Influence of Quality of Sleep on the Nocturnal Decline in Blood Pressure During Ambulatory Blood Pressure Monitoring

OBJECTIVE: To assess the influence of the quality of sleep on the nocturnal physiological drop in blood pressure during ambulatory blood pressure monitoring. METHODS: We consecutively assessed ambulatory blood pressure monitoring, the degree of tolerance for the examination, and the quality of sleep in 168 patients with hypertension or with the suspected "white-coat" effect. Blood pressure fall during sleep associated with a specific questionnaire and an analogical visual scale of tolerance for ambulatory blood pressure monitoring were used to assess usual sleep and sleep on the day of examination. Two specialists in sleep disturbances classified the patients into 2 groups: those with normal sleep and those with abnormal sleep. RESULTS: Fifty-nine (35 %) patients comprised the abnormal sleep group. Findings regarding the quality of sleep on the day of ambulatory blood pressure monitoring as compared with those regarding the quality of sleep on a usual day were different and were as follows, respectively: total duration of sleep (-12.4±4.7 versus -42.2±14.9 minutes, P=0.02), latency of sleep (0.4±2.7 versus 17±5.1 minutes, P<0.001), number of awakenings (0.1±0.1 versus 1.35±0.3 times, P<0.001), and tolerance for ambulatory blood pressure monitoring (8±0.2 versus 6.7±0.35, P=0.035). An abnormal drop in blood pressure during sleep occurred in 20 (18%) patients in the normal sleep group and in 14 (24%) patients in the abnormal sleep group, P=0.53. CONCLUSION: Ambulatory blood pressure monitoring causes sleep disturbances in some patients, and a positive association between quality of sleep and tolerance for the examination was observed.

Cross-sectional Study on Blood Pressure Control in the Department of Nephrology of the Escola Paulista de Medicina - UNIFESP

OBJECTIVE - To assess hypertension control rates in a specialized university-affiliated medical department, the influence of sex, diabetes, and obesity on that control, and the strategies for the treatment of hypertension. METHODS - We carried out a cross-sectional study with 1,210 patients followed up for at least 6 months. Information was gathered from medical and nursing records and comprised the following data: sex, age, weight, height, abdominal and hip circumferences, blood pressure, and class and number of the antihypertensive drugs prescribed. To assess obesity, we used body mass index and waist/hip ratio. Blood pressure was considered under control when its levels were below 140/90 mmHg. RESULTS - The study consisted of 73% females and 27% males. Most females (31.7%) were 50 to 59 years of age, and most males (28.3%) were 60 to 69 years. The blood pressure control rate found was 20.9% for the 1,210 patients and 23.4% for the hypertensive diabetic patients (n=290). Despite the low control rates found, 70% of the patients used 1 or 2 antihypertensive medications. A high prevalence of obesity (38%) was observed, and females had a greater abdominal obesity index than males did (90% vs 82%, p<0.05). Patients with a greater body mass index had less control of blood pressure. CONCLUSION - The percentage of hypertensive patients with controlled blood pressure levels was low and was associated with a high prevalence of obesity. These data indicate the need for reviewing the strategies of global treatment for hypertension.

Influence of balloon pressure inflation in patients undergoing primary coronary stent implantation during acute myocardial infarction: a quantitative coronary angiography analysis

OBJECTIVE:To verify the influence of moderate- or high-pressure balloon inflation during primary coronary stent implantation for acute myocardial infarction. METHODS: After successful coronary stent implantation, 82 patients were divided into 2 groups according to the last balloon inflation pressure: group 1 (³12 to <16 atm) and group 2 (³16 to 20 atm), each with 41 cases. All patients underwent late coronary angiography. RESULTS: In group 1, the mean stent deployment pressure was 13.58±0.92 atm, and in the group 2 it was 18.15±1.66 atm. Stents implanted with moderate pressures (³12 to <16 atm) had a significantly smaller postprocedural minimal lumen diameter, compared to with those with higher pressure, with lesser acute gain (2.7± 0.4 mm vs 2.9±04 mm; p=0.004), but the late lumen loss (0,9±0,8 mm vs 0,9±0,6 mm) and the restenosis (22% vs. 17.1%) and target-vessel revascularization rates (9.8% vs 7.3%) were similar between the groups. CONCLUSION: During AMI stenting, the use of high pressures (³16 atm) did not cause a measurable improvement in late outcome, either in the late loss, its index, and the net gain, or in clinical and angiographic restenosis rates.

