Predictors of blood pressure control in a tertiary hypertension clinic

AJH–May 2003–VOL. 16, NO. 5, PART 2

totaled the number of CAD risk factors to derive a CAD risk score. The mean result of RIA on two timed overnight urine specimens was used to determine the presence of microalbuminuria in patients. To analyze the data, we stratified the entire sample according to the presence or absence of impaired fasting glucose, then used two-tailed unpaired t-tests to compare parameters between the two groups. Pearson’s correlation coefficient was calculated to examine the relationship between FBG, UAE, BMI, lipid values, and the CAD risk score. The analysis was adjusted for patient usage of antiproteinuric medications. Results: We detected previously undiagnosed impaired fasting glucose in 13.9% of subjects. HDL score was significantly lower in subjects with IFG. The FBG value directly and strongly correlated with the degree of CAD risk. Conclusions: Impaired fasting glucose (prediabetes) and diabetes mellitus occur with increased frequency in hypertensive patients. IFG and diabetes in hypertension are associated with greater cardiovascular risk. Key Words: hyperglycemia, hypertension, coronary risk factors

P-565 PHARMACOEPIDEMIOLOGICAL, OBSERVATIONAL STUDY TO ASSESS CV RISK REDUCTION IN HIGH RISK HYPERTENSIVE PATIENTS TREATED WITH AMLODIPINE. CORONARIA STUDY Juan Cosı´n, Amparo Herna´ ndiz, Amparo Aguilar, Jose L Zamorano, Luis Rodrı´guez-Padial, Rosa Arı´stegui, Beatriz Armada, on behalf of CORONARIA study investigators. Cardiovascular Research Unit, Hospital Universitario La Fe, Valencia, Spain; Echocardiographic Laboratory, Hospital San Carlos, Madrid, Spain; Cardiology Department, Hospital Virgen de la Salud, Toledo, Spain; Medical Unit, Pfizer, S.A., Madrid, Spain. The aim of this study was to assess the reduction in cardiovascular (CV) risk using the Framingham equation after blood pressure reduction treatment in high risk hypertensive patients achieving optimum blood pressure control according to internationally accepted scientific recommendations of the 1999 WHO-ISH Guidelines. This is a one year open label, observational, multicenter prospective cohorts study in hypertensive patients (BP ⫽140/90 or ⫽130/85) with at least another cardiovascular riskfactor, who according to the WHO-ISH guidelines and the physician judgement an antihypertensive treatment need to be started, added or changed (switched or increased dose). Patient evaluations should occur at baseline (month 0), at month 2 (follow-up visit), at month 6 and at 1 year (final visit), consistent with the clinical practice to manage hypertensive patients. The primary assessment parameter was the percent change from baseline in CV risk, estimated Framingham equation after one year of treatment. 7455 patients with an average age 63.5⫹11 years, female gender 48.6% were included in the intention-to-treat sample. 29% of patients were diabetics and 29% were smokers. The mean values of systolic blood pressure and diastolic blood pressure changed significantly from 162.5⫾13.2 and 95.3⫾8.6 mmHg at baseline to 135.8⫾11.7 and 80.7⫾7.7 mmHg after 12 months treatment with amlodipine 5-10 mg/ day. The CV risk of the patients changed from a mean baseline value of 24.9 ⫾ 16.4 to a final mean of 16.2 ⫾ 12.4. Significantly diferences has been found in the reduction of CV risk between males and females from 33.2 ⫾ 17.2 to 22.2 ⫾ 13.8 and 16.0 ⫾ 9.4 to 9.8 ⫾ 6.0 respectively, as well as in diabetics patients (32.0 ⫾ 17.2 to 19.9 ⫾ 13.1) compared with no diabetics (22.0 ⫾ 15.1 to 14.7 ⫾ 11.8). In all cases p⬍0.0001. Amlodipine is a drug with a high efficacy rate in the treatment of hypertension with beneficial effects in the management of CV risk. Key Words: hypertension, cardiovascular risk

