What is the relevance of the HOPE study in general practice?

The unique findings from the HOPE (Heart Outcomes Prevention Evaluation) study strongly support extending the use of the angiotensin-converting enzyme (ACE) inhibitor ramipril as a preventive agent for patients at high risk of cardiovascular events with normal left ventricular function. In addition, ramipril provides significant benefit in diabetic patients. These findings will impact on how ramipril is used in primary care, where ACE inhibitors are currently underprescribed. Patients reflecting the inclusion criteria of the HOPE study should be considered as suitable candidates for long-term ramipril therapy as an addition to their existing drug regimen. Screening should include control of kidney function (by serum creatinine), particularly within the first two weeks of treatment, in addition to regular monitoring of serum potassium. However, the HOPE study shows that ramipril is well tolerated at high doses and over a long treatment period. The effectiveness of therapy should also be regularly reviewed and dose adjustments made where necessary. If concern remains, referral to a specialist--a cardiologist or a diabetologist--may ultimately be necessary.

Regression of left ventricular hypertrophy in hypertensive patients treated with indapamide SR 1.5 mg versus enalapril 20 mg: the LIVE study.

OBJECTIVE: To compare the efficacy of indapamide sustained release (SR) 1.5 mg and enalapril 20 mg at reducing left ventricular mass index (LVMI) in hypertensive patients with left ventricular hypertrophy (LVH). DESIGN: The LIVE study (left ventricular hypertrophy regression, indapamide versus enalapril) was a 1 year, prospective, randomized, double-blind study. For the first time, a committee validated LVH before inclusion, provided on-going quality control during the study, and performed an end-study reading of all echocardiograms blinded to sequence. SETTING: European hospitals, general practitioners and cardiologists. PATIENTS: Hypertensive patients aged > or = 20 years with LVH (LVMI in men > 120 g/m2; LVMI in women > 100 g/m2). Data were obtained from 411 of 505 randomized patients. INTERVENTIONS: Indapamide SR 1.5 mg, or enalapril 20 mg, daily for 48 weeks. MAIN OUTCOME MEASURES: LVMI variation in the perprotocol population. RESULTS: Indapamide SR 1.5 mg significantly reduced LVMI (-8.4 +/- 30.5 g/m2 from baseline; P< 0.001), but enalapril 20 mg did not (-1.9 +/- 28.3 g/m2). Indapamide SR 1.5 mg reduced LVMI significantly more than enalapril 20 mg: -6.5 g/m2, P = 0.013 (-4.3 g/m2 when adjusted for baseline values; P = 0.049). Both drugs equally and significantly reduced blood pressures (P< 0.001), without correlation with LVMI changes. Indapamide SR progressively reduced wall thicknesses throughout the 1-year treatment period. In contrast, the effect of enalapril observed at 6 months was not maintained at 12 months. CONCLUSIONS: Indapamide SR 1.5 mg was significantly more effective than enalapril 20 mg at reducing LVMI in hypertensive patients with LVH.

User procedure for self-measurement of blood pressure. First International Consensus Conference on Self Blood Pressure Measurement.