The influence of patient's consciousness regarding high blood pressure and patient's attitude in face of disease controlling medicine intake

OBJECTIVE: To assess the relation between blood pressure control and the following: the Morisky-Green test, the patient's consciousness regarding high blood pressure, the patient's attitude in face of medicine intake, the patient's attendance at medical consultations, and the subjective physician's judgment. METHODS: We studied 130 hypertensive patients with the following characteristics: 73% females, 60±11 years, 58% married, 70% white, 45% retired, 45% with incomplete elementary schooling, 64% had a familial income of 1 to 3 minimum wages, body mass index of 30±7 kg/m², consciousness regarding the disease for a mean period of 11±9.5 years, and mean treatment duration of 8 ±7 years. RESULTS: Only 35% of the hypertensive individuals had blood pressure under control and a longer duration of treatment (10±7 vs 7±6.5 years; P<0.05). The retiree predominated. The result of the Morisky-Green test did not relate to blood pressure control. In evaluating the attitude in face of medicine intake, the controlled patients achieved significantly higher scores than did the noncontrolled patients (8±1.9 vs 7 ±2, P<0.05). The hypertensive patients had higher levels of consciousness regarding their disease and its treatment, and most (70%) patients attended 3 or 4 medical consultations, which did not influence blood pressure control. The physicians attributed significantly higher scores regarding adherence to treatment to controlled patients (6±0.8 vs 5±1.2; P<0.05). CONCLUSION: Consciousness regarding the disease, the Morisky-Green test, and attendance to medical consultations did not influence blood pressure control.

Blood Pressure Control in Hypertensive Patients in the "Hiperdia Program": A Territory-Based Study

Background:Systemic hypertension is highly prevalent and an important risk factor for cardiovascular events. Blood pressure control in hypertensive patients enrolled in the Hiperdia Program, a program of the Single Health System for the follow-up and monitoring of hypertensive patients, is still far below the desired level.Objective:To describe the epidemiological profile and to assess blood pressure control of patients enrolled in Hiperdia, in the city of Novo Hamburgo (State of Rio Grande do Sul, Brazil).Methods:Cross-sectional study with a stratified cluster random sample, including 383 adults enrolled in the Hiperdia Program of the 15 Basic Health Units of the city of Porto Alegre, conducted between 2010 and 2011. Controlled blood pressure was defined as ≤140 mmHg × 90 mmHg. The hypertensive patients were interviewed and their blood pressure was measured using a calibrated aneroid device. Prevalence ratios (PR) with 95% confidence interval, Wald's χ2 test, and simple and multiple Poisson regression were used in the statistical analysis.Results:The mean age was 63 ± 10 years, and most of the patients were females belonging to social class C, with a low level of education, a sedentary lifestyle, and family history positive for systemic hypertension. Diabetes mellitus (DM) was observed in 31%; adherence to the antihypertensive treatment in 54.3%; and 33.7% had their blood pressure controlled. DM was strongly associated with inadequate BP control, with only 15.7% of the diabetics showing BP considered as controlled.Conclusion:Even for hypertensive patients enrolled in the Hiperdia Program, BP control is not satisfactorily reached or sustained. Diabetic hypertensive patients show the most inappropriate BP control.

Functional Vascular Study in Hypertensive Subjects with Type 2 Diabetes Using Losartan or Amlodipine

Background: Antihypertensive drugs are used to control blood pressure (BP) and reduce macro- and microvascular complications in hypertensive patients with diabetes. Objectives: The present study aimed to compare the functional vascular changes in hypertensive patients with type 2 diabetes mellitus after 6 weeks of treatment with amlodipine or losartan. Methods: Patients with a previous diagnosis of hypertension and type 2 diabetes mellitus were randomly divided into 2 groups and evaluated after 6 weeks of treatment with amlodipine (5 mg/day) or losartan (100 mg/day). Patient evaluation included BP measurement, ambulatory BP monitoring, and assessment of vascular parameters using applanation tonometry, pulse wave velocity (PWV), and flow-mediated dilation (FMD) of the brachial artery. Results: A total of 42 patients were evaluated (21 in each group), with a predominance of women (71%) in both groups. The mean age of the patients in both groups was similar (amlodipine group: 54.9 ± 4.5 years; losartan group: 54.0 ± 6.9 years), with no significant difference in the mean BP [amlodipine group: 145 ± 14 mmHg (systolic) and 84 ± 8 mmHg (diastolic); losartan group: 153 ± 19 mmHg (systolic) and 90 ± 9 mmHg (diastolic)]. The augmentation index (30% ± 9% and 36% ± 8%, p = 0.025) and augmentation pressure (16 ± 6 mmHg and 20 ± 8 mmHg, p = 0.045) were lower in the amlodipine group when compared with the losartan group. PWV and FMD were similar in both groups. Conclusions: Hypertensive patients with type 2 diabetes mellitus treated with amlodipine exhibited an improved pattern of pulse wave reflection in comparison with those treated with losartan. However, the use of losartan may be associated with independent vascular reactivity to the pressor effect.

