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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.

RESUME Toutes les etudes epidemiologiques realisees en France depuis 2007 montrent une stabilite ou meme une diminution du nombre de patients hypertendus traites et controles. La Societe Francaise d’Hypertension Arterielle a lance un travail afin d’analyser cette situation alarmante et proposer differentes actions afin d’ameliorer la prise en charge de l’HTA en France. 37 medecins, chercheurs, pharmaciens, infirmiers et patients ont redige un document comportant 60 propositions reparties en 10 chapitres. Une prevention hygieno-dietetique des l’ecole doit etre favorisee en particulier dans les DOM-ROM. Une plus grande transparence des reseaux de soins locaux du medecin generaliste au centre specialise doit exister pour nos concitoyens associant plus infirmiers et pharmaciens. Une meilleure prise en charge de l’HTA passe aussi par le remboursement de la mesure ambulatoire de la pression arterielle, des appareils d’automesure et des combinaisons de 2 ou 3 antihypertenseurs. Les dosages d’antihypertenseurs doivent etre disponibles afin d’ameliorer l’observance. La formation des professionnels de sante doit etre accentuee. Il faut favoriser la recherche fondamentale, clinique et en organisation de sante. Enfin, les techniques non medicamenteuses, la E sante et en particulier la telemedecine doivent etre validees avant leur diffusion. Ces differentes propositions sont actuellement presentees aux autorites de sante.

Resume But Evaluer le controle des facteurs de risque chez les patients coronariens a distance d’une readaptation cardiaque. Methodes Les donnees de 2005 a 2015 de readaptation cardiaque ambulatoire de 4 semaines avec un suivi a 1 an ont ete analysees. La morbidite, la mortalite cardiovasculaire, les facteurs de risque ont ete compares aux etudes Reach et Euroaspire. Resultats Sur 1091 patients coronariens, 746 (68 %) ont ete suivis a 1 an : 60 ans (20–85 ans) 15 % de femmes, 44 % hypertendus, 36 % fumeurs, 17 % diabetiques et 74 % dyslipidemiques. A la fin du stage, il existe une nette amelioration (PA ≤ 140/90 mmHg et IMC > 30 : 80 et 20 % vs 65 et 25 % en debut de stage ; LDL Conclusion L’education des patients coronariens lors d’un stage de readaptation cardiaque ameliore significativement la prise en charge des facteurs de risque, la morbidite et la mortalite. Neanmoins, le controle obtenu en fin de stage diminue a un an.

La Presse Medicale - In Press.Proof corrected by the author Available online since lundi 29 octobre 2018

International audience; Since 2016, the French Society of Hypertension has warned about the decline in the management of high blood pressure in France: stagnation, or even decreased number of people who know their blood pressure level, take a treatment and are controlled. These results are lower than those observed in many other countries. Blood pressure is measured with an old method in the doctor's office. Accepted, simple and cost-effective, this method is currently unavoidable for reasons of feasibility and social habit. It has been used in observational and intervention studies that are the basis of the medical reasoning for screening, treatment and drug control of hypertension. In practice, it is too often poorly applied and unpredictable. It is now necessary to measure blood pressure in mmHg using a validated oscillometric automatic device coupled to a specific upper arm cuff adapted to the arm circumferences for the diagnosis and monitoring of high blood pressure in the doctor's office and at home. The auscultatoric measurement is only recommended if any doubt about the reliability of the electronic measurement. Blood pressure measurement is basically performed on both arms to detect asymmetry and then on the arm with the highest blood pressure. It is performed in sitting or lying position after a few minutes of rest without speaking and without having smoked and then in standing position to diagnose orthostatic hypotension, especially in elderly, diabetic and multi-medicated subjects. The blood pressure measurement during the consultation must be repeated and include at least 3 consecutive measurements at one minute intervals. The average of the last 2 measurements determines the blood pressure level. It is recommended to perform BP measurements outside the medical environment for the diagnosis and monitoring of hypertension; Home BP measurement is preferred to ambulatory blood pressure measurement for practical reasons unless otherwise specified. The home blood pressure measurement should include three measurements in the morning at breakfast and three measurements in the evening before bedtime at one minute intervals for at least three days. Prior training must be provided. In treated hypertensive patients, a masked hypertension should be considered as an uncontrolled hypertension and antihypertensive therapy adapted accordingly. The measurement of central BP pressure (aorta) should be limited to clinical research.

