essai clinique de sujets avec une HTA systolique.

OBJECTIVE: In patients with uncontrolled systolic hypertension, to estimate the value of home blood pressure monitoring in addition to office blood pressure for inclusion in a trial. METHODS: 80 patients with systolic hypertension, defined as SBP > or =140 mmHg and pulse pressure > or =60 mmHg, were treated for 4 weeks with a thiazide diuretic at usual dose (25 mg HCTZ or 1.5 mg indapamide or methyclothiazide 5 mg). Blood pressure was measured using an automatic monitor (Omron M6) at office and at home in the 3 days prior the visit. Subjects with an uncontrolled hypertension were included in the second part of the trial only if there fulfilled inclusion criteria: office SBP > or =140 mmHg and home SBP > or =135 mmHg (mean of 18 measurements obtained on 3 consecutive days) and office pulse pressure > or =60 mmHg. RESULTS: After 4 weeks with diuretic treatment, 62% of patients fulfilled 3 criteria and were included in the second part of the trial. It was observed 76% of patients with office SBP > or =140 mmHg, 72% with office pulse pressure > or =60 mmHg and 70% with both office SBP and PP criteria. However, only 67% of patients had home SBP > or =135 mmHg. Discrepancy between office and home SBP was observed and subjects with a white coat hypertension was noticed in 14% and masked hypertension in 5%. CONCLUSION: If patients with systolic hypertension have to be included into a drug trial because there are uncontrolled, home blood pressure monitoring in addition to office blood pressure is a very useful criteria for inclusion because misclassifications due to white coat or masked hypertension is frequent in these patients.

[Assessement of home blood pressure with a monitor including MAM technology: comparison with the standard monitor]. / Relevé d'automesure utilisant un autotensiomètre incluant la technologie MAM: avec la méthode de référence.

OBJECTIVES: To compare two periods of three days of home blood pressure monitoring (HBPM) using two different monitors with one including MAM (microlife average mode) technology. METHODS: In 152 hypertensive subjects referred to hypertension specialists, a self-measurement of blood pressure was performed sequentially with an Omron M6 (arm cuff, A/A, BHS validation) or Microlife BP-3AC1 with the MAM technology. Each patient recorded home blood pressure during two periods of 3 days with 3 measures in the morning and 3 in the evening. Order for use of each monitor was randomised. BP values were reported on a standardized document. RESULTS: In this population, aged 60 +/- 14 years, with 57% of men and a mean blood pressure of 150 +/- 21/84 +/- 21 mmHg, the home blood pressure values were 141.5 +/- 18.7/79.9 +/- 9.6 mmHg with the OMRON monitor and 138.2 +/- 17.1/79.9 +/- 10.1 mmHg with the Microlife monitor. Values between the two monitors differed about 5 mmHg for the mean SBP and about 2.8 mmHg for the mean DBP. The mean HBPM values does not differ between the two methods for more than 2.5 mmHg, 5 mmHg, 10 mmHg and 15 mmHg in 29%, 49%, 80% and 90% for SBP and in 42%, 76%, 94% and 98% for DBP respectively. CONCLUSIONS: For most of patients, mean SBP/DBP obtained with home blood pressure Measurement during three days are comparable when using monitor operated with MAM technology or not.

[General anesthesia for bronchoscopy and lipidol bronchography in children and infants]. / Anesthésie générale pour bronchoscopie et bronchographie lipiodolée chez l'enfant et le nourrisson

In 160 cases of children and infants, a technique of general anesthesia is described (penthiobarbital-suxamethonium, then halothane-oxygen with a mask in spontaneous ventilation if the bronchoscopy is followed by lipiodol bronchography). This technique is simple and efficacious and makes the child comfortable, especially in cases of repeated operation, and for the operator whose gestures are more rapid and less traumatising and this permits rapid awakening. No incidents or severe complications were noted.