OBJECTIVE: To review the medical literature regarding the methodology of self-measurement of blood pressure and to provide some practical recommendations regarding protocol and procedure for measurement, documentation and analysis of data, choice and provision of devices and education of patients and physicians. PROCEDURE AND PROTOCOL FOR MEASUREMENTS: Technical recommendations regarding measurement of blood pressure do not differ from usual guidelines. Frequency of measurement remains a matter of discussion. At the beginning of the self-measurements of blood pressure and during the titration phase, there should be a 7-day measurement period with two measurement of blood pressure each morning and two measurements in the evening at pre-stipulated times. For long-term observation, a minimum measurement period of 1 week per quarter is required. The minimum number of measurements performed during each period should be a total of 12 readings recorded within seven working days. Depending on individual needs (e.g. poor compliance) or for pharmacologic studies, a higher frequency of readings could be used. DOCUMENTATION AND ANALYSIS OF DATA: Owing to the lack of reliability of patients' diaries, the use of printer-equipped or memory-equipped devices is advocated. All the recorded data, except those obtained on the first day, must be used for analysis. CHOICE AND PROVISION OF DEVICES: Self-measurement of blood pressure should be performed with validated fully automated devices using a brachial cuff. The preference should be given to apparatus offering the possibility of storing and transmitting measurements. Wrist apparatus should be used with caution due to the risk of measurement errors if it is used inappropriately. A manual device should be considered for patients suffering from irregular cardiac rhythms and patients with large or small arm circumferences, since automated devices have not been validated for use in these situations. Reimbursement of hypertensive patients using validated devices should be considered, so long as they are adequately trained and supervised. EDUCATION OF PATIENTS: In a therapeutic perspective, self-measurement of blood pressure should be performed by trained patients under the supervision of their practitioner. Teaching must be performed by skilled staff in hypertension centers and ultimately in general practice. Self-measurement of blood pressure is to be recommended for any hypertensive patient who is sufficiently motivated to participate in the treatment of his own hypertension. Patients with physical problems or mental disabilities that make them unable to perform or to understand the measuring technique represent the limits of the method. Education of patients must encompass information about hypertension and cardiovascular risk, blood-pressure-measurement procedures, advice on items of equipment and their proper use, protocols, and interpretation of data. A patient's proficiency must be checked before he or she should be considered competent at performing the procedure. Annual reevaluation is required.

[Spanish Society of Cardiology practice guidelines on ambulatory monitoring of electrocardiogram and blood pressure]. / Guías de práctica clínica de la Sociedad Española de Cardiología en la monitorización ambulatoria del electrocardiograma y presión arterial.

In the present paper, a historical review and a clinical up-date are done on two procedures of great medical interest: Holter electrocardiography and ambulatory blood pressure monitoring. Technical and methodological characteristics of each procedure are carefully exposed, emphasizing each the lack of an international agreement in order to establish regulations that make all the equipment homogeneous and reliable in order to increase both accuracy and reliability in diagnosis. Based on published international scientific documents and the personal experience of the authors, guidelines for clinical applications, indications and limitations of each technique are analyzed in relation to capacities of the Spanish political and social public health system profile. New concepts and dynamics of developments such as; dynamic QT, RR variability or pulse wave velocity are exposed, in the frame of the present time and future for improving efficiency and clinical application.

[Arterial hypertension and pregnancy: diagnostic criteria and therapeutic approach]. / Hipertensión arterial y embarazo: criterios diagnósticos y enfoque terapéutico.

Arterial hypertension is a relatively common complication of pregnancy, affecting about 10% of all normal pregnancies. The American College of Obstetric and Gynecology established in 1972 four different forms of arterial hypertension during pregnancy: a) arterial hypertension related to pregnancy, the so-called pre-eclampsia; b) arterial hypertension unrelated to pregnancy or chronic arterial hypertension; c) Pre-eclampsia superimposed on chronic arterial hypertension, and d) Transient or late arterial hypertension (third trimester). Pre-eclampsia and arterial hypertension are two different illnesses with different approaches and treatments. The mechanisms involved in arterial hypertension and pre-eclampsia of pregnant women are presently very well known, including genetic causes, alterations on the renin-angiotensin system, imbalance between vasoconstrictor and vasodilator agents derived from endothelial activity of the spiral arteries of the placenta, such as; prostacyclins, thromboxane A2, nitric oxide, endothelin-1, etc. The placenta is the key factor in inducing pre-eclampsia, and its expulsion during delivery or cesarean section is the definite cure of the process. All hypertensive forms during pregnancy increase the risks on both the mother and the fetus. Maternal risk is based on renal, metabolic and haematologic disorders, leading in some cases to cerebral haemorrhage or hepatic rupture. In the fetus, pre-eclampsia significantly increases the risk of still-birth, abruptio placentae, hypocalvaria, intrauterine growth retardation, and prematurity. Clinical, biochemical and haematologic manifestations of pre-eclampsia are very typical, facilitating an early and easy diagnosis.

