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In stable coronary heart disease, uncontrolled risk factors are strongly associated with incident myocardial infarction. We analysed the management of hypertension in 746 stable coronary patients recruited between 2005 and 2015 in a single-centre prospective study. Risk factors and pharmacological treatments were documented prior to and immediately after cardiac rehabilitation, and 1 year later. One year post-cardiac rehabilitation, all cardiovascular risk factors were significantly better controlled with the notable exception of hypertension: blood pressure (BP) 140/90 mmHg in 60% of the total population vs 49% (N = 450) of hypertensive patients (20% or 10%, according to the ACC/AHA 2017 or ESH/ESC guidelines, respectively). Of those who had achieved normotension by the end of cardiac rehabilitation, 42% had uncontrolled hypertension again 1 year later; in addition, body weight had increased, while physical activity and antihypertensive drug use had dropped (differences between controlled or uncontrolled hypertension at 1 year post-cardiac rehabilitation, NS). Three factors were correlated with BP elevations: discontinuation of betablockade: +7.9 mmHg; age65 years: +6.2 mmHg; diabetes mellitus: +7.6 mmHg. Only 48% hypertensive patients were on guideline-recommended antihypertensive polytherapy. Although 28% were still hypertensive post-cardiac rehabilitation, and hypertension remained uncontrolled in 70% 1 year later, 61% antihypertensive prescriptions were not adjusted post-cardiac rehabilitation. One year post-cardiac rehabilitation, hypertension was the only cardiovascular risk factor that had not improved. This can be attributed to three main reasons, all associated with BP elevations: precipitous reduction in betablockade, physicians' inertia when faced with uncontrolled hypertension and lack of adherence to international guidelines.

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Erectile dysfunction (ED) is not routinely discussed with patients in cardiology practices whereas it may impact the ability of patients to stay on therapy. Most of the studies about ED and antihypertensive therapies have several methodological limitations. Diuretics and beta-blockers have been shown to have a deleterious effect on ED. ISRA inhibitors, calcium antagonists, vasodilator beta-blockers and alpha-blockers have been shown to have a neutral impact on ED. Angiotensin 2 inhibitors, nebivolol and alpha-blockers use has sometimes beneficial effect on ED. In case of ED due to antihypertensive treatment, drugs can be switched each other but careful attention in patients with a high cardiovascular risk is required.

Summary Background Sleep-related disordered breathing is common in patients with chronic heart failure. Aim To assess the efficacy of short-term nocturnal ventilatory therapy combined with exercise training (V + ET) compared with exercise training alone (ET) in patients with chronic heart failure with sleep-disordered breathing. Methods Patients in New York Heart Association functional class II–IIIb, with an apnoea-hypopnoea index (AHI) > 15/h, and enrolled in a cardiac rehabilitation programme, were centrally randomized to V + ET or ET. Subjects were classified as having obstructive sleep apnoea (OSA) ( n = 49) or central sleep apnoea (CSA)/mixed ( n = 69). The primary outcome was the change in the 10-second average oxygen consumption at maximum exercise (VO 2peak ) at the end of the cardiac rehabilitation programme. Results Fifty-eight patients were randomized to V + ET and 60 patients to ET. The median increase in VO 2peak was 15% [interquartile range 6–36%] in the V + ET group and 16% [0–31%] in the ET group ( P = 0.34). AHI decreased in both groups, but significantly more in the V + ET group ( P = 0.006). The decrease in the ventilatory efficiency (VE/VCO 2 ) slope was not statistically different between the two-randomization groups ( P = 0.10). In subjects with CSA, the VE/VCO 2 slope decreased significantly more in the V + ET group ( P = 0.03), while there was no difference between the two-randomization groups in subjects with OSA ( P = 0.75). Six cardiovascular events occurred in patients with OSA (all randomized to the ET group); in subjects with CSA, two events occurred in the V + ET group and three in the ET group. Conclusions Short-term nocturnal ventilation combined with exercise training does not increase the exercise capacity of patients with chronic heart failure.

