[Evaluation of the ExSel® self-questionnaire to screen for an excess salt intake in patients followed in a nephrology consultation]. / Évaluation de l'autoquestionnaire ExSel® pour dépister une consommation excessive de sel chez les patients consultant en néphrologie.

AIM: To evaluate the reliability of the ExSel® self-questionnaire to detect an excess salt intake (≥12g/24h) in patients consulting for hypertension and/or renal failure. METHODS: Results of the ExSel® self-questionnaire were compared to 24h sodium excretion using the Cohen's kappa test and a Chi2 test. Sensitivity, specificity, VPP and VPN were calculated. A ROC curve was realized to find an accurate cut-off. RESULTS: Mean characteristics of the 101 patients with reliable results were: age of 67±12 years, Body Mass Index 28.4±5.6kg/m2, SBP/DBP 139±23/74±13mmHg (98% were hypertensives. Mean salt intake was 7.5±3.1g/24h and mean creatininuria was 13.9±20.1mmol/24h. An excess salt intake (≥12g/24h) was observed in 8% of the patients. The Kappa test at 0.17 and the Chi2 at 0.66 signify that the agreement was very low. Sensitivity was 37%, specificity 90%, PPV 20% and NPV 94%. The AUC under the ROC curve was too low (0.665) to determine a threshold adapted to the renal patients. CONCLUSIONS: The ExSel® autoquestionnaire is not adapted to outpatients, mainly hypertensives (98%) followed in a nephrology consultation to detect an excess salt consumption.

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.

Can we identify response markers to antihypertensive drugs? First results from the IDEAL Trial.

Current antihypertensive strategies do not take into account that individual characteristics may influence the magnitude of blood pressure (BP) reduction. Guidelines promote trial-and-error approaches with many different drugs. We conducted the Identification of the Determinants of the Efficacy of Arterial blood pressure Lowering drugs (IDEAL) Trial to identify factors associated with BP responses to perindopril and indapamide. IDEAL was a cross-over, double-blind, placebo-controlled trial, involving four 4-week periods: indapamide, perindopril and two placebo. Eligible patients were untreated, hypertensive and aged 25-70 years. The main outcome was systolic BP (SBP) response to drugs. The 112 participants with good compliance had a mean age of 52. One in every three participants was a woman. In middle-aged women, the SBP reduction from drugs was -11.5 mm Hg (indapamide) and -8.3 mm Hg (perindopril). In men, the response was significantly smaller: -4.8 mm Hg (indapamide) and -4.3 (perindopril) (P for sex differences 0.001 and 0.015, respectively). SBP response to perindopril decreased by 2 mm Hg every 10 years of age in both sexes (P=0.01). The response to indapamide increased by 3 mm Hg every 10 years of age gradient in women (P=0.02). Age and sex were important determinants of BP response for antihypertensive drugs in the IDEAL population. This should be taken into account when choosing drugs a priori.

[Renal denervation for treating hypertension: experience at the University Hospital in Lyon]. / Dénervation rénale dans le traitement de l'hypertension artérielle résistante : expérience du CHU de Lyon.

AIM: We report the first experience of Lyon's university hospital regarding renal denervation to treat patients with resistant essential hypertension. PATIENTS AND METHODS: Over a one-year period, 17 patients were treated (12 men, 5 women) with renal denervation. Baseline characteristics were as follows: age 56.5±11.5 years, BMI 33±5kg/m(2) and ambulatory blood pressure 157±16/87±13mmHg with 4.2±1.5 anti-hypertensive treatment. RESULTS: We did not observe intra-operative or early complications. After a median follow-up of 3 months and with the same anti-hypertensive treatment, office systolic blood pressure (SBP) and diastolic blood pressure (DBP) decrease respectively of 20±15 (P<0.001) and 10±13mmHg (P=0.014) (n=17). After six months of follow-up, ambulatory blood pressure (ABPM) decrease of 17.5±14.9mmHg (P=0.027) for SBP and of 10.5±9.6mmHg (P=0.029) for DBP (n=6). Among these patients, five of them were controlled (ABPM inferior to 130/80mmHg) and electrical left ventricular hypertrophy indexes decreased: R wave in aVL lead of 4±3mm (P=0.031), Sokolow index of 3±3mm (P=0.205), Cornell voltage criterion of 9±7mm (P=0.027) and Cornell product of 1310±1104 (P=0.027). CONCLUSION: Our results are in accordance with data from other centers. On average blood pressure decreases significantly but important inter individual variations are observed. The procedure seems safe.