Elevated Blood Pressure and Obesity in Childhood: A Cross-Sectional Evaluation of 4,609 Schoolchildren

Background: The incidence of obesity in children is increasing worldwide, primarily in urbanized, high-income countries, and hypertension development is a detrimental effect of this phenomenon. Objective: In this cross-sectional study, we evaluated the prevalence of excess weight and its association with high blood pressure (BP) in schoolchildren. Methods: Here 4,609 male and female children, aged 6 to 11 years, from 24 public and private schools in Maringa, Brazil, were evaluated. Nutritional status was assessed by body mass index (BMI) according to cutoff points adjusted for sex and age. Blood pressure (BP) levels above 90th percentile for gender, age and height percentile were considered elevated. Results: The prevalence of excess weight among the schoolchildren was 24.5%; 16.9% were overweight, and 7.6% were obese. Sex and socioeconomic characteristics were not associated with elevated BP. In all age groups, systolic and diastolic BP correlated with BMI and waist and hip measurements, but not with waist-hip ratio. The prevalence of elevated BP was 11.2% in eutrophic children, 20.6% in overweight children [odds ratio (OR), 1.99; 95% confidence interval (CI), 1.61-2.45], and 39.7% in obese children (OR, 5.4; 95% CI, 4.23-6.89). Conclusion: Obese and overweight children had a higher prevalence of elevated BP than normal-weight children. Our data confirm that the growing worldwide epidemic of excess weight and elevated BP in schoolchildren may also be ongoing in Brazil.

Relevance to Home Blood Pressure Monitoring Protocol of Blood Pressure Measurements Taken Before First- Morning Micturition and in the Afternoon

Background: The importance of measuring blood pressure before morning micturition and in the afternoon, while working, is yet to be established in relation to the accuracy of home blood pressure monitoring (HBPM). Objective: To compare two HBPM protocols, considering 24-hour ambulatory blood pressure monitoring (wakefulness ABPM) as gold-standard and measurements taken before morning micturition (BM) and in the afternoon (AM), for the best diagnosis of systemic arterial hypertension (SAH), and their association with prognostic markers. Methods: After undergoing 24-hour wakefulness ABPM, 158 participants (84 women) were randomized for 3- or 5-day HBPM. Two variations of the 3-day protocol were considered: with measurements taken before morning micturition and in the afternoon (BM+AM); and with post-morning-micturition and evening measurements (PM+EM). All patients underwent echocardiography (for left ventricular hypertrophy - LVH) and urinary albumin measurement (for microalbuminuria - MAU). Result: Kappa statistic for the diagnosis of SAH between wakefulness-ABPM and standard 3-day HBPM, 3-day HBPM (BM+AM) and (PM+EM), and 5-day HBPM were 0.660, 0.638, 0.348 and 0.387, respectively. The values of sensitivity of (BM+AM) versus (PM+EM) were 82.6% × 71%, respectively, and of specificity, 84.8% × 74%, respectively. The positive and negative predictive values were 69.1% × 40% and 92.2% × 91.2%, respectively. The comparisons of intraclass correlations for the diagnosis of LVH and MAU between (BM+AM) and (PM+EM) were 0.782 × 0.474 and 0.511 × 0.276, respectively. Conclusions: The 3 day-HBPM protocol including measurements taken before morning micturition and during work in the afternoon showed the best agreement with SAH diagnosis and the best association with prognostic markers.

Blood Pressure Variation Throughout Pregnancy According to Early Gestational BMI: A Brazilian Cohort

Background: The maternal cardiovascular system undergoes progressive adaptations throughout pregnancy, causing blood pressure fluctuations. However, no consensus has been established on its normal variation in uncomplicated pregnancies. Objective: To describe the variation in systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels during pregnancy according to early pregnancy body mass index (BMI). Methods: SBP and DBP were measured during the first, second and third trimesters and at 30-45 days postpartum in a prospective cohort of 189 women aged 20-40 years. BMI (kg/m2) was measured up to the 13th gestational week and classified as normal-weight (<25.0) or excessive weight (≥25.0). Longitudinal linear mixed-effects models were used for statistical analysis. Results: A decrease in SBP and DBP was observed from the first to the second trimester (βSBP=-0.394; 95%CI: -0.600- -0.188 and βDBP=-0.617; 95%CI: -0.780- -0.454), as was an increase in SBP and DBP up to 30-45 postpartum days (βSBP=0.010; 95%CI: 0.006-0.014 and βDBP=0.015; 95%CI: 0.012-0.018). Women with excessive weight at early pregnancy showed higher mean SBP in all gestational trimesters, and higher mean DBP in the first and third trimesters. Excessive early pregnancy BMI was positively associated with prospective changes in SBP (βSBP=7.055; 95%CI: 4.499-9.610) and in DBP (βDBP=3.201; 95%CI: 1.136-5.266). Conclusion: SBP and DBP decreased from the first to the second trimester and then increased up to the postpartum period. Women with excessive early pregnancy BMI had higher SBP and DBP than their normal-weight counterparts throughout pregnancy, but not in the postpartum period.

