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Hypertension is a leading cause of cardiovascular disease. The results were previously reported of a trial of home blood pressure (BP) telemonitoring and pharmacist management intervention in which the interventions stopped after 12 months. There were significantly greater reductions in systolic BP (SBP) in the intervention group than in the usual care group at 6, 12, and 18 months (-10.7, -9.7, and -6.6 mm Hg, respectively). To examine the durability of the intervention effect on BP through 54 months of follow-up and to compare BP measurements performed in the research clinic and in routine clinical care. Follow-up of a cluster randomized clinical trial among 16 primary care clinics and 450 patients with uncontrolled hypertension in a large health system from March 2009 to November 2015. A home BP telemonitoring intervention with pharmacist management or usual care. Change from baseline to 54 months in SBP and diastolic BP (DBP) measured as the mean of 3 measurements obtained at each research clinic visit. Among 450 patients, 228 (mean [SD] age, 62.0 [11.7] years; 54.8% male) were randomized to the telemonitoring intervention and 222 (mean [SD] age, 60.2 [12.2] years; 55.9% male) to usual care. Research clinic BP measurements were obtained from 326 of 450 (72.4%) study patients at the 54-month follow-up visit, including 162 (mean [SD] age, 62.0 [11.1] years; 54.9% male) randomized to the telemonitoring intervention and 164 (mean [SD] age, 60.0 [11.2] years; 57.3% male) to usual care. Routine clinical care BP measurements were obtained from 439 of 450 (97.6%) study patients at 6248 visits during the follow-up period. Based on research clinic measurements, baseline mean SBP was 148 mm Hg in both groups. In the intervention group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 126.7, 125.7, 126.9, and 130.6 mm Hg, respectively. In the usual care group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 136.9, 134.8, 133.0, and 132.6 mm Hg, respectively. The differential reduction by study group in SBP from baseline to 54 months was -2.5 mm Hg (95% CI, -6.3 to 1.2 mm Hg; P = .18). The DBP followed a similar pattern, with a differential reduction by study group from baseline to 54 months of -1.0 mm Hg (95% CI, -3.2 to 1.2 mm Hg; P = .37). The SBP and DBP results from routine clinical measurements suggested significantly lower BP in the intervention group for up to 24 months. This intensive intervention had sustained effects for up to 24 months (12 months after the intervention ended). Long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention if BP increases. ClinicalTrials.gov Identifier: NCT00781365.

BACKGROUND Current guidelines make no outcome-based recommendations on the optimal measurement schedule for home blood pressure (BP). METHODS We enrolled 4,802 randomly recruited participants from three populations. The participants were classified by their (i) cross-classification according to office and home BP (normotension, masked hypertension, white-coat hypertension, and sustained hypertension) and (ii) home BP level (normal BP, high normal BP, grade 1 and 2 hypertension), while the number of home measurement days was increased from 1 to 7. The prognostic accuracy of home BP with an increasing number of home BP measurement days was also assessed by multivariable-adjusted Cox models. RESULTS Agreement in classification between consecutive measurement days indicated near perfect agreement (κ ≥ 0.9) after the sixth measurement day for both office and home BP cross-classification (97.8% maintained classification, κ = 0.97) and home BP level (93.6% maintained classification, κ = 0.91). Over a follow-up of 8.3 years, 568 participants experienced a cardiovascular event, and the first home BP measurement alone predicted events significantly (P ≤ 0.003). The confidence intervals (CIs) were too wide and overlapping to show superiority of multiple measurement days over the first measurement day (hazard ratios per 10mm Hg increase in systolic BP at initial day, 1.11 [CI 1.07–1.16]; that at 1–7 days, 1.18 [CI 1.12–1.24]). Masked hypertension, but not white-coat hypertension, was associated with increased cardiovascular risk, irrespective of the number of home measurement days. CONCLUSION Even a single home BP measurement is a potent predictor of cardiovascular events, whereas seven home measurement days may be needed to reliably diagnose hypertension.

Ambulatory blood pressure (ABP) monitoring is recommended as a standard method for the evaluation of resistant hypertension (RH). This study assessed the diagnostic value of home blood pressure (HBP) monitoring in RH. Subjects on stable treatment with ⩾3 antihypertensive drugs were included. Clinic RH (CRH) was defined as elevated clinic blood pressure and true RH (TRH) as elevated ABP. The diagnosis of CRH was verified by ABP and HBP monitoring. The diagnostic value of HBP was assessed by taking ABP as reference method. Threshold for hypertension diagnosis was ⩾135/85 mm Hg (systolic and/or diastolic) for HBP and awake ABP and ⩾140/90 mm Hg for clinic blood pressure. Among 73 subjects on ⩾3 antihypertensive drugs, 44 (60%) had CRH and 40 (55%) TRH. There was agreement between ABP and HBP in diagnosing CRH in 82% of the cases (26 subjects (59%) with CRH and 10 (23%) without CRH; kappa 0.59). Regarding the diagnosis of TRH, there was agreement between ABP and HBP in 74% of the cases (36 subjects (49%) with TRH and 18 (25%) without TRH; kappa 0.46). The sensitivity, specificity, and positive and negative predictive values of HBP in detecting CRH were 93%, 63%, and 81% and 83%, respectively, and TRH were 90%, 55%, and 71%, and 82%, respectively (ABP taken as reference method). These data suggest that HBP is a reliable alternative to ABP in the evaluation of RH. These methods are necessary in both uncontrolled and controlled subjects on triple therapy to detect the white coat phenomenon and also masked RH.