[Microalbuminuria and urinary albumin excretion: French guidelines]. / Microalbuminurie et excrétion urinaire d'albumine: recommandations pour la pratique clinique.

UNLABELLED: Measurement of urinary albumin excretion (UAE) may be done on a morning urinary sample or on a 24 hour-urine sample. Values defining microalbuminuria are: - 24-hour urine sample: 30-300 mg/24 hours - Morning urine sample: 20-200 mg/mL or 30-300 mg/g creatinine or 2.5-25 mg/mmol creatinine (men) or 3.5-35 mg/mol (women). - Timed urine sample: 20-200 mug/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been shown in humans. In diabetic subjects, microalbuminuria is a marker of increased risk of cardiovascular (CV) and renal morbidity and mortality in type 1 and type 2 diabetic subjects. The increase in UAE during follow-up is also a marker of CV and renal risk in type 1 and type 2 diabetic subjects; its decrease during follow-up is associated with lower risks. In non-diabetic subjects, microalbuminuria is a marker of increased risk for diabetes mellitus, deterioration of the renal function, CV morbidity and all-cause mortality. It is a marker of increased risk for the development of hypertension in normotensive subjects, and is associated with unfavorable outcome in patients with cancer and lymphoma. Persistence or elevation of UAE overtime is associated with deleterious outcome in some hypertensive subjects. Measurement of UAE may be recommended in hypertensive subjects with 1 or 2 CV risk factors in whom CV risk remains difficult to assess, and in those with refractory hypertension: microalbuminuria indicates a high CV risk and must lead to strict control of arterial pressure. Studies focused on microalbuminuria in non-diabetic, non-hypertensive subjects are limited; most of them suggest that microalbuminuria predicts CV complications and deleterious outcome as it is in diabetic or hypertensive subjects. Subjects with a history of CV or cerebrovascular disease have an even greater CV risk if microalbuminuria is present than if it is not; however, in all cases, therapeutic intervention must be aggressive regardless of whether microalbuminuria is present or not. It is not recommended to measure UAE in non-diabetic non-hypertensive subjects in the absence of history of renal disease. Monitoring of renal function (UAE, serum creatinine and estimation of GFR) is annually recommended in all subjects with microalbuminuria. MANAGEMENT: in patients with microalbuminuria, weight reduction, sodium restriction (< 6 g/day), smoking cessation, strict glucose control in diabetic subjects, strict arterial pressure control are necessary; in diabetic subjects: use of maximal doses of ACEI or ARB are recommended; ACEI/ARB and thiazides have synergistic actions on arterial pressure and reduction of UAE; in non-diabetic subjects, any of the five classes of anti-hypertensive medications (ACEI, ARB, thiazides, calcium channel blockers or beta-blockers) can be used.

Microalbuminuria and urinary albumin excretion: French clinical practice guidelines.

Urinary albumin excretion (UAE) may be assayed on a morning urinary sample or a 24 h-urine sample. Values defining microalbuminuria are: 1) 24-h urine sample: 30-300 mg/24 h; 2) morning urine sample: 20-200 mg/ml or 30-300 mg/g creatinine or 2.5-25 mg/mmol creatinine (men) or 3.5-35 mg/mmol (women); 3) timed urine sample: 20-200 mug/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been obtained in humans. IN DIABETIC SUBJECTS: Microalbuminuria is a marker of increased risk of cardiovascular (CV) and renal morbidity and mortality in type 1 and type 2 diabetic subjects. The increase in UAE during follow-up is associated with greater CV and renal risks in type 1 and type 2 diabetic subjects; its decrease during follow-up is associated with lower risks. IN NON-DIABETIC SUBJECTS: Microalbuminuria is a marker of increased risk for diabetes mellitus, deterioration of renal function, CV morbidity and all-cause mortality. It is a marker of increased risk for the development of hypertension in normotensive subjects, and is associated with unfavorable outcome in patients with cancer and lymphoma. Persistence of elevated UAE during follow-up is associated with poor outcome in some hypertensive subjects. Measurement of UAE may be recommended in hypertensive medium-risk subjects with 1 or 2 CV risk factors in whom CV risk remains difficult to assess, and in those with refractory hypertension: microalbuminuria indicates a high CV risk and must lead to strict control of arterial pressure. Studies focused on microalbuminuria in non-diabetic non-hypertensive subjects are limited; most of them suggest that microalbuminuria predicts CV complications and deleterious outcome. Subjects with a history of CV or cerebrovascular disease have an even greater CV risk if microalbuminuria is present than if it is not; however, in all cases, therapeutic intervention must be aggressive regardless of whether microalbuminuria is present or not. It is not recommended to measure UAE in non-diabetic non-hypertensive subjects in the absence of history of renal disease. Monitoring of renal function (UAE, serum creatinine and estimation of GFR) is recommended annually in all subjects with microalbuminuria. MANAGEMENT: In patients with microalbuminuria, weight reduction, sodium restriction (<6 g per day), smoking cessation, strict glucose control in diabetic subjects, strict arterial pressure control are necessary; in diabetic subjects: use of maximal doses of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are recommended; ACEI/ARB and thiazides have synergistic actions on arterial pressure and reduction of UAE; in non-diabetic subjects, any of the five classes of anti-hypertensive medications (ACEI, ARB, thiazides, calcium channel blockers or beta-blockers) can be used.