Blood Pressure and Hemodynamic Adaptations after a Training Program in Young Individuals with Down Syndrome

Background:Cardiovascular diseases affect people worldwide. Individuals with Down Syndrome (DS) have an up to sixteen-time greater risk of mortality from cardiovascular diseases.Objective:To evaluate the effects of aerobic and resistance exercises on blood pressure and hemodynamic variables of young individuals with DS.Methods:A total of 29 young individuals with DS participated in the study. They were divided into two groups: aerobic training (AT) (n = 14), and resistance training (TR) (n = 15). Their mean age was 15.7 ± 2.82 years. The training program lasted 12 weeks, and had a frequency of three times a week for AT and twice a week for RT. AT was performed in treadmill/ bicycle ergometer, at an intensity between 50%-70% of the HR reserve. RT comprised nine exercises with three sets of 12 repetition-maximum. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) and hemodynamic variables were assessed beat-to-beat using the Finometer device before/after the training program. Descriptive analysis, the Shapiro-Wilk test to check the normality of data, and the two-way ANOVA for repeated measures were used to compare pre- and post-training variables. The Pearson’s correlation coefficient was calculated to correlate hemodynamic variables. The SPSS version 18.0 was used with the significance level set at p < 0.05.Results:After twelve weeks of aerobic and/or resistance training, significant reductions in variables SBP, DBP and MBP were observed.Conclusion:This study suggests a chronic hypotensive effect of moderate aerobic and resistance exercises on young individuals with DS.

Impact of Physical Activity Interventions on Blood Pressure in Brazilian Populations

Background:High blood pressure is associated with cardiovascular disease, which is the leading cause of mortality in the Brazilian population. Lifestyle changes, including physical activity, are important for lowering blood pressure levels and decreasing the costs associated with outcomes.Objective:Assess the impact of physical activity interventions on blood pressure in Brazilian individuals.Methods:Meta-analysis and systematic review of studies published until May 2014, retrieved from several health sciences databases. Seven studies with 493 participants were included. The analysis included parallel studies of physical activity interventions in adult populations in Brazil with a description of blood pressure (mmHg) before and after the intervention in the control and intervention groups.Results:Of 390 retrieved studies, eight matched the proposed inclusion criteria for the systematic review and seven randomized clinical trials were included in the meta-analysis. Physical activity interventions included aerobic and resistance exercises. There was a reduction of -10.09 (95% CI: -18.76 to -1.43 mmHg) in the systolic and -7.47 (95% CI: -11.30 to -3.63 mmHg) in the diastolic blood pressure.Conclusions:Available evidence on the effects of physical activity on blood pressure in the Brazilian population shows a homogeneous and significant effect at both systolic and diastolic blood pressures. However, the strength of the included studies was low and the methodological quality was also low and/or regular. Larger studies with more rigorous methodology are necessary to build robust evidence.

High Blood Pressure in Adolescents of Curitiba: Prevalence and Associated Factors

Abstract Background: Arterial hypertension is a major public health problem and has increased considerably in young individuals in past years. Thus, identifying factors associated with this condition is important to guide intervention strategies in this population. Objective: To determine high blood pressure prevalence and its associated factors in adolescents. Methods: A random sample of 1,242 students enrolled in public schools of the city of Curitiba (PR) was selected. Self-administered questionnaires provided family history of hypertension, daily energy expenditure, smoking habit, daily fat intake, and socioeconomic status. Waist circumference was measured following standardized procedures, and blood pressure was measured with appropriate cuffs in 2 consecutive days to confirm high blood pressure. Relative frequency and confidence interval (95%CI) indicated high blood pressure prevalence. Bivariate and multivariate analyses assessed the association of risk factors with high blood pressure. Results: The high blood pressure prevalence was 18.2% (95%CI 15.2-21.6). Individuals whose both parents had hypertension [odds ratio (OR), 2.22; 95%CI 1.28-3.85] and those with high waist circumference (OR, 2.1; 95%CI 1.34-3.28) had higher chances to develop high blood pressure. Conclusion: Positive family history of hypertension and high waist circumference were associated with high blood pressure in adolescents. These factors are important to guide future interventions in this population.