We conducted a pilot multicenter double-blind randomized placebo-controlled crossover pharmacodynamic study to evaluate the blood pressure (BP) and the hormonal effects of firibastat, a first-in-class aminopeptidase A inhibitor prodrug, in patients with hypertension.Thirty-four patients with daytime ambulatory BP of at least 135/85 mmHg and less than 170/105 mmHg, after a 2-week run-in period were randomly assigned to receive either firibastat (250 mg b.i.d. for 1 week uptitrated to 500 mg b.i.d. for 3 weeks) and then placebo for 4 weeks each or vice versa, with a 2-week washout period on placebo.At 4 weeks, daytime ambulatory systolic BP (SBP) decreased by 2.7 mmHg (95% confidence interval -6.5 to +1.1 mmHg) with firibastat versus placebo (P = 0.157). Office SBP decreased by 4.7 mmHg (95% confidence interval -11.1 to +1.8 mmHg) with firibastat versus placebo (P = 0.151). However, more the basal daytime ambulatory SBP was elevated, more the firibastat-induced BP decrease was marked. Firibastat did not influence 24h-ambulatory heart rate. Firibastat had no effect on plasma renin, aldosterone, apelin and copeptin concentrations. No major adverse events occurred. There was one episode of reversible skin allergy with facial edema.In patients with hypertension, a 4-week treatment with firibastat, tended to decrease daytime SBP relative to placebo. Firibastat did not modify the activity of the systemic renin-angiotensin system These results have justified designing a larger, powered trial of longer duration to fully assess its safety and effectiveness.http://www.clinicaltrials.gov. NCT02322450.

To improve the management of resistant hypertension, the French Society of Hypertension, an affiliate of the French Society of Cardiology, has published a set of eleven recommendations. The primary objective is to provide the most up-to-date information based on the strongest scientific rationale and that is easily applicable to daily clinical practice. Resistant hypertension is defined as uncontrolled blood pressure on office measurements and confirmed by out-of-office measurements despite a therapeutic strategy comprising appropriate lifestyle and dietary measures and the concurrent use of three antihypertensive agents including a thiazide diuretic, a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, for at least 4 weeks, at optimal doses. Treatment compliance must be closely monitored, as must factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression, drug interactions and vasopressor drugs). If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for potential target organ damage and secondary causes of hypertension. The recommended treatment regimen is a combination therapy comprising four treatment classes, including spironolactone (12.5-25 mg per day). In the event of a contraindication or a non-response to spironolactone, or if adverse effects occur, a β-blocker, an α-blocker, or a centrally acting antihypertensive drug should be prescribed. Because renal denervation is still undergoing assessment for the treatment of hypertension, this technique should only be prescribed by a specialist hypertension clinic.

The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure (BP) lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for resistant hypertension at 6 months. We report here the effect of denervation on 24-hour BP and its variability and look for parameters that predicted the BP response. Patients with resistant hypertension were randomly assigned to denervation plus stepped-care treatment or treatment alone (control). Average and standard deviation of 24-hour, daytime, and nighttime BP and the smoothness index were calculated on recordings performed at randomization and 6 months. Responders were defined as a 6-month 24-hour systolic BP reduction ≥20 mm Hg. Analyses were performed on the per-protocol population. The significantly greater BP reduction in the denervation group was associated with a higher smoothness index ( P =0.02). Variability of 24-hour, daytime, and nighttime BP did not change significantly from baseline to 6 months in both groups. The number of responders was greater in the denervation (20/44, 44.5%) than in the control group (11/53, 20.8%; P =0.01). In the discriminant analysis, baseline average nighttime systolic BP and standard deviation were significant predictors of the systolic BP response in the denervation group only, allowing adequate responder classification of 70% of the patients. Our results show that denervation lowers ambulatory BP homogeneously over 24 hours in patients with resistant hypertension and suggest that nighttime systolic BP and variability are predictors of the BP response to denervation. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

High blood pressure in pregnancy remains, by its complications, the leading cause of morbidity and maternal and fetal mortality. The frequency (5 to 10% of pregnancies) and the potential severity of this disease, both for mother and child, encourage to standardize and to optimize our medical practices. This is the main objective of this work. If the short-term complications for the mother and child are well known, long-term ones for the mother beginning to be better identified (in particular, the risk of recurrence in a subsequent pregnancy, the risk of chronic hypertension and the increased risk of cardiovascular events). The occurrence of hypertension during pregnancy disturbs the "classic" organization of care. Several health professionals are involved, the general practitioner, obstetrician, gynecologist, midwife, cardiologist, nephrologist… There is not always a care coordinator and decisions are sometimes taken with delay. These data encouraged the French Society of Hypertension to write a consensus offering easy and efficient recommendations. Educate women and all health professionals to hypertension and its management, in line with current scientific data, is one of the major challenges of this consensus.