Il n’y a pas « une » hypertension au cours de la grossesse mais « des » hypertensions, de mecanismes et de consequences differents pour la mere et le fœtus. L’hypertension arterielle (HTA) chronique est definie par une pression arterielle systolique (PAS) ≥ 140 mm Hg ou une pression arterielle diastolique (PAD) ≥ 90 mm Hg avant la grossesse ou avant la 20e semaine d’amenorrhee (SA). L’HTA gestationnelle est definie par une PAS ≥ 140 mm Hg ou une PAD ≥ 90 mm Hg survenant pendant ou apres la 20e SA. La pre-eclampsie (PE) est l’apparition d’une HTA et d’une proteinurie apres la 20e SA. Une PE severe s’accompagne de signes cliniques temoignant d’une souffrance viscerale. Une PE se developpe dans 1 a 2 % des grossesses, mais beaucoup plus frequemment (jusqu’a 34 %) en presence de facteurs de risque. L’HTA au cours de la grossesse reste, par ses complications, la premiere cause de morbidite et mortalite maternelles. Il n’y a pas de traitement curatif specifique de la PE hormis l’interruption de la grossesse. Le traitement de l’HTA au cours des six premiers mois de grossesse cherche a eviter les complications maternelles de l’HTA sans etre deletere sur le developpement fœtal. Toutes les HTA severes doivent etre traitees. Dans l’HTA legere a moderee, un traitement sera discute chez les patientes a haut risque cardiovasculaire (CV). L’objectif tensionnel est, pour toutes, une PAS inferieure a 160 mm Hg et une PAD comprise entre 85 et 100 mm Hg. A plus long terme, les societes savantes, dont la Societe francaise d’hypertension arterielle (SFHTA) et le College des gynecologues et obstetriciens francais (CNGOF), considerent la PE comme un facteur de risque emergeant specifique d’HTA chronique, d’accidents coronaires, d’accidents vasculaires cerebraux, d’insuffisance renale chronique et de mortalite cardio-neuro-vasculaire. Le risque de complications est d’autant plus important quand des accidents a la fois maternels et fœtaux sont survenus, ou encore precocement pendant la grossesse. Paradoxalement, l’information de ces femmes a risque est insuffisante par meconnaissance et par manque de sensibilisation des professionnels de sante. L’education de ces femmes est un enjeu majeur de prevention, en developpant des consultations d’information et d’annonce au decours de l’accouchement, en les incitant a optimiser leur hygiene de vie avec un suivi coordonne. Dans cet objectif, le consensus francais souligne l’opportunite de mettre en place des parcours de soins structures, qui, outre le suivi de ces femmes, visent a ameliorer les pratiques des professionnels de sante.

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.

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.

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.

RésuméPour améliorer la prise en charge de l’HTA résistante, la Société française d’HTA, filiale de la Société française de cardiologie publie onze recommandations dont l’objectif principal est d’apporter des informations actualisées ayant la meilleure justification scientifique et qui soient applicables dans la pratique quotidienne des professionnels de santé travaillant dans le système de santé français.L’HTA résistante est définie par une pression artérielle non contrôlée en consultation et confirmée par des mesures en dehors du cabinet médical, malgré une stratégie thérapeutique comprenant des règles hygiéno-diététiques adaptées et une trithérapie antihypertensive (diurétique thiazidique, bloqueur du SRA [ARA2 ou IEC] et inhibiteur calcique), depuis au moins 4semaines, à dose optimale.Il convient de rechercher une mauvaise observance et les facteurs qui favorisent la résistance (excès de sel, alcool, dépression et interférences médicamenteuses, substances ayant une action vasopressive).Si l’HTA résistante est confirmée, il est recommandé de demander l’avis d’un spécialiste en HTA pour rechercher une atteinte d’organe cible, une HTA secondaire.La stratégie thérapeutique recommandée est la quadrithérapie incluant la spironolactone (12,5 à 25mg/j). En cas de contre-indication ou de non réponse à la spironolactone, ou en présence d’effets indésirables, il est suggéré de prescrire un bêta-bloquant, ou un alpha-bloquant, ou un antihypertenseur central.L’intérêt de la dénervation rénale étant en cours d’évaluation, il est suggéré que l’indication de cette technique soit posée dans un centre spécialisé en HTA.SummaryTo 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 which is easily applicable to daily clinical practice for health professionals working within the French health system.Resistant hypertension is defined as uncontrolled blood pressure (BP) both 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 four weeks, at optimal doses.Treatment compliance must be closely monitored, as most factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression and drug interactions, or vasopressors).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 to 25mg/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.