[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.

[Management of hypertension and obesity: the observatory of management of uncontrolled hypertensives with respect to the presence or absence of overweight (PHYSIObs)]. / Prise en charge de l'hypertension artérielle et surcharge pondérale Observatoire de la prise en charge de patients hypertendus non contrôlés en fonction de la présence ou non d'un surpoids (PHYSIObs).

The object of this study was to compare the management of uncontrolled hypertensives (BP > 140/90 mmHg) by general practitioners with respect to the presence or absence of overweight (BMI > or =25 Kg/m2). A 2/1 stratification allowed comparison of 4080 patients who were overweight and 1951 patients with a normal body weight (normal BMI < 25 Kg/m2). The BP of patients who were overweight (> or =25 Kg/m2) was slightly higher than those with a normal BMI (161 +/- 12 mmHg vs. 159 +/- 12 mmHg, p < 0.001). The presence of a metabolic syndrome (43% vs. 7%, ATPIII criteria) was, logically, commoner in the patients overweight. However, the practitioners only recognised the presence of a metabolic syndrome in 65% of the overweight patients (28% true positives and 37% true negatives). The practitioners fixed their target value of systolic BP at 136.5 +/- 5.6 mmHg, in accordance with the recent recommendations of the Health Authorities. The targets were judged to be difficult to obtain in 18% of the overweight group and in 5% of patients with normal body weights. This optimism contrasted with the prescriptions, especially in the overweight patients, 46% of whom were treated by monotherapy and who remained for 44% on monotherapy at the end of the consultation. This descriptive study confirms the lack of awareness of the metabolic syndrome in overweight patients and identifies barriers to effective management of the hypertension of these high risk patients.

[Association between blood pressure level and the follow up of the guidelines concerning the use of self blood pressure measurement]. / Association entre le niveau tensionnel en consultation et le suivi d'un protocole d'automesure.

OBJECTIVES: To evaluate the characteristics of hypertensive subjects who practise self measurement of blood pressure (SMBP) and their conditions of use, and to identify the properties of subjects using SMBP according the usual guidelines. METHODS: In 531 consecutive hypertensive subjects, referred to hypertension specialists, possessing a SMBP a questionnaire evaluating the condition of use of SMBP was given. Subjects following the guidelines about the use of SMBP have been compared to those using SMBP without specific design of supervision. RESULTS: In this population, aged 62 +/- 14 years, with 57% of men and a mean blood pressure of 147 +/- 23/82 +/- 12 mmHg, the SMBP devices have been bought without medical advice in 50% of cases (265/531). In 45% of cases (239/531), SMBP were made at the wrist. SMBP device was used every days in 26% of cases, every weeks in 27% of cases, every month or more in 22% of cases and only in case of uneasiness in 25% of cases. Blood pressure was measured only in the morning in 25% of cases, in the morning and evening in 31%, only the evening in 8% and at any time of the day in 36% of cases. More frequently 2 BP measurements were realized (47%) and in 19% of cases 3 measurements have been performed. In 15% of cases, the measurements were performed on 3 or 4 days consecutively, more frequently (85%) the measurements were realized without specific design ("once in awhile"). The data of SMBP were noted and showed to the doctor in 34% of cases. Only 12% (64/531) of subjects followed the usual guidelines concerning the use of SMBP (2 or 3 measurements, in the morning and the evening, during 3 or 4 consecutive days). Subjects following the guidelines for SMBP use have a higher SBP at the office than those using SMBP without specific design of supervision (155 +/- 25 mmHg vs 146 +/- 22 mmHg; p<0.01). CONCLUSION: Among hypertensives referred to hypertension specialists most of subjects use SMBP device without a specific design of supervision. Subjects with the most severe hypertension are those who have the best formation for SMBP.