Background Sleep-disordered breathing (SDB) is commonly in chronic heart failure (CHF) patients. Exercise training (ET) improves exercise tolerance and reduces cardiac decompensations in CHF population. Otherwise, ventilation therapy (VT) improves prognosis and exercise capacity in CHF patients with SDB. However, the effect of the combination therapy: ET and VT is still unexplored. The aim of our study is to evaluate the effects on hemodynamic status (cardiac decompensations) of ET and VT in stable CHF patients referred to cardiac rehabilitation (CR). Methods We included 118 stable CHF patients with an apnea-hypopnea index (AHI) >15/h diagnosed by polygraphy. They were randomized into exercise training (ET group n=58) or combined exercise and ventilation (ET+VT group n=60). The follow up period was the 8 weeks during which 20 exercise training sessions were scheduled. Severe episodes of cardiac decompensations were recorded. Results The mean age was 62.6±10.3 years, 89% were males, 50% NYHA class II and 50% in class III, mean LVEF was 30%. 40% and 60% of patients had respectively obstructive and central and/or mixed apneas, with a mean AHI 34.4±14.3/h. Patients of ET+VT group had significantly fewer acute cardiovascular events than those of ET group (2/60 vs. 7/58; 3.3% vs. 15.5%, p Conclusion Ventilation therapy combined with ET in severe CHF patients seems to reinforce benefits of ET alone. Screening of SDB in CR could be proposed in order to optimize the global management of the heart disease.

The study objective was to evaluate, by means of automated office and phone-transmitted home blood pressure (OBP and HBP) recordings, the effects of a fixed combination of valsartan 160 mg and hydrochlorothiazide (HCTZ) 25 mg in hypertensive patients previously uncontrolled with the combination of an angiotensin receptor antagonist and HCTZ. From 241 selected patients, 171 (71%) had uncontrolled hypertension OBP and HBP [mean baseline OBP and HBP systolic and diastolic (SBP/DBP): 157/91 and 152/87 mmHg]. In this open-design study, patients were directly switched from other angiotensin receptor blocker combination products to valsartan/HCTZ for 6 weeks. The same validated automated device was used for OBP and HBP recordings. At baseline, mean HBP was 152 +/- 15/87 +/- 10 mmHg and mean OBP was 157 +/- 12/91 +/- 9 mmHg. After 6 weeks of treatment with valsartan 160 mg and HCTZ 25 mg, a significant decrease in BP was observed both at home (146 +/- 17/83 +/- 12 mmHg) and at the office (151 +/- 18/87 +/- 11 mmHg), with a difference from baseline of -4 mmHg, p < 0.001 for DBP and of -6 mmHg for SBP, p < 0.001. The percentage of patients with office and home control was 24% and 23% respectively, with a kappa index at 0.459. Elevated OBP only (office hypertension) was observed in 3.6% and elevated HBP only (masked hypertension) in 10% of patients. In conclusion, treatment with valsartan and HCTZ 25 mg in patients with confirmed uncontrolled hypertension induced a clinically relevant decrease in BP with approximately 23% of additional patients strictly controlled with a single tablet. The use of an automated oscillometric device at the office and at home allowed the detection of controlled subjects with good agreement.

Correspondance : Jacques Blacher Unite hypertension arterielle, prevention et therapeutique cardiovasculaire Centre de diagnostic et de therapeutique Hotel-Dieu, AP-HP 1, place du Parvis Notre-Dame 75181 Paris cedex 4 jacques.blacher@htd.aphp.fr Membres du groupe de travail : Jacques Amar, Athanase Benetos, Jacques Blacher (redacteur), Guillaume Bobrie, Bernard Chamontin, Xavier Girerd, Jean-Michel Halimi, Daniel Herpin, Claire Mounier-Vehier, Jean-Jacques Mourad, Jean Ribstein, Bruno Schnebert, Bernard Vaisse.