Points essentiels L’hypertension arterielle au cours de la grossesse est associee a une forte morbidite et mortalite perinatale. L’existence d’une HTA par effet blouse blanche, de bon pronostic, est frequente durant la grossesse et doit etre exclue avant de debuter un traitement antihypertenseur. Quand utiliser l’automesure durant la grossesse ? Pour confirmer le diagnostic d’HTA ; pour surveiller la pression arterielle et alerter l’obstetricien lorsque survient une HTA severe ; pour adapter le traitement antihypertenseur et eviter un traitement excessif. Comment utiliser l’automesure durant la grossesse ? Acquerir un appareil adapte et homologue durant la grossesse ; comparer les resultats avec les valeurs de reference d’automesure de la pression arterielle lors des trois trimestres de la grossesse. L’automesure avec teletransmission durant la grossesse est une technique faisable, sure et bien acceptee par les patientes et constitue une bonne alternative aux consultations repetees ou a une surveillance de la pression arterielle en hospitalisation.

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.

Background: The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure–lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for resistant hypertension at 6 months. We report the influence of adherence to antihypertensive treatment on blood pressure control. Methods: One hundred six patients with hypertension resistant to 4 weeks of treatment with indapamide 1.5 mg/d, ramipril 10 mg/d (or irbesartan 300 mg/d), and amlodipine 10 mg/d were randomly assigned to renal denervation plus standardized stepped-care antihypertensive treatment, or the same antihypertensive treatment alone. For standardized stepped-care antihypertensive treatment, spironolactone 25 mg/d, bisoprolol 10 mg/d, prazosin 5 mg/d, and rilmenidine 1 mg/d were sequentially added at monthly visits if home blood pressure was ≥135/85 mm Hg after randomization. We assessed adherence to antihypertensive treatment at 6 months by drug screening in urine/plasma samples from 85 patients. Results: The numbers of fully adherent (20/40 versus 21/45), partially nonadherent (13/40 versus 20/45), or completely nonadherent patients (7/40 versus 4/45) to antihypertensive treatment were not different in the renal denervation and the control groups, respectively ( P =0.3605). The difference in the change in daytime ambulatory systolic blood pressure from baseline to 6 months between the 2 groups was –6.7 mm Hg ( P =0.0461) in fully adherent and –7.8 mm Hg ( P =0.0996) in nonadherent (partially nonadherent plus completely nonadherent) patients. The between-patient variability of daytime ambulatory systolic blood pressure was greater for nonadherent than for fully adherent patients. Conclusions: In the DENERHTN trial, the prevalence of nonadherence to antihypertensive drugs at 6 months was high (≈50%) but not different in the renal denervation and control groups. Regardless of adherence to treatment, renal denervation plus standardized stepped-care antihypertensive treatment resulted in a greater decrease in blood pressure than standardized stepped-care antihypertensive treatment alone. Clinical Trial Registration: URL: http://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.

Hypertension during pregnancy is associated with high perinatal morbidity and mortality. The prevalence of white coat hypertension is high during pregnancy and is associated with a good prognosis and must be excluded. The definition of hypertension during pregnancy is office BP≥140/90mmHg and ≥135/85mmHg with home BP and diurnal ambulatory BP. How to use HBPM during pregnancy? To get an adapted and validated BP humeral device during pregnancy; to use it in good conditions with the "3 rules". When to use HBPM during pregnancy? To confirm the diagnosis of hypertension; to monitor BP during pregnancy and to alert the obstetrician when severe hypertension occurs; to manage BP treatment and avoid excessive treatment. HBP and ABP monitoring may be used to exclude white coat effect but HBPM must be preferred when prolonged use.

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.