[Silent myocardial ischemia and nitrates]. / Ischémie myocardique silencieuse et dérivés nitrés.

Silent ischaemia (SI), generally identifiable as a transient abnormality of ECG, not accompanied by angina or equivalent clinical symptoms, is a common finding in patients suffering from coronary heart disease before and after myocardial infarction, or after surgical coronary revascularization or angioplasty. SI per se is considered to be a serious independent cardiovascular risk factor. From a pathophysiological point of view, SI is intimately related to myocardial oxygen imbalance, in which the demand, both at rest and during effort, exceeds the supply, essentially due to coronary arteriosclerosis or arterial spasm, or both, alongside other neuroendocrine and clotting factors which contribute to the final clinical picture. The absence of large-scale prospective studies prevents a rigorous assessment of whether the currently available anti-ischaemic treatments modify the cardiovascular prognosis related to the presence of SI. Long-acting nitrates, as well as beta-blockers and type L calcium channel blockers exert a beneficial effect on the total ischaemic load, improving not only the clinical profile of angina patients and their exercise tolerance, but also, in most published series, considerably decreasing the number of silent ischaemic events. Today's medical challenge therefore consists of determining whether the reduction of SI by means of anti-ischaemic drugs is accompanied by a proportional reduction of overall morbidity and mortality attributable to this process. As the asymptomatic nature of this type of ischaemia prevents evaluation on the basis of clinical data, it specialized analyses are necessary, such as stress ECG, Holter monitor, TEP, or Thallium 201 myocardial scan, and especially prognostic follow-up, in order to establish the real efficacy of drugs therapy. Coronary videoangiography and the various myocardial revascularization techniques can be applied when the ischaemia cannot be controlled clinically, and when a significant reduction of total ischaemic load is not obtained. In situations of pre-infarction ischaemia, some studies show that the use of nitrate vasodilators reduces the total ischaemic load, improving the clinical course of the disease and significantly reducing the total number of silent ischaemic episodes, although their secondary preventive action remains to be demonstrated. The anti-ischaemic action is more obvious for events triggered by physical effort (ergometry) than for those observed during Holter monitoring, which confirms that multiple mechanisms are responsible for inducing ischaemia and that circadian variability also depends on many factors, which is why the choice of an anti-ischaemic drug must be based on a thorough knowledge of the pathophysiological mechanisms which induce ischaemia and the anatomical and functional setting in which it develops. It has been clearly shown that nitrate vasodilators not only exert a beneficial action in terms of the control of painful or silent ischaemic events, but that they are also useful as coadjuvant therapy in the presence of signs of ischaemic ventricular dysfunction.

[Current status of arterial hypertension as a cardiology topic: point of view of the cardiologist. Task force on Arterial Hypertension of the Spanish Cardiology Society]. / Estado actual de la hipertensión arterial como materia de la cardiología: punto de vista del cardiólogo. Grupo de Trabajo de HTA de la SEC.

Even if arterial hypertension (HT) is a process of multiorganic involvement, it is nevertheless in practice, one of the most powerful factors for the development of cardiovascular complications that increases very seriously, both cardiovascular morbidity and mortality. Paradoxically, in Spain, a significant proportion of cardiologists have neglected for many years this disease, at least, at its initial phase, acting mainly, only when the usual and severe cardiovascular complications of HT were clinically well established. Currently, this attitude is changing in such a way, that in the near future, the cardiologist's commitment to HT, will be definitely engaged in both; basic research and clinical aspects. The Spanish Hypertension Working Group, has worked out in an inquiry sent to all Spanish cardiologists, in order to know their point of view in relation to the main aspects involving HT and cardiological practice. This paper collects the results of the answers given anonymously by the doctors.

High blood pressure and calcium antagonism.

