[Blood pressure lowering efficacy of beta-blockers added to monotherapy with a thiazid or a calcium antagonist--a survey of a Cochrane review]. / Betablokkere adderet til monoterapi med thiazid eller calciumantagonist ved hypertension--en gennemgang af et Cochranereview.

A blood pressure fall of 6-8/4-6 mmHg is seen when a beta-blocker is added to a thiazid or a calcium antagonist. Due to less protection against cardiovascular complications, most likely explained by an insufficient reduction in the central aortic blood pressure profile betablockers, especially atenolol, is no longer first choice treatment for hypertension, unless ischaemic heart disease or heart failure is present.

[Management of hypertension in the hypertension clinic]. / Opgaveglidning ved behandling af hypertension.

INTRODUCTION: A recent Cochrane report concluded that an effective system for hypertension control has yet to be identified. This manuscript presents results from four years' work in a nurse-guided hypertension clinic. The aim of the hypertension clinic was to reduce the number of physician-consultations and to optimize hypertension treatment. MATERIAL AND METHODS: All patients were initially examined by physicians. All follow-up visits were performed by the nurses of the hypertension clinic. They initiated and titrated antihypertensive medication according to a treatment algorithm or the physicians' instructions. Blood pressure (BP) measurement and recording of risk profile were performed in accordance with guidelines from the Danish Hypertension Association. RESULTS: During the four years, 186 patients were treated at the Hypertension Clinic. A total of 130 were discharged to general practice. 95% of these reached their target BP. In all, 56 patients continued treatment at cardiological or nephrological out-patient clinics, or preferred to stop their treatment at the hypertension clinic and refused further referral. Most of the patients received combination therapy with 2-7 different antihypertensive drugs. The three primary antihypertensive drugs were the three first drugs to be used and they comprised the majority of the combination therapy. Many patients received betablockers either as an antihypertensive drug or because of ischemic heart disease. CONCLUSION: Despite many risk factors and severe hypertension, 95% of the patients achieved their target BP. We hope the results will inspire physicians and GP's to adapt the concept.

Treating the hypertensive patient in a nurse-led hypertension clinic.

AIMS: This manuscript presents results from 4 years experience in a nurse-led hypertension clinic. The aim of the hypertension clinic was to optimize hypertension treatment and to reduce the number of physician consultations. MATERIALS AND METHODS: All patients were initially examined by cardiologists. All follow-up visits were performed by nurses. They initiated and titrated antihypertensive medication according to a stepwise treatment algorithm or the physicians' instructions. The blood pressure (BP) measurement technique and the recording of risk profile were performed as instructed by guidelines from the European Hypertension Society. RESULTS: During the first 4 years, 186 patients were treated in the hypertension clinic. One hundred and thirty patients were treated by the nurses alone and hereafter discharged to general practitioners; 95% of these patients reached target BP. Most of the patients received combination therapy with two to seven different antihypertensive drugs. The three primary antihypertensive drugs (calcium-channel blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and diuretics) were the first drugs to be used and they made up the main part of the combination therapy. CONCLUSION: In spite of many risk factors, co-existing cardiovascular diseases and severe hypertension, 95% of the patients achieved target BP when treated in a nurse-led hypertension clinic. We suggest that the data serves as an inspiration for other clinics and GPs to implement the concept.

[Hypertension and the heart]. / Hypertension og hjertet.

Within the latest ten years research in left ventricular hypertrophy as cardiac target organ damage has uncovered its prognostic importance, and studies indicate that treatment with angiotensin II receptor blockade is most effective in reducing left ventricular hypertrophy. In addition, reduction of left ventricular mass is associated with substantial and significant reduction of cardiovascular morbidity and mortality. Hypertension is strongly associated with increased risk of subsequent heart failure. Meta analysis data suggests that reduction in blood pressure is also associated with very substantial reductions in incident heart failure. In addition, the authors suggest that atrial fibrillation should be considered target organ damage with the resulting implications in terms of blood pressure reduction in guidelines, and that modern treatment of atrial fibrillation should also include reduction of traditional cardiovascular risk factors as well as blood pressure reduction for blood pressures exceeding 130/185 mmHg. Reductions which should be achieved using angiotensin converting enzyme inhibitor or angiotensin receptor blockers in order to improve the hemodynamic status of the patient.

[Insufficient blood pressure control following coronary revascularization]. / Insufficient blodtrykskontrol efter koronar revaskularisering.