International audience; BACKGROUND:Conflicting blood pressure-lowering effects of catheter-based renal artery denervation have been reported in patients with resistant hypertension. We compared the ambulatory blood pressure-lowering efficacy and safety of radiofrequency-based renal denervation added to a standardised stepped-care antihypertensive treatment (SSAHT) with the same SSAHT alone in patients with resistant hypertension.METHODS:The Renal Denervation for Hypertension (DENERHTN) trial was a prospective, open-label randomised controlled trial with blinded endpoint evaluation in patients with resistant hypertension, done in 15 French tertiary care centres specialised in hypertension management. Eligible patients aged 18-75 years received indapamide 1·5 mg, ramipril 10 mg (or irbesartan 300 mg), and amlodipine 10 mg daily for 4 weeks to confirm treatment resistance by ambulatory blood pressure monitoring before randomisation. Patients were then randomly assigned (1:1) to receive either renal denervation plus an SSAHT regimen (renal denervation group) or the same SSAHT alone (control group). The randomisation sequence was generated by computer, and stratified by centres. For SSAHT, after randomisation, spironolactone 25 mg per day, bisoprolol 10 mg per day, prazosin 5 mg per day, and rilmenidine 1 mg per day were sequentially added from months two to five in both groups if home blood pressure was more than or equal to 135/85 mm Hg. The primary endpoint was the mean change in daytime systolic blood pressure from baseline to 6 months as assessed by ambulatory blood pressure monitoring. The primary endpoint was analysed blindly. The safety outcomes were the incidence of acute adverse events of the renal denervation procedure and the change in estimated glomerular filtration rate from baseline to 6 months. This trial is registered with ClinicalTrials.gov, number NCT01570777.FINDINGS:Between May 22, 2012, and Oct 14, 2013, 1416 patients were screened for eligibility, 106 of those were randomly assigned to treatment (53 patients in each group, intention-to-treat population) and 101 analysed because of patients with missing endpoints (48 in the renal denervation group, 53 in the control group, modified intention-to-treat population). The mean change in daytime ambulatory systolic blood pressure at 6 months was -15·8 mm Hg (95% CI -19·7 to -11·9) in the renal denervation group and -9·9 mm Hg (-13·6 to -6·2) in the group receiving SSAHT alone, a baseline-adjusted difference of -5·9 mm Hg (-11·3 to -0·5; p=0·0329). The number of antihypertensive drugs and drug-adherence at 6 months were similar between the two groups. Three minor renal denervation-related adverse events were noted (lumbar pain in two patients and mild groin haematoma in one patient). A mild and similar decrease in estimated glomerular filtration rate from baseline to 6 months was observed in both groups.INTERPRETATION:In patients with well defined resistant hypertension, renal denervation plus an SSAHT decreases ambulatory blood pressure more than the same SSAHT alone at 6 months. This additional blood pressure lowering effect may contribute to a reduction in cardiovascular morbidity if maintained in the long term after renal denervation.FUNDING:French Ministry of Health.

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.

The aim of this study was to investigate the cognitive and electroencephalography (EEG) short-term effects of a calcium antagonist, nicardipine, compared to placebo and clonidine (which, having known sedative effects, acted as a negative control) for 15 days in elderly hypertensive patients with memory complaints. Nicardipine and clonidine were compared with placebo in a double-blind, randomized, three-way cross-over controlled study after a 2-week placebo run-in period. This was a phase II clinical study carried out on out-patients in a single research centre. Fifteen elderly (63 +/- 10 years) hypertensive patients, without dementia but with memory complaints, were included. Psychomotor performance and cognition were assessed using both an extensive battery of validated psychometric tests (which evaluated attention and vigilance, body sway and memory) and an EEG profile. Cardiovascular parameters measured were blood pressure and heart rate. No detrimental effects of nicardipine were found on attention, vigilance, body sway or memory. Nicardipine produced a significant increase in alpha EEG energies, which may indicate possible alerting effects. In contrast, clonidine induced well-known deleterious sedative effects in psychometric tests and in EEG analysis (decrease in alpha and increase in delta and theta waves). The two drugs produced equivalent decreases in blood pressure at steady state. In conclusion, clonidine induced well-known sedative effects, while nicardipine did not impair central nervous system activity and may have had some short-term alerting effects in elderly hypertensive patients with memory complaints. This study supports the hypothesis of a dissociation between blood pressure and direct drug effects on the central nervous system.

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 which is easily applicable to daily clinical practice for health professionals working within the French health system. Resistant hypertension is defined as uncontrolled blood pressure (BP) both 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 four weeks, at optimal doses. Treatment compliance must be closely monitored, as most factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression and drug interactions, or vasopressors). 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 to 25mg/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.

Hypertension during pregnancy is associated with high perinatal morbidity and mortality The prevalence of white coat hypertension is high during pregnancy and is associated with a good prognosis. This must be excluded before beginning antihypertensive treatment. When to use HBPM during pregnancy? To confirm the diagnosis of hypertension; to monitor BP during pregnancy and to alert the obstetrician when severe hypertension occurs; to manage BP treatment and avoid excessive treatment. How to use HBPM during pregnancy? To get an adapted and validated BP device during pregnancy; to compare the results with reference HBP values during the 3 trimesters of pregnancy. Telemetry to monitor BP at home during pregnancy is a feasible, safe and well-tolerated alternative to repeated clinic visits or BP monitoring during hospitalisations.