In 2017 the American Heart Association (AHA)/American College of Cardiology (ACC) changed the criteria to define hypertension (HTN). To re-analyze Venezuelan data to update HTN prevalence rates and estimate the number of adults with uncontrolled blood pressure (BP) using AHA/ACC criteria. The EVESCAM was a national population-based, cross-sectional, randomized cluster sampling study, which assessed 3,420 adults from July 2014 to January 2017, with a response rate of 77.3%. The mean of two BP measurements was obtained using a standard oscillometric device protocol. HTN was defined using both 2017 AHA/ACC guideline (BP ≥ 130/80 mmHg) and JNC7 (BP ≥ 140/90 mmHg) criteria. The crude prevalence of HTN using 2017 AHA/ACC guideline criteria was 60.4%, 13% higher than with the JNC7 criteria. The age-standardized prevalence was 55.4% in men and 49.0% in women (p < 0.001), 17.5% and 12.7% higher, respectively, compared with the JNC7 criteria. In subjects without self-reported HTN, the age-standardized prevalence of HTN was 43.4% in men and 32.3% in women, of whom, 22.9% and 19.2% were between 130-139/80-89 mmHg, respectively. In those with self-reported HTN, the prevalence of uncontrolled BP (≥130/80 mmHg) on antihypertensive medication was 66.8% in men and 65.8% in women. The total estimated number of subjects with HTN in Venezuela increased to 11 million, and only about 1.8 million are controlled. Using the new 2017 AHA/ACC guideline, the prevalence of HTN in Venezuela is approximately half of the adult population and associated with relatively poor BP control.

Treatments for pulmonary arterial hypertension have been mainly studied in patients with advanced disease (WHO functional class [FC] III and IV). This study was designed to assess the effect of the dual endothelin receptor antagonist bosentan in patients with WHO FC II pulmonary arterial hypertension. Patients with WHO FC II pulmonary arterial hypertension aged 12 years or over with 6-min walk distance of less than 80% of the normal predicted value or less than 500 m associated with a Borg dyspnoea index of 2 or greater were enrolled in this double-blind, placebo-controlled, multicentre trial. 185 patients were randomly assigned to receive bosentan (n=93) or placebo (n=92) for the 6-month double-blind treatment period via a centralised integrated voice recognition system. Primary endpoints were pulmonary vascular resistance at month 6 expressed as percentage of baseline and change from baseline to month 6 in 6-min walk distance. Analyses of the primary endpoints were done with all randomised patients who had a valid baseline assessment and an assessment or an imputed value for month 6. This trial was registered with ClinicalTrials.gov, number NCT00091715. Analyses were done with 168 patients (80 in the bosentan group, 88 in the placebo group) for pulmonary vascular resistance and with 177 (86 and 91) for 6-min walking distance. At month 6, geometric mean pulmonary vascular resistance was 83·2% (95% CI 73·8–93·7) of the baseline value in the bosentan group and 107·5% (97·6–118·4) of the baseline value in the placebo group (treatment effect −22·6%, 95% CI −33·5 to −10·0; p<0·0001). Mean 6-min walk distance increased from baseline in the bosentan group (11·2 m, 95% CI −4·6 to 27·0) and decreased in the placebo group (−7·9 m, −24·3 to 8·5), with a mean treatment effect of 19·1 m (95% CI 3·6–41·8; p=0·0758). 12 (13%) patients in the bosentan group and eight (9%) in the placebo group reported serious adverse events, the most common of which were syncope in the bosentan group and right ventricular failure in the placebo group. Bosentan treatment could be beneficial for patients with WHO FC II pulmonary arterial hypertension. Actelion Pharmaceuticals Ltd.

Endothelin-1, a potent vasoconstrictor and smooth-muscle mitogen, may have a role in the pathogenesis of pulmonary hypertension. The therapeutic efficacy of bosentan, an endothelin-receptor antagonist, was evaluated in this randomized clinical trial. Bosentan at a dose of 125 mg twice daily improved exercise capacity and functional class. Treatment with an endothelin-receptor antagonist improved exercise capacity. Pulmonary arterial hypertension is a debilitating disease characterized by an increase in pulmonary vascular resistance leading to right ventricular failure and death. 1 Pulmonary arterial hypertension with no apparent cause is termed primary pulmonary hypertension. Pulmonary arterial hypertension can also develop in up to 50 percent of patients with scleroderma. 2 , 3 The limited oral treatment options include long-term anticoagulant therapy 4 , 5 and therapy with calcium-channel blockers; the latter improve survival in a limited number of patients. 5 Beneficial effects have been reported with continuous intravenous infusion of epoprostenol (prostacyclin), but this treatment has drawbacks. 6 , 7 The efficacy of epoprostenol analogues that can . . .

