Impact of miscuffing during home blood pressure measurement on the prevalence of masked hypertension.

BACKGROUND: Masked hypertension has been associated with obesity. However, because most studies do not mention the specific cuff size used for home measurements, masked hypertension prevalence may have been overestimated in obese patients because of undersized cuffs. In this prospective, observational study, the effect of miscuffing on hypertension status was evaluated in patients with large arms. METHODS: Fifty-three patients with an upper-arm circumference >33cm, undergoing treatment for mild-to-moderate hypertension, took 2 sets of home blood pressure (BP) measurements (standard vs. large cuff) using the validated Microlife BP A100 Plus automated device. RESULTS: Mean BP was 143/85mm Hg at the office using a large cuff, 141/84mm Hg at home using a standard cuff, and 134/80mm Hg at home using a large cuff. Standard vs. large cuff home BP mean differences were 6.9mm Hg (95% confidence interval (CI) = 4.7-9.2; P < 0.0001) for systolic BP and 4.0mm Hg (95% CI = 2.4-5.5; P < 0.0001) for diastolic BP. Hypertension status differed significantly between standard vs. large cuffs: sustained hypertension (56.6% vs. 41.5%, respectively; P = 0.002), controlled hypertension (20.8% vs. 28.3%, respectively; P = 0.04), white coat hypertension (7.5% vs. 22.6%, respectively; P = 0.002), masked hypertension (15.1% vs. 7.5%, respectively; P = 0.04). CONCLUSIONS: In patients with large arms, use of an appropriately sized large cuff for home BP measurements led to a 2-fold reduction in masked hypertension. Regarding clinical and epidemiological implications, future studies investigating masked hypertension should specify cuff size for home BP measurements. The low market availability and increased cost of large cuffs should also be addressed.

Stress hyperglycaemia is an independent predictor of left ventricular remodelling after first anterior myocardial infarction in non-diabetic patients.

AIMS: Stress hyperglycaemia (SH) is associated with adverse outcome in patients with acute myocardial infarction (MI) but the mechanisms underlying this association are unknown. Our hypothesis was that SH on admission for acute MI may be associated with left ventricular (LV) remodelling. METHODS AND RESULTS: We analysed LV remodelling in 162 non-diabetic patients with anterior MI. SH was defined as a glycaemia on admission >or=7 mmol/L. Systematic echocardiographic follow-up was performed at 3 months and 1 year after MI. The changes in end-diastolic volume (EDV) and end-systolic volume (ESV) from baseline to 1 year were 11.4 +/- 16.5 and 6.4 +/- 12.4 ml/m(2), respectively, in patients with SH vs. 1.9 +/- 11.1 and 0.2 +/- 8.5 ml/m(2), respectively, in patients without SH (both P < 0.0001). When LV remodelling was defined as a >20% increase in EDV, it was observed in 46% patients in the SH group vs. 19% patients in the no SH group (P = 0.0008). By multivariable analysis, baseline wall motion score index (P = 0.001) and SH (P = 0.009) were independently associated with changes in EDV. SH was an independent predictor of LV remodelling [adjusted OR: 3.22 (1.31-7.94)]. CONCLUSION: SH is a major and independent predictor of LV remodelling after anterior MI in non-diabetic patients.

Parenchymal consequences of fibromuscular dysplasia renal artery stenosis.

PURPOSE: The aim of this study is to assess parenchymal consequences of fibromuscular dysplasia (FMD) renal artery stenosis (RAS) in hypertensive patients by spiral computed tomographic angiography (CTA). METHODS: Spiral CTA was performed in 20 essential hypertensive (EH) patients (40 EH kidneys and 20 hypertensive patients with unilateral FMD stenosis (20 poststenotic [S] kidneys, 20 opposite [OPP] kidneys). Renal length (RL; in millimeters), mean cortical thickness (MCT; in millimeters), cortical area (CA; in square millimeters), and medullary length (ML; in millimeters) were evaluated. RESULTS: Blood pressure, creatinine clearance, and long-standing hypertension were similar in both groups of patients. Compared with EH kidneys, S and OPP kidneys showed significant cortical thinning (MCT(EH) = 9.2 +/- 0.8 mm versus MCT(OPP) = 7.8 +/- 1.0 mm versus MCT(S) = 7.3 +/- 1.0 mm; P < 0.0001). RL and ML were reduced only in the S kidney group, with RL(EH) = 103 +/- 11 mm versus RL(OPP) = 105 +/-10 mm versus RL(S) = 96 +/- 11 mm; P = 0.05; and ML(EH) = 84 +/- 11 mm versus ML(OPP) = 89 +/- 9 mm versus ML(S) = 81 +/- 10 mm; P = 0.05, respectively. CA and MCT correlated significantly with creatinine clearance in the entire population (r = 0.43; P = 0.005; r = 0.35; P = 0.02, respectively). CONCLUSION: Unilateral RAS was associated with bilateral cortical thinning in FMD disease. Cortical atrophy appears to be an accurate marker of unilateral RAS. Its use as a potential screening method for RAS should be investigated further.

Renal atrophy outcome after revascularization in fibromuscular dysplasia disease.