Calcium ions are intimately involved in many aspects of cardiovascular function. Modification of calcium homeostasis therefore represents a key target for pharmacological intervention to achieve therapeutic control of hypertension. The calcium channel blockers (CCBs) act by blocking calcium influx through voltage-dependent L (long-acting) channels without affecting calcium release from the sarcoplasmic reticulum. The effect of blocking these channels is a decrease in the intracellular calcium concentration, which reduces vascular smooth muscle tone. The subsequent decrease in peripheral resistance causes a decrease in systemic blood pressure. The CCBs also decrease myocardial contractility, which decreases myocardial oxygen consumption. Overall, the CCBs at therapeutic doses improve the efficiency of ventricular function. They also have a number of other beneficial effects, including an antiproliferative effect. The CCBs in clinical use vary according to their relative selectivities for vascular and cardiac tissue and their applicability to the treatment of hypertension or ischaemic heart disease. The first-generation CCBs (verapamil, nifedipine and diltiazem) are associated with a relatively short duration of action and unwanted cardiovascular effects that were related to poor vascular selectivity. In addition, nifedipine was associated with a very rapid onset of action that caused a sudden vasodilation and reflex tachycardia in some patients. The newer second-generation CCBs, for example the dihydropyridines, amlodipine, felodipine and nisoldipine, show greatly improved vascular selectivity and longer durations of action, achieved in part by novel controlled-release dosage forms. They bind to target receptors in a slow and sustained fashion, producing a smooth onset of action and 24-hour control of blood pressure. Once-daily dosing of these longer-acting agents improves patient compliance and is associated with a good side-effect profile. The second-generation CCBs are suitable antihypertensive agents for a wide range of patients, including the elderly and black patients, and those with concomitant diseases that preclude the use of other antihypertensives.

[White coat hypertension under outpatient conditions: indications for ambulatory monitoring of arterial pressure]. / La hipertensión de bata blanca en el medio extrahospitalario: indicaciones de la monitorización ambulatoria de la presión arterial (MAPA).

Ambulatory blood pressure monitoring (ABPM) is to be considered an excellent diagnostic tool, progressively used by the clinicians in their routine medical practice, in order to assess both medical diagnosis and antihypertensive treatment efficacy. ABPM permits to distinguish with a high level of accuracy the true hypertensives, from the false hypertensives or from subjects with isolated clinical hypertension, the old so-called "white coat hypertension". Prognostic implications of hypertension and target organ involvement can be assessed more accurately with ABPM than with basal blood pressure measurement. ABPM also permits an excellent approach to 24-hour blood pressure load, establishing different categories of circadian curves. In the same way, the 24-hour monitoring observation period during a normal daily life, helps to identify the hot moments of circadian period, correlating them, with changes in blood pressure, and subsequently with cardiovascular events, particularly in the early morning hours, during the so-called circadian vulnerable period, in which a significant increase in both cardiovascular events and stroke are usually observed. Nevertheless, some limitations are still linked to ABPM systems and equipments; on the one hand, the lack of a cut-off point, to establish the limits of true normally, and on the other one; the today intermittent character of ABPM measurements, do not permit an exact assessment of 24-hour blood pressure profile, containing all the hemodynamic changes. Several ongoing studies, will bring in the near future the very necessary answers to all these interrogants.

[QKD: a new parameter for clinical research on hypertension]. / QKD: un nuevo parámetro de investigación clínica en la hipertensión arterial.

Structural and functional heart changes induced by hypertension are easily detected nowadays by ecocardiography-Doppler. Nevertheless, this diagnostic tool is less conclusive to evaluate the large arteries modifications during hypertension. High blood pressure induces from the beginning architectural changes in all artery beds, characterized by an increase in wall thickness, reversing secondary the ratio wall thickness/lumen radio. The increase in wall stiffness as a consequence of cellular hypertrophy and hyperplasia, modifies substantially both, distensibility and compliance, two major factors in determining the grade of left ventricular hypertrophy and performance. Evaluation of pulse wave velocity implemented with a new algorhythm (QKD) permits by non-invasive ambulatory long period of time method, an indirect approach to the arterial functional state in hypertension and aging, establishing in some instances, prognosis criteria, with an accuracy even better than that given by the 24-hour load pressure index.