INTRODUCTION: After coronary revascularization, anti-angina treatment is often withdrawn or reduced while the ejection fraction tends to improve. Both contribute to increase blood pressure (BP). The purpose of the present study was to evaluate BP control in patients after revascularization procedures. MATERIAL AND METHODS: In 190 patients (48 females) who had passed a coronary revascularization procedure at least 12 months earlier, the blood pressure was measured both at the ambulatory and at the clinic; blood samples were drawn for determination of lipids and plasma glucose; body mass index (BMI) was determined; the clinical history was taken with special emphasis on medication and smoking habits. RESULTS: The mean BP was 134.2 +/- 17.6/81.1 +/- 9.7 mmHg at the clinic and the daytime ambulatory value was 132.8 +/- 13.8/78.3 +/- 8.7 mmHg. Poor BP control was found in 42.6% of the patients according to clinic measurements and in 51.6% according to ambulatory measurements. Among the patients with known diabetes, 64.3% were poorly controlled according to clinic measurements and 75.0% according to ambulatory measurements. Medicines with BP lowering effects were taken by 79.0% of the patients. BMI was above 25 in 71.6% of the patients, whereas 58.9% of the patients had total cholesterol >or= 4.5 mmol/l. Twenty-eight percent were still smokers a year after revascularization. CONCLUSION: The BP control in patients after revascularization is unsatisfactory as approximately half of the study participants had a BP above the recommended ranges.

Treatment with beta-blockers in nurse-led heart failure clinics: titration efficacy and predictors of failure.

BACKGROUND: Beta-blockers (BBs) are a cornerstone in the treatment of chronic heart failure (HF), but several surveys have documented that many patients are not offered treatment or are not titrated to target doses. In part to address this problem, specialized, nurse-led HF clinics have been initiated in many countries. However, little information is available to describe if such programs are successful in initiating and up-titrating BBs in daily clinical practice. AIMS: To assess the proportion of patients with HF due to left ventricular systolic dysfunction on BB treatment three months after referral to a nurse-led HF clinic, and to identify baseline predictors of treatment failure. METHODS: Consecutive records from 14 Danish nurse-led HF clinics were used. RESULTS: 1533 patients met inclusion criteria. Mean age was 68.7 years and 72% were men. Three months after the initial HF clinic visit 63% of the patients were being treated with a BB. Mean dose (relative to target dose) was 63 (+/-35)% in patients receiving a BB and target dose was reached by 21%. Patients who were not on BBs were more often female, elderly and in NYHA class III-IV. In a multivariable model only lower age predicted BB use at three months (P<0.05). Younger age (P<0.001) and higher systolic blood pressure (P<0.001) were associated with higher doses of BB. CONCLUSION: BB up-titration continues to be a challenge even in specialized clinics dedicated to this task. Elderly patients appear to be less likely to receive treatment.

[Management of patients with myocardial rupture after acute myocardial infarction]. / Håndtering af patienter med myokardieruptur efter akut myokardieinfarkt.

Ventricular free wall rupture resulting in pericardial tamponade and shock is a known complication of myocardial infarction. In recent years, the widespread availability of echocardiographia has enabled prompt diagnosis. We report a patient with left ventricular free wall rupture in its most severe form who survived after surgical intervention. We point out the importance of rapid and precise diagnosis through echocardiographia. The presence of pericardial haematoma/fluid, haematoma in the ventricular wall or compression of the ventricles supports this diagnosis. Echocardiographia is an important tool for verifying the diagnosis in this group of patients.

Isolated systolic hypertension in an elderly Danish population. Prevalence and daytime ambulatory blood pressure.

Isolated systolic hypertension (ISH) is a major risk factor for cardiovascular complications. Nevertheless, data on the prevalence in a representative population do not seem to be available. The prevalence of ISH and the white coat effect was thus studied in a cross-sectional survey of 2806 inhabitants aged 70-80 years. In untreated subjects, the prevalence of ISH was 17.4% (95% CI 14.9-20.2) in women and 13.5% (95% CI 11.3-15.9) in men using clinic blood pressure at first visit. The prevalence increased significantly with age. The prevalence was reduced to 10.4% when using the average of all-visits clinic blood pressures. By a simulation model, it was demonstrated that his reduction mainly resulted from a regression towards the mean. Average all-visits clinic blood pressure was 172.6 +/- 10.4/81.1 +/- 6.0 mmHg. Less than one-third of those with all-visit ISH had sustained ISH. Identifying subjects with sustained ISH requires measurements in more than three visits.