[Is the white coat effect an alert reaction?]. / L'effet blouse blanche est-il une réaction d'alerte?

Is the white coat effect an alert reaction? In this cross-sectional study we compared the white coat effect on systolic blood pressure with the systolic blood pressure reactivity obtained during a stress test. The influence of the sympathetic system (LF band of systolic BP) and the parasympathetic system (HF band of pulse rate) on white coat systolic blood pressure and stress test systolic blood pressure were analysed. We stratified 174 subjects into two groups, according to their blood pressure: hypertensives (HT, n=44, BP>140/90 mmHg) and normotensives (NT, n=130). The BP was recorded during an occupational health consultation, over 24 hours, and beat to beat during a stress test (Finapress). White coat systolic BP was calculated as the difference between the consultation BP and the average systolic BP over 24 hours. The white coat systolic BP was not related with an increase in pulse rate. In contrast, during the stress test the increases in systolic BP and pulse rate were correlated (r=0.44; p<0.001). The white coat systolic BP was lower than the stress test systolic BP in the NT (6.6 +/- 7.2 vs 23 +/- 12 mmHg; p<0.001) and in the HT (16 +/- 11 vs 29 +/- 17 mmHg; p<0.001). The HT had a lower parasympathetic index than the NT (0.45 +/- 0.43 vs 0.92 +/- 0.83 bpm2; p<0.001). In the HT the white coat systolic BP was positively correlated with the stress test systolic BP (r=0.47: p<0.01) and negatively with the parasympathetic activity index. In conclusion, for recently diagnosed and untreated HT an early alteration of the parasympathetic system reveals that the white coat effect is a low amplitude alert reaction.

[Professional stress and blood pressure reactivity to stress do not predict blood pressure at 5 years]. / Le stress professionnel et la réactivité pressionnelle au stress ne prédisent pas la pression artérielle à 5 ans.

High job strain has been reported to be associated with higher blood pressure. Job strain could lead to hypertension if individual perception of stress or cardiovascular reactivity to stress are high. We report the results of the first five-year follow up study, which aimed to assess the respective influences of perception of professional strain and cardiovascular reactivity to a mental stress test on BP. A cohort of 292 healthy subjects (mean +/- SEM, 38 +/- 1 years) was followed for progression to hypertension outcome which was defined as an increase in SBP or DBP higher than 7 mmHg or a DBP higher than 95 mmHg during the follow-up. The high strain (HS) group representing 20.9% of the subjects was compared with the remaining subjects (NHS). Similarly the 20.9% subjects with the highest BP stress reactivity (HR) were compared with the remaining subjects (NHR). The Kaplan-Meier survival estimates revealed that neither high job strain, nor high stress reactivity, increased incidence of progression to hypertension. Age, alcohol, salt diet, BMI, and occupation did not interfere with our results. In conclusion, high stress cardiovascular reactivity and high job strain do not appear to be major risk markers for future high BP in healthy young adults. Stress could be associated with high BP at a short term and could explain high blood pressure in a long run only in stress-sensible subjects.

One-year hypertension incidence and its predictors in a working population: the IHPAF study.

THE AIMS OF OUR STUDY WERE: (i). to estimate the yearly incidence rates based on one vs two visits in a working population and (ii). to identify incident hypertension modifiable risk factors. A total of 21566 normotensive subjects were included in a 1-year cohort study. Blood pressure (BP) levels at inclusion and at the second year screening were measured on the basis of two visits, that is, if BP was over 140/90 mmHg in untreated subjects, they were invited to a control visit 1 month later. Height and weight were measured and behavioural risk factors were collected. Among the 17465 subjects who completed the entire protocol (9691 men and 7774 women), 17026 remained normotensive at a 1-year interval and 439 (325 men and 114 women) became hypertensive. Crude yearly incidence rates based on one visit were 6.21% in men and 3.06% in women, compared with 3.04% in men and 1.34% in women when incidence rates were based on two visits, a more than twofold difference. Age and body mass index at baseline were the two major independent determinants of incident hypertension in both genders. Smoking and alcohol consumption were significant risk factors in men but not in women, and a low educational level only in women. BP measurement on separate occasions is necessary to avoid overestimation of incidence. Weight in both genders and alcohol consumption in men were the main modifiable predictors of hypertension.