PURPOSE: To assess clinical, biological, and kidney parameters before and 6 months after revascularization of renal artery stenosis due to fibromuscular dysplasia (FMD). METHODS: Twenty hypertensive patients (18 women; mean age 48.7 +/- 15.4 years) with unilateral de novo FMD stenosis were studied before and 6 months after revascularization (balloon angioplasty 19; bypass surgery 1). Blood pressure and creatinine clearance were measured, and renal length, cortical thickness, cortical area (CA), and medullary length (ML) were evaluated by spiral computed tomographic angiography (CTA) in 20 poststenotic and 20 contralateral kidneys. RESULTS: Six months after revascularization, the systolic and diastolic blood pressures decreased by 19 mmHg and 10 mmHg, respectively (p=0.02), the number of antihypertensive drugs decreased by 1 (p=0.01), but the increase in creatinine clearance was not significant. At baseline, the poststenotic kidneys were significantly more atrophied than the contralateral normal kidney (ML in normal kidney 89 +/- 9 mm versus 81 +/- 10 mm in poststenotic kidney, p<0.001; CA in normal kidney 824 +/- 149 mm(2) versus 703 +/- 156 mm(2) in poststenotic kidney, p<0.01), which persisted at 6 months (ML in normal kidney 89 +/- 10 versus 80 +/- 11 in poststenotic kidney, p<0.001; CA in normal kidney 807 +/- 145 mm(2) versus 696 +/- 157 mm(2) in poststenotic kidney, p<0.01). Renal length was still within normal range in all kidneys, and the morphological parameters remained stable after revascularization. CONCLUSIONS: We demonstrated significant cortical/medullary atrophy in poststenotic kidneys compared to contralateral normal kidneys. Despite intraparenchymal disease, clinical outcome was favorable after revascularization. Cortical/medullary thinning appears to be an early marker of renal ischemia that could support revascularization in FMD disease.

Cortical thickness: an early morphological marker of atherosclerotic renal disease.

BACKGROUND: Although kidney size is still the most commonly used morphological parameter, it is not sensitive enough for early detection of atherosclerotic renal disease (ARD). The purpose of this work was to evaluate morphological abnormalities on both post-stenotic and contralateral kidneys, by using spiral computed tomography angiography (CTA). METHODS: Spiral CTA was performed in 49 hypertensive patients. Renal diameters, renal length, and cortical thickness were measured in 26 post-stenotic kidneys, 26 contralateral kidneys and 46 control kidneys. Mean cortical thickness, cortical area, and medullary length were calculated. RESULTS: The right and left control kidneys were of comparable morphology. The post-stenotic kidneys showed significant cortical atrophy. The contralateral kidneys also underwent cortical disease, as judged by comparison with control kidneys. A threshold of 800 mm2 was identified for the cortical area that allowed us to distinguish control kidneys from post-stenotic kidneys. Similarly, a threshold of 8 mm was identified for mean cortical thickness. Renal length was still within normal range in all kidney groups. The measurement of superior pole segments appeared to be more sensitive than measurement at other locations for identifying significant intrarenal lesions. There was no significant correlation between clinical and morphological parameters. CONCLUSIONS: These results suggest that cortical parameters are more sensitive for early diagnosis of ARD than kidney size. Cortical atrophy should be a useful marker for guidance for revascularization.

Randomized, comparative, double-blind study of amlodipine vs. nicardipine as a treatment of isolated systolic hypertension in the elderly.

A 90-day, multicenter, randomized, double-blind, parallel-group study was conducted to compare the efficacy of amlodipine (once a day) with nicardipine (two to three times a day), in the treatment of isolated systolic hypertension (ISH) in the elderly. Patients (n = 133) aged > or = 60 years, with ISH were randomized to receive either amlodipine 5 mg/day, or nicardipine 60 mg/day (titrated if necessary to 10 mg/day and 100 mg/day, respectively) for 90 days. Efficacy was assessed by measuring office blood pressure (BP), and 24-h ambulatory blood pressure monitoring (ABPM). The two treatments substantially and comparably reduced office systolic blood pressure (SBP) and pulse pressure (PP), and also produced a slight decrease in diastolic blood pressure (DBP). Amlodipine reduced SBP, as assessed by ABPM, to a significantly greater extent than nicardipine. Both treatments were well-tolerated. The sustained effect of amlodipine, compared with nicardipine, was reflected in its significantly greater antihypertensive activity, particularly during the nocturnal period, as assessed by ABPM. The study demonstrates that once a day dose of amlodipine is an effective antihypertensive treatment for elderly ISH patients.

Renal atrophy in atherosclerotic renovascular disease: gradual changes 6 months after successful angioplasty.

OBJECTIVE: To assess renal morphology using spiral computed tomographic angiography (CTA) before and 6 months after angioplasty of unilateral atherosclerotic renal artery stenosis (RAS). METHODS: Spiral CTA scans from 14 hypertensive patients (7 men; mean age 57.4 +/- 13.1 years) with significant RAS were performed before and 6 months after angioplasty; renal length, mean cortical thickness (MCT), cortical area (CA), and medullary length (ML) were measured from the axial slices in the 14 contralateral and 14 poststenotic then revascularized kidneys. Blood pressure, creatinine clearance, and number of antihypertensive drugs were analyzed. RESULTS: At 6 months, the systolic blood pressure was significantly reduced (p=0.007), but the number of antihypertensive drugs and the creatinine clearance did not change significantly. Most morphological parameters before and after angioplasty were different in the contralateral versus poststenotic kidneys (renal length, p=0.01; MCT, p=0.01; ML, p=0.03; CA, p=0.008). After angioplasty, there was an 11% drop in cortical atrophy associated with a mean 4-mm increase in medullary length in the poststenotic/revascularized kidneys. The contralateral kidneys exhibited corticomedullary thinning after angioplasty. CONCLUSIONS: In atherosclerotic renal disease, cortical thinning could be a useful timesaving marker to assess the significance of the lesion and to evaluate associated distal lesions. The favorable blood pressure outcome supports the existence of reversible ischemic lesions, particularly in the medulla. Angioplasty appears to be useful for the poststenotic kidney, according to the morphological study.