Screening obstructive sleep apnea-hypopnea syndrome in hypertensive patients: a comparative study of the efficiency of the Epworth sleepiness scale.

BACKGROUND: Untreated Obstructive Sleep Apnea Hypnopnea Syndrome (OSAHS) is a known factor contributing to resistant hypertension (HT). Continuous Positive Airways Pressure (CPAP) is effective to decrease blood pressure (BP) in severe OSAHS. In our clinical practice, hypertensive patients seem less symptomatic with regard to severe OSAHS than normotensive patients, leading to a risk of underdiagnosis when OSAHS is screened with Epworth Sleepiness Scale (ESS). We aimed to confirm that severe OSAHS is less symptomatic in HT patients than normotensive patients using ESS. METHODS: We retrospectively compared two age, gender-matched groups - 100 hypertensive patients and 100 normotensive patients - with severe OSAHS defined as an AHI (Apnea Hypopnea Index) ≥30. OSAHS was considered symptomatic when ESS > 10. RESULTS: The two groups of patients did not differ significantly with respect to main characteristics including Body Mass Index (BMI), AHI and ODI (Oxygen Desaturation Index). Systolic and Diastolic BP were higher in HT patients (p < 0.01). HT patients were less symptomatic with regard to severe OSAHS with a lower ESS (10.0 vs 11.9, p < 0.01), and a lower number of patients with an ESS > 10 (30% vs 58%, p < 0.01). In multivariable analysis adjusted on age, gender, Obesity, Systolic BP, Diastolic BP, AHI and ADO, normotension was significantly associated with symptomatic OSAHS (OR = 2.83, [1.298-6.192], p < 0.01). CONCLUSIONS: In our study on patients with severe OSAHS, ESS score was lower in hypertensive patients than in normotensive patients. This discrepancy may lead to an underestimation of severe OSAHS in hypertensive patients.

Genetic diagnosis of familial hypercholesterolemia is associated with a premature and high coronary heart disease risk.

BACKGROUND: Familial hypercholesterolemia (FH) is a common autosomal dominant disease associated with premature coronary heart disease (CHD). Studies tend to show that patients with FH associated with an identified mutation (mutation+ FH) are at higher risk than patients without an identified mutation (mutation- FH). We compared the clinical and biological profile and the risk of CHD in patients with mutation+ FH and mutation- FH. HYPOTHESIS: In addition to LDL-C, a pathogenic mutation predicts premature CHD in FH. METHODS: We successively included all patients with suspected FH (LDL-C > 190 mg/dL if age > 18 years; LDL-C > 160 mg/dL if age < 18 years) and compared patients with a pathogenic mutation with those without an identified pathogenic mutation. RESULTS: We studied 179 patients with mutation+ FH and 147 with mutation- FH. The mean age was 44 (± 18) years. The lipid profile was more atherogenic in those with mutation+ FH, who had higher LDL-C (254 ± 69 mg/dL vs 218 ± 35 mg/dL; P < 0.01) and lower HDL-C (53 ± 14 mg/dL vs 58 ± 17 mg/dL; P < 0.01). Despite the more atherogenic nonlipid cardiovascular profile of patients with mutation- FH, the age of CHD onset was earlier in patients with mutation+ FH (48 vs 56 years; P = 0.026). After multiple adjustment, the presence of a positive mutation was significantly associated with premature CHD (OR: 3.0, 95% CI: 1.38-6.55, P < 0.01). CONCLUSIONS: Patients with mutation+ FH have a more atherogenic lipid profile and a 3-fold higher risk of premature CHD, as well as earlier onset of CHD, than patients with mutation- FH.

Segmentation of lumen and outer wall of abdominal aortic aneurysms from 3D black-blood MRI with a registration based geodesic active contour model.

Segmentation of the geometric morphology of abdominal aortic aneurysm is important for interventional planning. However, the segmentation of both the lumen and the outer wall of aneurysm in magnetic resonance (MR) image remains challenging. This study proposes a registration based segmentation methodology for efficiently segmenting MR images of abdominal aortic aneurysms. The proposed methodology first registers the contrast enhanced MR angiography (CE-MRA) and black-blood MR images, and then uses the Hough transform and geometric active contours to extract the vessel lumen by delineating the inner vessel wall directly from the CE-MRA. The proposed registration based geometric active contour is applied to black-blood MR images to generate the outer wall contour. The inner and outer vessel wall are then fused presenting the complete vessel lumen and wall segmentation. The results obtained from 19 cases showed that the proposed registration based geometric active contour model was efficient and comparable to manual segmentation and provided a high segmentation accuracy with an average Dice value reaching 89.79%.