[Risk profiles of hypertension in normotensive subjects]. / Profils de risque d'hypertension artérielle chez le normotendu.

The aim of this study was to evaluate the influence of 10 factors suspected to be involved in hypertension genesis (age, body mass index, alcohol consumption, sodium to potassium urinary excretion ratio, systolic BP and heart rate response to mental stress, baroreflex sensitivity (BRS), job demand, job latitude (Karasec's questionnaire), and personality (Bortner's score). A cohort of 213 normotensive healthy subjects was followed during five years. Using K-means clustering technique we have defined 7 homogeneous groups of subjects. Four groups with different combinations of these factors had a significantly higher 5-year systolic BP increase. The common characteristic of these groups was a low BRS. In conclusion, cluster analysis is well suited to analyse combined effect of factors on hypertension genesis. Only low BRS seems to be the common factor involved in hypertension development.

[Medical management of libido disturbances in treated hypertensive patients: differences between men and women]. / Prise en charge médicale des troubles de la libido chez les hypertendus traités: différence entre homme et femme.

UNLABELLED: Decrease in sexual desire is a disturbance affecting treated hypertensive subjects of both sexes. In contrast with erection problems, this abnormality has rarely been studied in hypertensives treated with antihypertensive drugs. OBJECTIVES: To evaluate, using a self-administered questionnaire, the prevalence of sexual disturbance (decrease in sexual desire) in treated hypertensive subjects and to determine the management of these troubles. METHODS: In 428 hypertensive subjects, living in France and referred to hypertension specialists, a self-administered questionnaire evaluating the quality of sexual activity was given before the consultation. Nine specific questions focused on the quality of sexual function for the last 6 months in men or women (interest for sexuality, sexual desire, sexual pleasure). Secondly, the doctors were questioned about their management of these sexual disturbances. RESULTS: In this population of treated hypertensives, including 270 men and 158 women, with a blood pressure level of 139 +/- 20/84 +/- 13 mmHg, a decrease in sexual desire was reported by 47% of men (127/270) and 48% of women (76/158). Sexual disturbance was related to antihypertensive drugs in 46% of cases (93/203), more often in men (59% [75/127]) than in women (24%, [18/76]), p < 0.001). In subjects with sexual disturbance, a specific medical management has been proposed in 35% of cases (71/203), especially in men (in 46% of cases [58/127], and consisted in a specialized consultation for 34% (43/127) and/or the prescription of Sildenafil for 20% (26/127). In women, the lack of management of these troubles was more often observed than in men (82% vs 54%; p < 0.01). Modifications of antihypertensive treatments were rarely observed in 15% of cases (30/203) comparatively in men and women. CONCLUSIONS: Men and women with treated hypertension are at "high risk" of sexual disturbance. Management of sexual dysfunction in these subjects concerns only 35% of cases, especially men, including specific treatments and/or consultations, but changing in antihypertensive drugs still remains rare.

[Target organ effects in untreated hypertension]. / Atteinte des organes cibles dans l'HTA jamais traitée.

The parallel investigation of the renal and cardiac complications of recent and never treated systemic hypertension has only rarely been undertaken. The aim of this study was to define the renal function of never treated hypertensive subjects, separated into white coat hypertensives (HTbb: n = 19, BP at consultation 153/97 mmHg) or permanent hypertensives (HT: n = 49, BP at consultation 169/104 mmHg) as a function of their 24 hour BP. Their renal functions were then compared with those of normotensive subjects (NT: n = 10). The 68 hypertensive subjects seen consecutively underwent renal function investigation (DFG: glomerular filtration rate, DPR: renal plasmatic debit, and muAlb: microalbuminuria over 24 hours), and myocardial echography (measurement of the left ventricular mass index, IMVG). The white coat hypertensives had a normal renal function, while the permanent hypertensives had a significant decrease in DPR and a significantly higher muAlb compared to the normotensives. Compared to the white coat hypertensives, the permanent hypertensives had a significantly lower DFG and DPR, as well as a higher muAlb and IMVG. In all the hypertensives (white coat and permanent) the 24 hour systolic BP was significantly correlated with muAlb (r = 0.51, p < 0.001), filtration fraction (r = 0.30, p < 0.05), and IMVG (r = 0.52, p < 0.001). The renal and myocardial parameters were not significantly correlated. In conclusion, there seems to be a continuum between the level of ambulatory BP and the effect on target organs without a parallel progression of the renal and myocardial effects. From a practical point of view, only ambulatory BP measurement allows differentiation of permanent hypertensives who have a very early renal and/or myocardial effect, while white coat hypertensives are spared.

