Microalbuminuria (MA) is a well recognized marker of cardiovascular complications in hypertension, but whether MA can predict adverse outcome in this clinical condition is still a subject for debate. The fact that in hypertensive cohorts those patients who showed an increase in albumin excretion rate also manifested an increased incidence of morbid events indicates that the presence of MA in hypertension may carry an increased cardiovascular risk. However, the prognostic significance of MA remains controversial because no results of prospective studies performed in hypertensive subjects without diabetes mellitus are available. Several factors can affect the prevalence of MA in hypertension, including severity of the disease, selection procedures, concomitant risk factors, degree of obesity, age, and sex distribution. This accounts for the large differences in the prevalence of MA that can be found in the literature, with prevalence rates going from a low of 4.7% to a high of 40%. There is still conflict over whether MA in hypertension is due to increased intraglomerular pressure or to glomerular damage. The data from the literature suggest that in subjects with mild hypertension the main determinant of albumin excretion rate is the haemodynamic load. In subjects with more severe hypertension and hypertensive complications, the augmented urinary albumin leak is probably the consequence of a systemic microvascular disturbance which involves the glomeruli. In this respect, the insulin resistance state often associated to high blood pressure appears as one of the main pathogenetic factors. Whether management of hypertensive populations may be improved by monitoring of albumin excretion rate and whether antihypertensive drugs which are more effective in decreasing urinary albumin can be more beneficial in patients with MA remains to be determined.

Clinical value of microalbuminuria in hypertension.

La prise en charge du patient hypertendu repose à la fois sur les valeurs de la pression artérielle et sur le niveau de risque cardio-vasculaire global (RCV). L’HTA est définie de façon consensuelle par une PAS 140 mmHg et/ou une PAD 90 mmHg, mesurées au cabinet médical, et confirmées (au minimum par 2 mesures par consultation, au cours de 3 consultations successives, sur une période de 3 à 6 mois).

Prise en charge des patients adultes atteints d'hypertension artérielle essentielle

Resistant (or refractory) hypertension (RH) is a clinical diagnosis based on blood pressure (BP) office measurements. About one third of subjects with suspected RH have indeed pseudo-resistant hypertension and 24-h ambulatory-blood pressure-monitoring aids to precisely identify them. Our aim was to determine those clinical, laboratory or echocardiographic variables that may be associated with subjects with sustained hypertension (namely true RH). We carried out a cross-sectional analysis of 143 patients consecutively enrolled with the clinical diagnosis of RH. All patients underwent clinicaldemographic, laboratory evaluation, 2D-echocardiography and 24-h ambulatory-blood pressure-monitoring. Pseudoresistant hypertension or white-coat RH was defined if office BP was X140 and/or 90mmHg and 24-h BP o130/ 80mmHg. One-hundred and three (72%) patients had true RH and 40 (28%) patients had white-coat RH. True RH patients had significantly higher diabetes prevalence and higher office-systolic blood pressure (SBP) levels. Regarding target organ damage, left ventricular mass index (LVMI) and 24-h urinary albumin excretion (UAE) were also higher in true RH after adjustment for possible confounders (P ¼0.031 and P ¼0.012, respectively). In a logistic regression analysis, only office-SBP (multivariate OR (95%CI): 1.030 (1.003–1.057), P ¼0.030) and UAE (multivariate OR (95% CI): 2.376 (1.225–4.608), P ¼0.010) were independently associated with true RH. We conclude that true resistant hypertension is associated with silent target organ damage, especially UAE. In patients with suspected RH, assessment of 24 h ambulatory BP is the most accurate way to detect a population with high risk for target-organ damage.

/pdf/urinary-albumin-excretion-is-associated-with-true-resistant-2zygxiz4vy.pdf

Urinary albumin excretion is associated with true resistant hypertension

Ambulatory blood pressure monitoring (ABPM) can be considered a major achievement in clinical medicine. However, its superiority over traditional clinical measurement has often been overemphasized in the literature. In both cross-sectional and longitudinal studies, ABPM has been compared with clinical blood pressure calculated from only a few readings taken over a short period of time. For reasons of costs and practicality, ABPM should not be considered as a routine test in the assessment of the hypertensive patient. Most patients with borderline hypertension or isolated clinical hypertension can be profitably assessed with multiple clinical readings and self-blood pressure monitoring. Patients with large short-term or long-term blood pressure oscillations appear as optimal candidates to ABPM. The many methodological problems associated with the use of this technique suggest that ABPM is performed only by experienced doctors.