BACKGROUND Masked hypertension has been associated with obesity. However, because most studies do not mention the specific cuff size used for home measurements, masked hypertension prevalence may have been overestimated in obese patients because of undersized cuffs. In this prospective, observational study, the effect of miscuffing on hypertension status was evaluated in patients with large arms. METHODS Fifty-three patients with an upper-arm circumference >33cm, undergoing treatment for mild-to-moderate hypertension, took 2 sets of home blood pressure (BP) measurements (standard vs. large cuff) using the validated Microlife BP A100 Plus automated device. RESULTS Mean BP was 143/85mm Hg at the office using a large cuff, 141/84mm Hg at home using a standard cuff, and 134/80mm Hg at home using a large cuff. Standard vs. large cuff home BP mean differences were 6.9mm Hg (95% confidence interval (CI) = 4.7-9.2; P < 0.0001) for systolic BP and 4.0mm Hg (95% CI = 2.4-5.5; P < 0.0001) for diastolic BP. Hypertension status differed significantly between standard vs. large cuffs: sustained hypertension (56.6% vs. 41.5%, respectively; P = 0.002), controlled hypertension (20.8% vs. 28.3%, respectively; P = 0.04), white coat hypertension (7.5% vs. 22.6%, respectively; P = 0.002), masked hypertension (15.1% vs. 7.5%, respectively; P = 0.04). CONCLUSIONS In patients with large arms, use of an appropriately sized large cuff for home BP measurements led to a 2-fold reduction in masked hypertension. Regarding clinical and epidemiological implications, future studies investigating masked hypertension should specify cuff size for home BP measurements. The low market availability and increased cost of large cuffs should also be addressed.

To improve the secondary prevention, particularly hypertension management among coronary patients.In 2004-2005, out of 175 coronary patients having taken part in a cycle of the Educoeur center of the health network Rivarance, 131 (75%) aged between 32-79 years of age (an average of 61 years with 11% women, 52% hypertensive, 24% smokers, 10% diabetics and 72% with unbalanced dyslipidemia (LDL1g/l)) were re-examined within 12 months and were compared with a French cohort of the EuroAspire II study (365 patients - Lancet 2001). 56% were treated by angioplasty, 24% by coronary bypass and 20% by medical treatment. The 4-week ambulatory educational program consisted of a physical education with 22 meetings of cardiac rehabilitation (ergo cycle, carpet, segmentary muscular work, steps and balneotherapy) and a therapeutic and dietetic education (18 courses and cooking workshops, supermarket visits and self BP measurement). These 131 patients were re-examined 3, 6 and 12 months after by the paramedical team. The GP and nurses were taught recommendations on CV risk factors management. The patients were followed by a computerized medical file. BP (average of 3 measurements by OMRON M4), total cholesterol (CT), weight, physical activity (insufficient if less than 3 walks of 30 min per week), smoking and drugs intake were analyzed on J0 then at one year and were compared with the French results of EuroAspire II. [table: see text]The education and the follow-up of the patient in a network of health improve CV risk factors and particularly hypertension management of these coronary patients but this decreases with time.

VALNORM was designed to assess the impact on blood pressure (BP) control of a specific training in new European Society of Hypertension-International Society of Hypertension (ESH-ISH) guidelines for hypertension management. It was an 8-week prospective, randomized, open, blinded end points design study. General practitioners (GPs) located in France were randomized in two groups: group 1 (G1) without training to the guidelines and free attitude for the prescription whereas group 2 (G2) received a specific training in ESH guidelines. The primary efficacy criteria was strict BP control at week 8 (systolic BP/diastolic BP [SBP/DBP]140/90 mm Hg and/or SBP/DBP130/80 mm Hg if diabetes or renal insufficiency). All physicians used the same treatment (valsartan 80 or 160 mg once daily alone or in fixed combination with hydrochlorothiazide 12.5 or 25 mg once daily). BP was measured in the GPs' office with an electronic device. The groups GPs included 4,436 patients with essential uncontrolled hypertension (G1: 595 physicians, 2,308 patients; G2: 502 physicians, 2,128 patients). Patients' main characteristics were: age = 61 +/- 13 years, 52% female, BP = 160 +/- 13/92 +/- 9 mm Hg. No difference was observed between the two groups. The primary efficacy criteria showed in G2: 47.8% of BP control vs. G1: 44.7%, P = .005. Subgroup analysis according to age, body mass index (BMI), previous diabetes, and antihypertensive treatment showed that higher efficacy in G2 was more significant in these high-risk subgroups: age60 years (G1: n = 1,150, G2: n = 1,035), BMI/=25 kg/m(2) (G1: n = 1540, G2: n = 1430), diabetes (G1: n = 267, G2: n = 290), no previous antihypertensive treatment (G1: n = 1,111, G2: n = 1,005). The percentage of patients with controlled BP in each subgroup was: diabetes: G1 11.2% vs. G2 17.9% (P = .001), age60 years: G1 40.3% vs. G2 43.7% (P = .022), BMI/=25 kg/m(2): G1 43.2% vs. G2 45% (P = .165), untreated: G1 48.2% vs. G2 52.4% (P = .005). Specific training on the guidelines showed a positive impact on BP control, highly significant in patients at high cardiovascular risk such as diabetic hypertensive patients.