[Hypertension etiological work up: Hormonological assessment always before imaging?] / Bilan étiologique de l'HTA : dosages hormonaux toujours avant imagerie ?

The purpose is to consider the practical management of etiological work up in hypertension, beyond national or international recommendations, leading to consider the prior practice of hormonal assays or renal, renovascular or adrenal imaging. The ease of access to imaging, difficulties to meet the requirements to obtain reliable hormonal assays explain the use of first-line imaging in clinical practice. The renal and adrenal CT angiography provides diagnostic orientation without allowing a formal conclusion. Incidentaloma prevalence in the general population, increasing with age, underlines the limitations of a decision based only on imaging. The discovery of adrenal morphological abnormalities justifies the realization of hormonal assays to determine their causal relationship with hypertension. The aldosterone/PRA ratio, in standardized conditions, has the best diagnostic performance to screen for primary aldosteronism and is the pivotal test of the etiological diagnosis of hypertension. The identification of a subclinical Cushing should be considered in patients with adrenal morphological abnormalities, particularly in case of metabolic syndrome. The abdominal CTscan is initially recommended in the diagnosis of pheochromocytoma, but the recommende boichemical testing is urine metanephrines whose result will lead to search a pheochromocytoma or an extra-abdominal paraganglioma. Many drug interactions must be considered in order to interpret hormonal measurements and avoid erroneous diagnosis. Finally, a genetic context and the possibility of endocrine causes with normal abdominal CT scan should be considered: extra-abdominal paraganglioma, parathyroid adenoma and Cushing's disease with pituitary adenoma, requiring a multidisciplinary decision. The efficiency of imaging as first-line in the screening of secondary hypertension is relative and confrontation with hormone assays will be critical to the diagnostic and therapeutic management. In young women, hormonal measurements precede imaging in the etiological investigation of hypertension.

[Management of arterial hypertension before 20weeks gestation in pregnant women]. / Traitements antihypertenseurs et objectifs thérapeutiques de l'hypertension de la femme enceinte (HTA chronique préexistante, HTA gestationnelle) avant le sixième mois de grossesse.

In the first 6 months of pregnancy, the primary goal of antihypertensive treatment is to prevent the complications of severe hypertension. Initiation of antihypertensive drug treatment is recommended in pregnant women with severe hypertension (blood pressure>160/110mmHg). Initiation of antihypertensive drug treatment should also be considered in pregnant women at high cardiovascular risk (diabetes, chronic kidney disease, personal history of cardiovascular disease) with moderate hypertension (blood pressure between 140-159/90-109mmHg). A systolic blood pressure goal<160 and a diastolic blood pressure goal between 85 and 100mmHg is recommended in pregnancy. Labetalol, nifedipine, nicardipine and alphamethyldopa should be considered preferential antihypertensive drugs in pregnancy. Salt restriction, physical exercise and weight loss have not demonstrated any effect in the prevention of preeclampsia and serious maternal complications of hypertension.

Ignorance of cardiovascular preventive measures is associated with all-cause and cardiovascular mortality in the French general population.

BACKGROUND: Cardiovascular disease (CVD) is the primary cause of premature death in Western countries. AIM: To assess the effect of patient ignorance of CVD risk modifiers on mortality. METHODS: We studied 4930 men and women in primary prevention, who consulted at the Department of Preventive Cardiology of a university hospital in France from 1995 to 2011. Questionnaires on socioeconomic level, medical history, cardiovascular risk factors, knowledge of CVD, drug intake, lifestyle and dietary recommendations, and adherence to treatments were administered by trained medical staff. Vital status (cause and date of death, in patients who died) was obtained through the French National Database. Multivariable predictive relationships with total mortality were evaluated using the Cox proportional hazards model. RESULTS: Mean follow-up was 8.6 years; 123 deaths, including 31 cardiovascular deaths, were recorded. Overall, 1305 patients (26%) were ignorant of CVD preventive measures; their mean age (53 years) was similar to that of the non-ignorant population, but most were men with a low educational level, a higher body mass index and significantly more cardiovascular risk factors (diabetes, hypertension). The ignorant group's lifestyle did not conform to cardiovascular guidelines, with less physical activity and more frequent inappropriate diet and smoking. All-cause and cardiovascular mortalities were higher among these patients. In the multivariable analysis, after adjusting for age, sex, smoking status, diabetes, hypertension, body mass index and educational status, ignorance of CVD preventive measures remained significantly associated with all-cause mortality (hazard ratio 1.93, 95% confidence interval 1.31-2.83; P<0.01). CONCLUSION: Ignorance of cardiovascular risk modifiers was significantly associated with all-cause mortality in a general French population.