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.

Objectif Les troubles respiratoires du sommeil (TRS) sont frequents chez les patients insuffisants cardiaques (IC). L’entrainement physique ameliore la capacite d’effort et le pronostic de ces patients. Toutefois, l’effet du traitement des TRS pendant la readaptation cardiaque n’est pas connue. Le but de l’etude est d’evaluer l’apport eventuel de la ventilation chez des patients IC apneique sur les capacites d’effort. Methodes Nous avons inclus 118 patients IC avec IAH > 15/h (polygraphie), randomises en deux groupes : G1 (entrainement seul, n = 58) et G2 : (combine entrainement + ventilation adaptee au type d’apnee, n = 60). Ces patients ont beneficie de 20 seances d’entrainement avec evaluation des capacites d’effort par epreuve cardiopulmonaire avant et en fin de programme. Les evenements indesirables ont ete recueillis durant le programme de readaptation (8 semaines). Resultats Population : âge : 62 ± 10 ans, 89 % sexe masculin, FEVG : 30 % ; IAH moyen 34 ± 14/h. Tous les patients ameliorent significativement leur pic de VO2 (G1 : 13,8 ± 4,6 a 16,3 ± 5,7 et G2 : 14,0 ± 4,1 a 17,2 ± 5,7 mL/kg/min, sans difference significative entre les deux groupes). En revanche, l’amelioration de la pente VE/VCO2 est significative ( p = 0,02) dans le groupe combine. Enfin, le nombre de decompensations cardiaques pendant l’etude est significativement moindre dans le G2 (G1 = 7,6 % vs G2 = 3,3 %, p Conclusion Chez les IC avec IAH > 15/h, la ventilation n’apporte pas d’augmentation supplementaire sur le pic de VO2, mais permet de reduire la pente VE/VCO2 et semble, a court terme, reduire les decompensations cardiaques.

Objectif Les troubles respiratoires du sommeil (TRS) sont frequents dans l’insuffisance cardiaque. L’entrainement physique (EP) ameliore la capacite d’effort et le pronostic chez ces patients. L’EP ameliore les TRS chez les patients avec apnees obstructives. Mais le role de l’EP sur les apnees centrales et mixtes est mal connu. L’objectif est d’evaluer les effets de l’EP sur l’index d’apnee hypopnee (IAH) chez ses patients insuffisants cardiaques adresses en readaptation cardiaque. Methodes Au total, 58 patients en insuffisance cardiaque (fraction d’ejection 15/h, adresses en readaptation ont ete inclus dans cette etude prospective, multicentrique. Avant et apres le programme de readaptation cardiaque les patients ont beneficie d’une evaluation de la VO2 et d’une polygraphie du sommeil. Resultats L’âge moyen est de 65 ± 10 ans, 89 % d’hommes, 52 % en classe II de NYHA et 46 % en classe III. Au debut du programme 45 % avaient des apnees obstructives, 55 % des apnees centrales ou mixtes. Apres 8 semaines d’EP, la FEVG et le pic de VO2 ont augmente respectivement de 30 ± 7 a 37 ± 10 % et de 13,8 ± 4,6 a 16,3 ± 5,5, p Conclusion L’entrainement physique permet une reduction significative des apnees centrales ou mixtes chez les patients en insuffisance cardiaque. La readaptation doit faire partie de la prise en charge des patients IC avec TRS.

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.