Too much of a good thing? A critique of overemphasis on the use of ambulatory blood pressure monitoring in clinical practice.

Summary Introduction: Hypertension remains a formidable cardio- vascular problem in the entire world. Untreated or poor- ly controlled hypertension predisposes to target-organ damage and is often followed by serious cardiovascular events. Knowledge of the type and distribution of end- organ damage in newly diagnosed hypertensive patients would help to determine the interventions or preventative measures needed in such patients. Objective: To assess target-organ involvement in newly diagnosed, untreated hypertensive patients presenting at the University College Hospital, Ibadan, Nigeria. Methods: Newly diagnosed hypertensive men and women were recruited consecutively into the study. Target-organ damage was assessed using electroctrocardiography, echocardiography, renal function assessment (including tests for albuminuria) and fundoscopy. Results: A total of 68 subjects were recruited, but only 54 (79.4%), with a mean age of 59.1 (± 12.4) years, completed the study. There were 29 (± 53.7%) men, mean age 63.5 (± 12.6) years, and 25 (46.3%) women, mean age 54.1 (± 10.4) years. Fifty per cent of the subjects had no symptoms. Some form of albuminuria was found in about 40.7%. Seventy-one per cent (71%) had between grade 1 and 2 hypertensive retinopathy. Only six (11.1%) had glomerular filtration rate greater than 90 ml/min. Systolic function was impaired in three (5.6%) of the subjects. Diastolic dysfunction was present in 36 (66.7%) subjects. Conclusion: Target-organ damage already exists in newly diagnosed hypertensive subjects before presentation. We suggest early screening for cardiovascular risk factors and possibly a reduction in the criteria for the definition of hypertension in black Africans.

Unexpectedly high prevalence of target-organ damage in newly diagnosed Nigerians with hypertension.

Relationship of left ventricular mass with clinic blood pressure measured over a six-month period vs. ambulatory blood pressure: p1.112

According to recent international guidelines the decision on whether to treat young subjects during the early phase of hypertension should be based not only on their office blood pressure but also on their ambulatory blood pressure and whether target organ damage has occurred. Few data on the prevalence of hypertensive complications in young subjects with mild hypertension are available. In the Hypertension and Ambulatory Recording Venetia Study (HARVEST), a multicenter trial conducted in northeast Italy, the percentage of young borderline-to-mild hypertensive subjects with echocardiographic left ventricular hypertrophy was 4.5% and the percentage with concentric remodeling was 4%. Clear differences in cardiac size and geometric adjustment to ambulatory systolic pressure between the two sexes were found. The impact of blood pressure on the walls of the left ventricle and on the left ventricular mass was remarkable in women but weak in men. The assessment of left ventricular systolic function confirmed that many young mild hypertensive subjects have an increased ejective performance. The left ventricular contractility evaluated by midwall measurement was, however, found to be depressed in 9.2% of the HARVEST participants. Their left ventricular diastolic function was similar to that of 50 normotensive controls. The prevalence of microalbuminuria [albumin excretion rate (AER) > 30 mg/24 h) was 6.1%, only slightly higher than that found by other authors among normotensive subjects and much lower than that observed among patients with more severe hypertension. For our stage I hypertensives, however, the AER was correlated to the 24 h blood pressure with high statistical significance, whereas we found no relationship between the AER and left ventricular mass index either for all of the subjects taken together or for the men and women considered separately. The results suggest that renal and cardiac involvement do not occur in parallel during the initial phase of hypertension.

Target organ damage and ambulatory blood pressure in stage I hypertension. The Hypertension and Ambulatory Recording Venetia Study.

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Relationship of left ventricular mass with clinic blood pressure measured over a six-month period vs. ambulatory blood pressure: p1.112

Target organ damage and ambulatory blood pressure in stage I hypertension. The Hypertension and Ambulatory Recording Venetia Study.