Predictive Accuracy of the European Society of Cardiology SCORE Among French People.

PURPOSE: Assessment of cardiovascular (CV) risk with a predictive algorithm is recommended for managing CV disease prevention. The aim of this study was to assess the predictive accuracy of the European Society of Cardiology SCORE among French people. METHODS: Our analysis was based on the Third French MONICA population-based survey (1995-1996) and on a sample of subjects referred (from 1995 to 2000) for a CV checkup in a preventive cardiology unit. Vital status was obtained 10 years after inclusion. The 10-year predicted risk of CV death was calculated using the SCORE equation for low-risk countries and was compared with the 10-year incidence of CV death observed in the cohort. RESULTS: The sample was composed of 6915 participants aged 35 to 64 years, among whom 56 CV deaths occurred during the followup. The median risk SCORE (0.97%) did not differ from the 10-year incidence of CV death observed in the cohort (1.05%; 95% CI, 0.81-1.37). The median risk SCORE calculated for different categories of sex, age, educational level, family history of premature CV disease, physical activity, impaired fasting glucose, smoking, systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol did not differ from the 10-year incidence of CV death observed in these categories. The C-statistic of the SCORE equation was 79% (73-85). Using a 5% threshold to discriminate people at high risk, 93% of participants were correctly classified (subjects with SCORE ≥5% who died from a CV causes during followup and those with SCORE <5% who did not). CONCLUSIONS: Among middle-aged French people, the SCORE equation adequately predicts CV death.

Dutch Lipid Clinic Network low-density lipoprotein cholesterol criteria are associated with long-term mortality in the general population.

BACKGROUND: Heterozygous familial hypercholesterolaemia (HeFH) is a severe autosomal dominant disease that is underdiagnosed, inadequately treated and has a severe long-term cardiovascular risk. Few studies have evaluated the long-term risk of high low-density lipoprotein cholesterol (LDL-C) concentrations. AIM: To evaluate long-term mortality in a large cohort of healthy subjects, according to LDL-C concentrations. METHODS: Based on a sample of 6956 subjects visiting a preventive cardiology department, we selected adult subjects without a personal history of cardiovascular disease. From 1995 to 2011, 4930 healthy subjects were examined and followed up until 31 December 2011. All-cause deaths were collected exhaustively. A Cox-based multivariable analysis evaluated long-term total mortality risk according to Dutch Lipid Clinic Network (DLCN) LDL-C concentrations. RESULTS: After a mean follow-up of 8.6 years, 123 all-cause deaths were recorded (cumulative mortality rate, 2.5%). In the final multivariable model, major risk factors such as age, sex, tobacco use and diabetes were significantly associated with mortality. After adjustment for age, sex, tobacco use, hypertension, diabetes and statin therapy, and in comparison with subjects with LDL-C<4 mmol/L (<155 mg/dL), subjects with LDL-C between 4 and <5 mmol/L (155 to <190 mg/dL) had a hazard ratio (HR) of 1.99 (95% confidence interval [CI] 1.31-3.02; P=0.001), subjects with LDL-C between 5 and <6.5 mmol/L (190 to <250 mg/dL) had an HR of 1.81 (95% CI, 1.06-3.02; P=0.030), subjects with LDL-C between 6.5 and<8.5 mmol/L (250 to <330 mg/dL) had an HR of 2.69 (95% CI, 1.06-6.88; P=0.038) and subjects with LDL-C ≥ 8.5 mmol/L (≥330 mg/dL) had an HR of 6.27 (95% CI, 0.84-46.57; P=0.073). After excluding patients on statins at baseline, subjects with LDL-C ≥ 8.5 mmol/L (≥330 mg/dL) had an HR of 8.17 (95% CI, 1.08-62.73; P=0.042). CONCLUSIONS: The severity of LDL-C elevation is associated with a higher risk of death in healthy subjects. DLCN LDL-C concentrations may be used in daily practice to identify patients with HeFH who warrant aggressive treatment.