To determine values for home blood pressure (HBP) during pregnancy, nurses taught 45 healthy pregnant women to use a HBP method for 1 week before 15 weeks of gestation, between weeks 15 and 27, and after 28 weeks for the last 3 months of gestation. HBP values were significantly lower during the second trimester and higher during the last trimester (102 +/- 8/59 +/- 7*, 101 +/- 8/57 +/- 8*, 105 +/- 8*/62 +/- 9* mm Hg;*P0.05) than during other trimesters. Heart rate increased significantly during the pregnancy. The present study suggests upper limits for HBP: 118/73, 117/73, and 121/80 mm Hg, respectively during the 3-month gestational periods. These findings may be helpful in providing clinicians with comparative values so as begin to establish reference values for HBP during pregnancy.

To study left ventricular (LV) geometry in secondary hypertension and its evolution following etiologic treatment, echocardiography was performed in a total of 73 patients: 40 patients with renovascular hypertension (RVH), 21 with aldosterone-producing adenoma (APA), and 12 with pheochromocytoma (PH). Repeat echocardiography was possible in 43 of these patients, 3-24 months following curative renal revascularization or adrenal surgery. Age, sex ratio, and initial drug treatment score were comparable in the three etiologic categories, but 24-h ambulatory blood pressure and LV mass index were significantly higher in APA and RVH than in PH. End-diastolic LV volume was significantly smaller in PH than in APA and RVH. After treatment, the greatest reduction in LV mass occurred in APA (-18%, P < .05) and the lowest in PH (-5%, NS). Both patients with APA and those with PH exhibited a significant decrease in LV wall thickness, whereas LV diameter tended to decrease in APA patients and to increase in PH patients. No significant cardiac changes occurred in RVH patients after treatment. Although LV mass index and ambulatory blood pressure were correlated both before and after treatment, LV mass index changes did not correlate with changes in ambulatory blood pressure or with the known duration of hypertension. Systolic function was normal before and following etiologic treatment in the three categories. These findings suggest that, in addition to blood pressure, volume and/or humoral factors influence the pathogenesis of left ventricular hypertrophy and its reversibility.

To try to improve the cardiovascular risk of resistant hypertensive patients in general medicine in Brittany after using french hypertension recommendations.581 hypertensive patients under 3 antihypertensive drugs have asked for an exoneration of the patients' social contribution: 297 (51%) were uncontrolled at their general practitioner (GP) among whom 106 (36%) have refused to take part in the program. 191 resistant hypertensive patients followed by 170 different GP have been pre-included. After a meeting between the social security physician, the GP measured blood pressure (BP) with a validated BP device and passed it on to the patient for a self-BP measurement (SBPM). In the case of a confirmed resistance, after specialist opinion, the treatment was then modified and the patient was checked after four months by his GP for a new clinical and self BP measurement.After the initial automated BP measurement by GP, 51 patients (27%) had in fact controlled hypertension. Out of 136 resistant hypertensive patients (mean: 63 ys) during consultation (60% with systolic isolated hypertension), 121 (89%) have been closely followed during the whole study period among who 114 were also resistant with SBPM (94%). Only 8 patients (6%) were controlled at home. A check-up with specialist opinion was conducted: ECG (82%), echocardiography (59%), vascular echography (35%), funduscopy (30%), plasma renin/aldosterone measurement (15%), renal artery exploration (26%). Eight (7%) secondary hypertension have been founded. After 4 months, 32 (26%) obtained controlled hypertension during GP consultation and 15% during SBPM but the 20/32 controlled patients (62%) had a masked hypertension. Cholesterol levels (63% of dyslipidemics) and the body mass index (80% of overweighed patients) have not varied. On the contrary, 12/28 (48%) has stopped smoking. The coronary risk using Anderson's model has only decreased from 16.5% to 13.8%.If this health program has shown its feasibility and the good participation of the GPs, treatment of hypertension and others risk factors really remains insufficient. On the contrary, the use of a validated automatic BP device has been really well carried out. Its use has allowed reclassifying as controlled one third of the resistant hypertensive patients and as uncontrolled at home one patient out of two which were controlled with GP. These results prove the necessity to increase this BP measurement technique in this population.