[Cardiovascular impact of psychological stress]. / Stress mental et système cardiovasculaire.

The cardiovascular impact of stress depends on, first individual perception of stress and second individual cardiovascular reactivity to a stressful stimulation. Psychological stressors are filtered by cognitive appraisal mechanisms before causing biological response so that, for the same strain, individual effects may differ. Therefore, due to complexity of stress personal management, a multilevel stress measurement strategy is needed. To measure stress cardiovascular impact, stress should be precisely quantified. Recently, questionnaires have been developed to score not only the strain but also the personal perception of the strain. Individual stress reactivity can be evaluated by hormone response (epinephrine, norepinephrine, steroids) or by cardiovascular reactivity to a stress test. Until now, all the studies found that stress was independently related to blood pressure especially in active people. Prospective studies are still ongoing to definitively prove that stress could explain hypertension in a subset of hypertensives.

[Sexual dysfunction in treated hypertensive patients. Results of a national survey]. / Troubles de la sexualité chez les hypertendus traités. Résultats d'une enquête nationale.

OBJECTIVES: To evaluate, using an self-administered questionnaire, the characteristics of sexual function in treated hypertensives. METHODS: In 459 hypertensive subjects, aged of 59 +/- 12 years, living in France and referred to hypertension specialists, a self-administered questionnaire evaluating quality of life and antihypertensive treatment was given before the consultation. Several questions focused on the quality of sexual function since the last 12 months (interest for sexuality, sexual pleasure, quality of erection). Details on antihypertensive treatments and cardiovascular characteristics were obtained from medical records. Antihypertensive treatments were prescribed since more than 10 years for 39% of subjects, since 5-10 years for 25%, since 1-5 years for 26%, and since less than 1 year for 10%. RESULTS: In this population of treated hypertensives, blood pressure level was higher in men than in women (145 +/- 22/86 +/- 13 vs 135 +/- 25/76 +/- 15; p < 0.01). In the questionnaire, the section with sexual function questions was filled out extensively in 92% of men (248/268), but only in 74% of women (142/191). Sexual disturbance was declared by 38% of cases (148/390), but rate was significantly higher in men as compared to women (49% vs 18%; p < 0.01). In men, these modifications were characterised by an interest for sexuality decreased for 58%, unchanged for 41% and increased for 1%. Sexual pleasure was decreased for 49%, unchanged for 50%, and increased for 1%. Quality of erection was modified in 45%. The erections were less frequent for 31%, less durable for 19% and impossible for 11%. In women, interest for sexuality was decreased for 41% and unchanged for 59%, sexual pleasure was decreased for 34% and unchanged for 66%. Logistic regression analysis indicates that gender (p < 0.001), greater number of antihypertensive tablets (p < 0.01), prescription of diuretics (p = 0.03) and presence of coronaropathy (p = 0.01) were independent determinants for sexual disturbance in treated hypertensives. CONCLUSION: This study indicates that sexual disturbance is declared by 38% of patients treated for hypertension. Because complaints are more frequent in men, treated with multiple medications including a diuretic, a specific interrogation should be proposed more regularly in these patients in order to detect and to deal with, if possible, sexual disability.

[Rational choice for second antihypertensive agent after failure of the first monotherapy: therapeutic strategy]. / Choix raisonné du deuxième antihypertenseur après l'échec d'une première monothérapie: la stratégie des paniers thérapeutiques.