Aim To improve secondary prevention in coronary patients from the 6th area of Brittany (France). Context The cardiovascular (CV) mortality decreased in France by half in 10 years but remains at 13% at 1 year. Brittany is one of the French areas with the highest mortality rate (national mean: 100, Brittany 114, Paris 82: INSERM 2003–2005). Program Since December 2003, in the Educoeur center, the program of 4-week ambulatory education proposed by group of 10 patients consisted of a physical education with 22 meetings of cardiac rehabilitation (ergo cycle, carpet, segmentary muscular work, steps and balneotherapy), a therapeutic, physical and dietetic education (19 courses and workshops cook, supermarket visit and blood pressure measurement) and discussion with cardiologists and a psychologist. The data from the first 44 groups were analysed at D0 then at one year and were compared with the results of Euroaspire 3 study. Analysed data include BP, total cholesterol (CT), BMI, physical activity and nicotinism. The number of hospitalisations and mortality were compared with Reach study. Results At D0: Of 411 patients that have taken part to the program, 347 (84%) were coronary patients and 253 (73%) were reexamined in 12 months. About 80% were treated essentially by angioplasty or by coronary bypass: They are aged 61 (32–79) years, 9% are women, 50% were hypertensive, 27% current or recent smokers, 11% are diabetics and 76% have dyslipidemia (LDL>1 g/l). At the end of the course, the patient satisfaction is estimated at 9.07/10. The maximum loading attack was 115 Watt at D0, 138 Watt at the end of the training course and at 1 year testifying to a 20% increase of the physical benefit of physical education and its maintenance at 1 year. 33% had anxiety and 10% breakdown scores. During this follow-up of 1 year, 5/347 patients (1.44 %) died (3 (0.86%) CV mortality) and 35 (13.8%) patients were hospitalised in cardiology department (46 hospitalisations including 16 (35%) for non-CV chest pain or vagal dizziness)). Discussion Because of lack of availability in term of places, patients took part in this training course only 152 days after their hospitalisation and 34% of enrolled patients withdrew during this delay. For the included patients, this multidisciplinary program make it possible to improve very significantly the control of their risk factors: sufficient activity (+/36%), total cholesterol (+/28%), nicotinism (61% stopped smoking), and to decrease anxiodepressive symptoms. These results seemed to be better than those of Euroaspire. At the end of the training course, the satisfaction of the patients was high and the control of risk factors (BP, dyslipidemia, obesity, sufficient activity and nicotinism) was slightly better, but not significantly, than the results obtained at 1 year. At 1 year, total and CV mortality (1.15% vs 2.89%, and 0.86% vs 1.93%) and number of CV hospitalisation (13.6% versus 15.2%) seemed to be better in our center than those of the Reach study. Conclusion The education and the follow-up of the patient by a specialised team within a health network make it possible to improve very significantly their CV risk factors and their remote stabilisation at 1 year. Objectif Ameliorer la prevention secondaire chez les patients coronariens du territoire n°6 de Bretagne. Contexte La mortalite par infarctus a ete reduite en France de moitie en 10 ans, mais reste a 1 an de 13%. La Bretagne est l9une des regions francaises les plus touchees avec une surmortalite importante (moyenne nationale 100, Bretagne 114, Paris 82: INSERM 2003–2005). Programme Depuis decembre 2003, le centre Educoeur propose par groupe de 10 patients, un programme d’education en ambulatoire de 4 semaines avec suivi a 1 an. Le programme comprend une education physique (1 cours, 22 seances), une education therapeutique, dietetique (18 cours et ateliers:dont cuisine, visite de supermarche, automesure, entretiens de groupe avec les cardiologues), une consultation de tabacologie et un soutien psychologique (groupe de parole±entretiens individuels). Les donnees des 44 premiers cycles ont ete analysees a partir du dossier medical partage informatise:pression arterielle (PA), IMC, activite physique, tabagisme, bilan biologique, le moral (questionnaire HAD). Le taux d9hospitalisations et la mortalite a 1 an ont ete compares a l’etude Reach et les facteurs de risque a l’etude Euroaspire. Resultats A l9inclusion: Sur 411 patients pris en charge, 347 (84%) sont coronariens et 253 (73%) ont ete suivis a 1 an. Pres de 80% sont revascularises essentiellement par angioplastie. Ils sont âges de 61 (32-79) ans, 9% sont des femmes, 50% sont hypertendus, 27% fumeurs en cours ou recents, 11% diabetiques et 76% dyslipidemiques. En fin de stage la satisfaction des patients en fin de stage est estimee a 9.07/10. A 1 an versus T0: Augmentation de 20% des capacites a l’epreuve d9effort (115 watts, 138 watts en fin de stage et a 1 an). 33% ont des criteres d9anxiete et 10% sont depressifs versus respectivement 47% et 24% a J0. 5/347 patients (1.44%) sont decedes dont 3 (0.86%) de cause cardiovasculaire. 35 (13.8%) ont ete hospitalises pour une cause cardiovasculaire (46 hospitalisations, dont 16 (35%) pour douleur d9origine non cardiovasculaire ou malaise de type vagal). Discussion Le manque de places disponibles a retarde la prise en charge des patients a 152 jours apres hospitalisation et 34% des patients inscrits se sont desistes durant l9attente. Pour les patients pris en charge, le programme multidisciplinaire a permis en 1 an d9augmenter significativement le controle des facteurs de risque suivants: activite suffisante (+36%), cholesterol total (+28%), tabagisme (61% on arrete de fumer), et de diminuer les symptomes anxio-depressifs. Ces resultats semblent plus satisfaisants que ceux d9Euroaspire. En fin de stage, la satisfaction percue des patients etait importante et les resultats en terme de controle de la PA, de la dyslipidemie, de l9obesite et du tabagisme etaient legerement meilleurs qu’a 1 an, sans difference significative. A 1 an, par comparaison a l’etude reach, les taux de mortalite (1.15% versus 2.89%, de cause cardiovasculaire 0.86% versus 1.93%) et d9hospitalisations pour cause cardiovasculaire (13.6% versus 15.2%) semblent moindres dans notre etude. Conclusion L’education des patients coronariens dans un reseau de soins associe a un stage de readaptation physique ameliore significativement la prise en charge des facteurs de risque a 1 an.