[The clinical utility of the automatic ambulatory recording of the arterial pressure in the diagnosis, prognosis and treatment of arterial hypertension]. / Utilidad clínica del registro ambulatorio automático de la presión arterial en el diagnóstico, pronóstico y tratamiento de la hipertensión arterial.

Ambulatory blood pressure monitoring (ABPM) is, nowadays, one of the most powerful medical tools, in the evaluation of blood pressure (BP) behaviour during a normal daily life, particularly in hypertensive patients, and to assess with a high level of accuracy, the antihypertensive effectiveness of the pharmacological compounds. In this paper, we present the main indications and limitations of the method, and a new circadian classification of arterial hypertension based on an average deviation index (ADI), resulting of the addition of all the systolic and diastolic ambulatory measurements exceeding 140/90 mmHg recorded along the 24-hour extrahospital monitoring, and dividing the result by two. The study was carried out in 939 hypertensive patients diagnosed by means of basal blood pressure measurements (BP > 140/90 mmHg), and in 45 normal volunteers. Hypothetically, this ADI may vary only from 0 (normal curve) to 100% (complete abnormal circadian curve). From ADI 0 to 100, we have established 4 categories of circadian curves as follows: curve 0 or "normal" if the ADI varies from 0 to 5%, curve type I or "borderline" (white coat phenomenon) if ADI moves between 6 and 30%, curve type II or "diurnal" if the ADI varies from 31 to 65%, and finally curve type III or "sustained", if the ADI goes further on than 66%. The results indicate clearly a high percentage of white coat hypertension (30%) where 4% showed an ADI less than 5%. A half approximately of the patients showed diurnal hypertension, and a quarter of them, both diurnal and nocturnal hypertension, so-called sustained hypertension. 75% of all the hypertensive patients showed spontaneous normotensive values at nighttime.(ABSTRACT TRUNCATED AT 250 WORDS)

[Analysis of high frequency and low amplitude late potentials in the body surface electrocardiogram, in acute and chronic stages of ischemic cardiopathy]. / Análisis de los potenciales tardíos de alta frecuencia y baja amplitud del electrocardiograma de superficie, en las fases aguda y crónica de la cardiopatía isquémica.

A study to evaluate late potentials (LP) was carried out in 50 patients diagnosed as suffering from coronary heart disease. All the patients were divided into two groups: Group A, was made of 25 patients in the acute period of myocardial infarction, and group B, was made of other 25 patients in the chronic phase, with more of 3 months of evolution from the acute event. Average age in group A was 54.2 years, and 58.1 years in group B. Twenty normal volunteer subjects (group C) were also studied as a reference group. All the subjects in the 3 groups were in normal sinus rhythm, and no one of them showed bundle branch block in the basal ECG. Analysis of the vector magnitude was made for each point of the averaged wave, as the result of the mean root square of the addition of bipolar leads X, Y and Z, using a LP-3000 Fidelity Medical Inc. equipment, with a four poles Butterworth filter. LP were detected in 32% of the patients in group A, and in 56% of the group B (p less than 0.001). No LP was observed in patients of the group C. Concerning the localization of myocardial infarction, maximum CPK value, or Lown's grade of ventricular arrhythmias observed in coronary care unit, or in the 3rd week Holter monitoring, did not show significant statistical correlationship with the presence of LP in group A.(ABSTRACT TRUNCATED AT 250 WORDS)

[Non-invasive long-term monitoring of blood pressure and arrhythmias in hypertensive patients treated with metoprolol]. / Nichtinvasive Langzeitregistrierung von Blutdruck und Arrhythmien bei Hypertonikern unter Behandlung mit Metoprolol.

Non-invasive long-term-registration of blood-pressure and ECG was performed in 20 ambulatory patients at the age of 31 to 69 years. The method was also used to observe the effect of metoprolol. Mean arterial pressure was above 113 mm Hg, and could be reduced to values below 113 mm Hg. In 4 cases an additional dose of a diuretic was necessary. Metoprolol had also a positive effect on reduction of ventricular extrasystoles in the ECG-monitoring.