This study evaluated a strategy to treat naive hypertensive patients, based on a single monotherapy followed, in uncontrolled patients, by a rationale choice for the second antihypertensive treatment. Subjects with essential hypertension, entered into the study if their BP measured with an OMRON 705CP was > 140/90 mmHg on two separate visits. Patients were allocated to single treatment in a balanced randomized design to receive either a "group 1" treatment (ACE inhibitor, beta-blocking drug or ARB) or a "group 2" treatment (calcium channel-blocking drug or thiazide diuretic). After one month of treatment at a standard dose, if BP was > 140/90 mmHg, first adaptation was a fixed combination therapy with one drug from "group 1" and one drug from "group 2". At 3 months, patients with BP < 140/90 mmHg were considered to have reached BP goal. Forty-eight patients entered the study with a mean age of 53 +/- 11 years. Initial SBP/DBP (mmHg) was 164 +/- 16/97 +/- 8. After 1 month, 40% achieved the target BP, 52% were uncontrolled with no side effects and 8% were uncontrolled and had side effects. After 3 months, 84% achieved BP goal and a fixed combination therapy was prescribed in 52% of the controlled patients. The initial monotherapy was maintained alone or in combination in 70% of the controlled patients. A strategy based on a single monotherapy followed, if necessary, by a rational choice for the second treatment in a fixed combination therapy is effective to achieve BP control in 84% of naive hypertensive patients.

Renal elimination of amikacin and the aging process.

OBJECTIVE: Although amikacin is primarily eliminated via glomerular filtration, drug concentrations are not consistently predicted in all patients. To better describe the relationship between amikacin clearance and both age and renal function, we used a new heuristic approach involving statistical analysis of dependence. DESIGN AND SETTING: Retrospective pharmacokinetic study using data from seven centres in France. PARTICIPANTS: 634 patients with sepsis aged between 18 and 98 years of age who received intravenous amikacin. METHODS: Clearance of amikacin was modelled using the NonParametric EM algorithm for a two-compartment model (NPEM2) with intravenous infusion. RESULTS: A total of 2499 serum amikacin determinations was available for analysis. The relationship between the clearance of amikacin and age was weak. Interestingly, the Z method, which filters data based on dependence criteria, selected data that were best fitted by a polynomial function (r = 0.90; p < 0.001). This representation of the polynomial function was similar to a previously proposed theoretical model describing covariations between the clearance of amikacin and age. However, the polynomial function applied to only 33% of the patients that were selected by the Z method. The correlation between the clearance of amikacin and renal function was also relatively low (r = 0.39). The Z method exhibited a continuous and strong dependence pattern between the clearance of amikacin and age for 49% of the patients. CONCLUSIONS: The Z methodology, which filters data using dependence criteria, confirms that age, renal function and amikacin clearance are strongly related, but only in less than half of a large sample of patients with sepsis without renal pathology. These results suggest that other variables should be taken into account in order to improve the description of the behaviour of amikacin. The Z methodology improved the classical description of relationships between variables, and should be applied to better select pertinent variables in pharmacokinetic studies.

Limits of clinical tests to screen autonomic function in diabetes type 1.

OBJECTIVES: A precocious detection of cardiac autonomic dysfunction is of major clinical interest that could lead to a more intensive supervision of diabetic patients. However, classical clinical exploration of cardiac autonomic function is not easy to undertake in a reproducible way. Thus, respective interests of autonomic nervous parameters provided by both clinical tests and computerized analysis of resting blood pressure were checked in type 1 diabetic patients without orthostatic hypotension and microalbuminuria. MATERIAL AND METHODS: Thirteen diabetic subjects matched for age and gender to thirteen healthy subjects volunteered to participate to the study. From clinical tests (standing up, deep breathing, Valsalva maneuver, handgrip test), autonomic function was scored according to Ewing's methodology. Analysis of resting beat to beat blood pressure provided autonomic indices of the cardiac function (spectral analysis or Z analysis). RESULTS: 5 of the 13 diabetic patients exhibited a pathological score (more than one pathological response) suggesting the presence of cardiovascular autonomic dysfunction. The most discriminative test was the deep breathing test. However, spectral indices of BP recordings and baro-reflex sensitivity (BRS) of these 5 subjects were similar to those of healthy subjects and of remaining diabetic subjects. CONCLUSION: Alteration in Ewing's score given by clinical tests may not reflect an alteration of cardiac autonomic function in asymptomatic type 1 diabetic patients, because spectral indices of sympathetic and parasympathetic (including BRS) function were within normal range. Our results strongly suggest to confront results provided by both methodologies before concluding to an autonomic cardiac impairment in asymptomatic diabetic patients.