Background and Objectives Approximately 100 000 heart attacks occur every year in France. Brittany is one of the regions of France with the highest mortality rate. Regional differences can be explained in part by cardiovascular risk factors. Screening for risk factors and bringing them under control could reduce morbidity and mortality. Our objective was to determine whether systematic screening of patients at high cardiovascular risk (HCVR) followed by appropriate care is possible and effective at a district level. Programme The Prevarance programme involves: (1) raising the awareness of the population within the Dinan district (25 000 inhabitants) by letter, newspapers, posters, public notices, etc; (2) identifying the cardiovascular risk of men aged 50 to 54 years and women aged 60 to 64 years, (3) providing free specialised multidisciplinary care to those with HCVR (defined by at least two risk factors+age, or HCVR diabetes, or cardiovascular or renal complications). The inclusion period was from 1 November 2006 to 31 December 2007 and was followed by care until 31 December 2008. Community health professionals were trained in therapeutic patient education (TPE) and benefited from the assistance of a clinical research assistant. The general practitioner (GP) received a lump sum if at least 60% of the targeted population within their practice was screened during the year. Results A total of 47 community health professionals participated in the programme (18 out of 22 GPs assisted by 11 pharmacists and a TPE team including 15 community nurses, 2 dieticians and 1 physical activity trainer). All the GPs fulfilled their contract. Average duration of care was 510 days (ie, 19 months). Of the 945 patients targeted, 685 were screened (73%): 17% smokers, 36% with high blood pressure (treated or not), 8% diabetics, 7% heavy drinkers, 27% too sedentary, and 55% overweight (BMI>25 kg/m 2 ). Of these, 171 (25%) were HCVR patients: 62% in primary prevention, 19% in secondary prevention, and 19% with HCVR diabetes. After a mean follow-up of 19 months, 63/171 HCVR patients (37%) were participating in the programme. Results were significant in all HCVR patients and more marked in programme participants: decrease in blood pressure (from 144/52 to 134/79 mm Hg, p Discussion and Conclusion Our multidisciplinary and multiprofessional programme of primary prevention had an impact both on participation and clinical outcomes. Most GPs participated and acquired raised awareness of the concept of CV risk. Awareness was also raised in patients, there was a willingness to participate in screening and a significant reduction in cardiovascular risk was recorded in patients receiving care for over 19 months. The impact was achieved mainly by prescribing medication for hypertension and dyslipidemia. The programme has shown that (1) screening for cardiovascular risk by all participating GPs is feasible, (2) that 25% of the population in this age group is at high cardiovascular risk, (3) 37% of screened patients agreed to receive free, specialised care, and (4) a reduction in overall cardiovascular risk can be achieved in less than 1.5 years in a third of HCVR patients. Objectif/contexte Pres de 100 000 infarctus surviennent par an en France. La Bretagne est l9une des regions francaises les plus touchees avec une surmortalite importante. De telles differences regionales s9expliquent au moins en partie par les facteurs de risque cardiovasculaire. Le depistage et controle de ces facteurs de risque pourrait reduire cette surmorbi-mortalite. Un depistage systematique des patients a haut risque cardiovasculaire (HRCV) sur un canton, suivi d9une prise en charge adaptee est-il possible et efficace? Programme Le programme PREVARANCE consiste (1) apres information de la population du canton de Dinan (25 000 habitants) (courriers, journaux, affiches…), (2) a depister le risque cardiovasculaire des hommes de 50 a 54 ans et des femmes de 60 a 64 ans et (3) en cas de haut risque cardiovasculaire (HRCV) (defini par au moins 2 facteurs de risque + âge ou un diabete a HRCV ou une complication cardiovasculaire ou renale) a proposer une prise en charge gratuite et specialisee par une equipe multidisciplinaire. Periode d9inclusion: du 1/11/2006 au 31/12/2007, suivi de la prise en charge jusqu9au 31/12/2008. Les professionnels de sante liberaux ont beneficie de formations a l’education therapeutique et de l9aide d9une assistante de recherche clinique. Une remuneration forfaitaire du MG etait prevue en cas de depistage d9au moins 60% de sa clientele d’âge cible en 1 an. Resultats Ont participe a ce programme 47 professionnels de sante liberaux (18/22 medecins generalistes (MG) aides par 11 pharmaciens et 1 equipe d’education therapeutique -15 infirmieres liberales, 2 dieteticiennes et 1 educateur physique-. 100% des MG ont respecte leur contrat. Le delai moyen de prise en charge dans le programme a ete de 510 jours soit 19 mois. Description des patients a l9inclusion: Sur 945 patients cibles, 685 ont ete depistes (73%): 17% fumeurs, 36% hypertendus traites ou non, 8% diabetiques, 7% buveurs excessifs, 27% realisant une activite physique insuffisante et 55% en surpoids (IMC>25 kg/m2). 171 (25%) etaient a HRCV: 62% en prevention primaire, 19% en prevention secondaire et 19% avec un diabete a haut RCV. Apres un suivi moyen de 19 mois, des 171 patients a HRCV, 63 (37%) ont participe au programme. Resultats significatifs chez tous les patients a HRCV, plus marques chez les patients dans le programme: reduction de la pression arterielle (de 144/52 a 134/79 mmHg; p Au total, 32% des patients a HRCV ne l’etaient plus en fin de programme. Discussion Ce programme cantonal multidisciplinaire et multiprofessionnel de prevention primaire a induit un impact professionnel (participation et sensibilisation au concept du risque CV de la grande majorite des MG) et clinique (sensibilisation de la population, participation au depistage, reduction significative du risque cardiovasculaire des patients pris en charge sur 19 mois). Cet impact semble obtenu en modifiant principalement l9HTA et la dyslipidemie par traitement medicamenteux. Conclusion Le programme a montre (1) qu9un depistage du risque cardiovasculaire est realisable par 100% des MG participants (2) que 25% de la population de cette tranche d’âge est a haut risque cardiovasculaire (3) que 37% des patients depistes ont accepte de beneficier de la prise en charge specialisee et gratuite (4) qu9un impact clinique en terme de reduction globale du risque cardiovasculaire est atteignable en moins d’1,5 an pour 1/3 des patients a HRCV.