Interventional studies have shown that increased intake of fruit and vegetables reduces blood pressure (BP). However, the contribution of specific dietary components has not been evaluated. The aim of the present study was to determine, in patients with stage I hypertension, the antihypertensive effect of juice of the so-called sweetie fruit (a hybrid between grapefruit and pummelo) with and without high flavonoid content. A double-blind, cross-over study was conducted in 12 patients. Each patient received alternately high-flavonoid (HF) sweetie juice and low-flavonoid (LF) sweetie juice, each for a 5-week period. The LF sweetie juice had 25% of naringin and 30% of narirutin content compared with the original HF sweetie juice. The HF sweetie juice was more effective than LF sweetie juice in reducing diastolic blood pressure ( P = .04). Systolic blood pressure declined in both groups; however there was no significant difference between subjects given HF sweetie versus those given LF sweetie juice. In this study HF sweetie juice was shown to have a significant beneficial effect in reducing diastolic blood pressure, compared with the effect observed with LF sweetie juice, in patients with stage I hypertension. These data suggest that the active ingredients associated with the antihypertensive effect of sweetie juice are the flavonoids naringin and narirutin.

The number of effective, long-term treatments for pulmonary hypertension is limited. In this double-blind, randomized trial, an aerosolized form of iloprost, a stable analogue of the pulmonary vasodilator prostacyclin, was assessed over a 12-week period. Iloprost had a beneficial effect on the combined end point of the distance walked in six minutes and an improvement in the New York Heart Association functional class. A continuous infusion of prostacyclin was the first therapy shown to reduce mortality in a controlled study of patients with severe pulmonary hypertension. 1 However, its use is associated with a number of serious drawbacks. The lack of pulmonary selectivity results in systemic side effects, tolerance leads to progressive increases in the dose, and there may be recurrent infections of the intravenous catheter. 2 As an alternative, inhaled nitric oxide possesses pulmonary selectivity, but it is less potent than prostacyclin in the pulmonary vasculature. 3 , 4 Moreover, an interruption in the inhalation of continuous nitric oxide may cause rebound pulmonary hypertension. 5 , 6 Designed . . .

BACKGROUND The aim was to determine the proportions and correlates of essential hypertension among children in a tertiary pediatric hypertension clinic. METHODS We evaluated 423 consecutive children and collected demographic and clinical history by retrospective chart review. RESULTS We identified 275 (65%) hypertensive children (blood pressure >95th percentile per the “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents”) from 423 children referred to the clinic for history of elevated blood pressure. The remainder of the patients had normotension (11%), white coat hypertension (11%), prehypertension (10%), and pending diagnosis (3%). Among the 275 hypertensive children, 43% (n = 119; boys = 56%; median age = 12 years; range = 3–17 years) had essential hypertension and 57% (n = 156; boys = 66%; median age = 9 years; range = 0.08–19 years) had secondary hypertension. When compared with those with secondary hypertension, those with essential hypertension had a significantly older age at diagnosis (P = 0.0002), stronger family history of hypertension (94% vs. 68%; P < 0.0001), and lower prevalence of preterm birth (20% vs. 46%; P < 0.001). There was a bimodal distribution of age of diagnosis in those with secondary hypertension. CONCLUSIONS The phenotype of essential hypertension can present as early as 3 years of age and is the predominant form of hypertension in children after age of 6 years. Among children with hypertension, those with essential hypertension present at an older age, have a stronger family history of hypertension, and have lower prevalence of preterm birth.

Systemic sclerosis-related interstitial lung disease (SSc-ILD) is the leading cause of death in SSc. In this study, we aimed to describe the baseline severity and evolution of forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) in patients with SSc-ILD and to assess the baseline clinical, biological and high-resolution CT scan (HRCT) predictors of this evolution. Baseline and serial FVC and DLCO were collected in 75 SSc-ILD patients followed during 6.4±4.2 years (n = 557 individual data). FVC and DLCO evolution was modelled using a linear mixed model with random effect. During follow-up, FVC was stable while DLCO significantly decreased (-1.5±0.3%/year (p<0.0001). Baseline NYHA functional class III/IV, extensive SSc-ILD on HRCT and DLCO<80% were associated with a lower baseline FVC. Absence of digital ulcers extensive SSc-ILD, and FVC<80% and were associated with a lower baseline DLCO. Presence or history of digital ulcers and presence of pulmonary hypertension at baseline or during follow-up were associated with a faster decline of DLCO overtime. Neither age, gender, subtype of SSc nor specificity of autoantibodies were associated with baseline severity or outcome of lung function tests. In this SSc-ILD population, FVC was therefore stable while DLCO significantly declined over time. ILD extension was associated with baseline FVC and DLCO but not with their evolution. Presence or history of digital ulcers and pulmonary hypertension were predictors of a faster decline of DLCO over time.