The Labdane Ent-3-Acetoxy-Labda-8(17), 13-Dien-15-Oic Decreases Blood Pressure In Hypertensive Rats

Abstract Background: Labdane-type diterpenes induce lower blood pressure via relaxation of vascular smooth muscle; however, there are no studies describing the effects of labdanes in hypertensive rats. Objective: The present study was designed to investigate the cardiovascular actions of the labdane-type diterpene ent-3-acetoxy-labda-8(17), 13-dien-15-oic acid (labda-15-oic acid) in two-kidney 1 clip (2K-1C) renal hypertension. Methods: Vascular reactivity experiments were performed in aortic rings isolated from 2K-1C and normotensive (2K) male Wistar rats. Nitrate/nitrite (NOx) measurement was performed in aortas by colorimetric assay. Blood pressure measurements were performed in conscious rats. Results: Labda-15-oic acid (0.1-300 µmol/l) and forskolin (0.1 nmol/l - 1 µmol/l) relaxed endothelium-intact and endothelium-denuded aortas from both 2K-1C and 2K rats. Labda-15-oic acid was more effective at inducing relaxation in endothelium-intact aortas from 2K pre-contracted with phenylephrine when compared to the endothelium-denuded ones. Forskolin was more potent than labda-15-oic acid at inducing vascular relaxation in arteries from both 2K and 2K-1C rats. Labda-15-oic acid-induced increase in NOx levels was lower in arteries from 2K-1C rats when compared to 2K rats. Intravenous administration of labda-15-oic acid (0.3-3 mg/kg) or forskolin (0.1-1 mg/kg) induced hypotension in conscious 2K-1C and 2K rats. Conclusion: The present findings show that labda-15-oic acid induces vascular relaxation and hypotension in hypertensive rats.

Ambulatory Blood Pressure Monitoring: Five Decades of More Light and Less Shadows

Abstract Casual blood pressure measurements have been extensively questioned over the last five decades. A significant percentage of patients have different blood pressure readings when examined in the office or outside it. For this reason, a change in the paradigm of the best manner to assess blood pressure has been observed. The method that has been most widely used is the Ambulatory Blood Pressure Monitoring - ABPM. The method allows recording blood pressure measures in 24 hours and evaluating various parameters such as mean BP, pressure loads, areas under the curve, variations between daytime and nighttime, pulse pressure variability etc. Blood pressure measurements obtained by ABPM are better correlated, for example, with the risks of hypertension. The main indications for ABPM are: suspected white coat hypertension and masked hypertension, evaluation of the efficacy of the antihypertensive therapy in 24 hours, and evaluation of symptoms. There is increasing evidence that the use of ABPM has contributed to the assessment of blood pressure behaviors, establishment of diagnoses, prognosis and the efficacy of antihypertensive therapy. There is no doubt that the study of 24-hour blood pressure behavior and its variations by ABPM has brought more light and less darkness to the field, which justifies the title of this review.

The imidazoline receptors and the central regulation of the arterial blood pressure: a minireview

Recently, we proposed the hypothesis according to wich the central hypotensive effect of clonidine and related substances could be related to an action upon specific receptors, requiring the imidazoline or imidazoline-like structures, rather than alpha2-adrenoceptors. Since then, direct evidences have been accumulated to confirm the existence of a population of imidazoline specific binding sites in the brainstem of animals and man, more precisely in the Nucleus Reticularis Lateralis (NRL) region of the ventrolateral medulla (VLM), site of the antihypertensive action of clonidine. The purification of the putative endogenous ligand of the imidazoline receptors - named endazoline - is currently being attempted from human brain extracts. This new concept might at last lead to the expected dissociation of the pharmacological mechanisms involved, on the one hand, in the therapeutic antihypertensive effect, and on the other, in their major side-effect, which is sedation. In fact, it has been recently confirmed that hypotension is mediated by the activation of imidazoline preferring receptors (IPR) within the NRL region, while sedation is attributed to the inhibition of alpha2-adrenergic mechanisms in the locus coeruleus, which is involved in the control of the sleep-waking cycle. The IPRmay constitute on interesting target for new drugs in the treatment of arterial hypertension. Finally, dysfunctions of this modulatory system which could be involved in the pathophysiologyof some forms of the hypertensive disease are under investigation.