Background Reboxetine [(R,S)-2[(R,S)-α-(2-ethoxyphenoxy)benzyl]morpholine methanesulfonate] is a racemic compound that consists of equal proportions of R,R- and S,S-enantiomers. This study investigated the hemodynamic effects of reboxetine and the R,R-enantiomer compared with placebo in volunteers. The pharmacokinetics of reboxetine and its enantiomers were also investigated in the study. Methods Nine healthy, male volunteers received single doses of 4 mg reboxetine, 2 mg R,R-enantiomer, and placebo at weekly intervals. Reboxetine and the R,R-enantiomer were well tolerated in all volunteers. Results The heart rates of patients in the supine and standing positions were increased after reboxetine administration compared with the R,R-enantiomer (P < .05, except supine heart rate at 6 hours) and placebo (P < .05). Supine systolic and diastolic blood pressure was also increased by 3 ± 4 and 1 ± 4 mm Hg, respectively, after reboxetine compared with R,R-enantiomer (−2 ± 4 and −4 ± 3 mm Hg) and placebo (−4 ± 4 and −4 ± 4 mm Hg) administration. The systolic and diastolic blood pressure measurements for subjects while standing did not differ significantly among treatments. There was no significant difference between the maximum plasma concentration, mean time to maximum plasma concentration, plasma half-life, or area under the plasma concentration–time curve (AUC) of the R,R-enantiomer after reboxetine or R,R-enantiomer administration. The ratio of the mean AUC values for the R,R- and S,S-enantiomers was 2.1. Conclusion These findings suggest that the S,S-enantiomer is responsible for the hemodynamic effects of reboxetine in humans. Increases in supine blood pressure after reboxetine administration may be interpreted as regression to the mean value and not caused by any treatment effect. Clinical Pharmacology & Therapeutics (1999) 66, 282–287; doi