POSTERS: Risk Factors/Global Assessment

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P-566 CARDIOVASCULAR RISK ASSESSED BY AMBULATORY BLOOD PRESSURE MONITORING Roger Badia, Mariano de la Figuera, Ernest Vinyoles, Marta Arcas, Elisabet Escola, Pere Lladonet. Primay Care., CAP La Mina, Barcelona, Catalonia, Spain. The aim of this study was to evaluate how information provided by ambulatory blood pressure monitoring (ABPM) could predict cardiovascular events in hypertensive patients. It’s a retrospective longitudinal study, with a convenience sampling, in two primary care centers. A total of 251 hypertensive patients without basal antihipertensive treatment were included and followed up for 6 (3.5) years [rank: 1 month-13 years]. A basal ABPM (SpaceLabs 90207) was performed, and Framingham basal cardiovascular risk was calculated. We classified subjects according their basal ABPM cardiovascular risk: Low Risk (Day-time blood pressure (BP) ⬍135/⬍85 mmHg), Medium Risk (⬎135 and/or ⬎85 mmHg day-time BP and 24 hours-pulse pressure (PP) ⬍55 mmHg) or High Risk (⬎135 and/or ⬎85 mmHg day-time BP and 24 hours-PP ⬎54 mmHg). During follow-up every cardiovascular event was recorded. Bivariant analysis and logistic regression model were applied. Mean age: 51,07 (16) years; women: 134 (53,3%); smokers: 61 (24 %); diabetics: 30 (12%), without target organ damage: 124(56,3%); mean Framingham basal 10 years cardiovascular risk: 11,8%(9,4). A total of 22 (9,5%) cardiovascular events were recorded: [12 (50%) coronary events, 6 (25%) strokes] and 2 died. The age, co-morbid pathologies, office BP and PP, ambulatory pressure and 24 hours-PP, calculated ABPM risk, Framingham risk and diabetes were significantly associated to cardiovascular events. But just ABPM Low Risk predicted good cardiovascular prognostic (OR: 0,09 [IC 95% 0,01-0,77]). We conclude that optimal day-time BP control could predict good cardiovascular prognostic. The calculated ABPM cardiovascular risk provides useful additional risk information. Key Words: Cardiovascular risk, Ambulatory blood pressure monitoring, Primary Care

P-567 PREDICTORS OF BLOOD PRESSURE CONTROL IN A TERTIARY HYPERTENSION CLINIC Renee Ellis, Munavvar Izhar, William J. Elliott, Dilip Pandey, Gilberto Neri, Pavan Chopra, Henry R. Black. Department of Preventive Medicine, Rush-Presbyterian-St. Luke’s Medical Center, 1700 W. Van Buren, Suite #470, Chicago, IL. Blood pressure control in the United States is suboptimal. Several surveys in our clinic between 1998 and 2001 showed the prevalence of blood pressure control (ⱕ140/90 mm Hg) between 68-72%. We attempted to identify characteristics of our population that were predictors for controlled blood pressure that might explain these observed differences. Randomly selected charts of 165 patients (average age 57 ⫹/-14 years, 56% male, 63% white, 63% with a family history) were abstracted. Comparisons were made using Stata 5.0 between the group that achieved blood pressure control (n⫽107) and those who did not. Blood pressures were taken in a standardized fashion, supervised by the same physician (hypertension specialists) at each visit. The age-adjusted odds ratio (OR) and 95% confidence intervals (95% CI) were calculated for the following characteristics: age (OR⫽0.99, 95% CI: 0.97-1.01), gender (n⫽73 females, OR ⫽1.27, 95% CI: 0.66-2.48), race (n⫽104 white, OR⫽0.70, 95% CI: 0.36-1.34), family history (n⫽104, OR⫽1.86, 95% CI: 0.993.61), no weight change (n⫽17, OR⫽1.42, 95% CI: 0.40-5.1), weight gain compared to weight loss (n⫽148, OR⫽ 0.68, 95% CI: 0.33-1.34). Thus gender, family history, race and weight change were not signif-

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icant predictors of controlled hypertension. The only factor that was significant was the initial systolic blood pressure, which showed a pvalue for trend ⬍ 0.002 across the quartiles. Initial SBP (mm Hg)

n

OR (95% CI)

⬍149 149–160 161–178 ⬎178

42 41 43 39

1.00 (0.98–1.03) 0.61 (0.20–1.81) 0.25 (0.09–0.69) 0.15 (0.05–0.43)

These data suggest that the only characteristic that significantly predicted blood pressure control in our clinic was the initial systolic blood pressure, in agreement with previous work. Aside from this finding, there were no characteristics in our population that could be identified that would explain why we obtain higher blood pressure control rates compared to the general population. Key Words: Risk Factors, Hypertension Control, Hypertension Specialist

P-568 APOPROTEIN E POLYMORPHISM AND MICROALBUMINURIA IN TYPE 2 DIABETIC PATIENTS Giovanni Gaudio, Pietro Margaroli, Alberto Schizzarotto, Attilio Cristallo, Ivano Cosini, Piermario Bossi, Sergio Masnaghetti, Franco Rotolo, Luigina Guasti. Department Internal Medicine, Bellini Hospital, Somma Lombardo, Varese, Italy; Department Internal Medicine, Inubria University, Varese, Varese, Italy. In humans apo E presents a genetic polymorphism, with three common alleles (e2, e3, e4) coding for three isoforms (E1, E2, E3). Apoprotein (Apo) E polymorphism has been associated with the development of atherosclerosis, being the allele E4 associated with increased cardiovascular risk. It is well known that diabetes is related with accelerated atherosclerosis and microalbuminuria is used to evaluate initial renal damage. The aim of this study was to determine whether Apo E polymorphism was associated with microalbuminuria in patients with type 2 diabetes and hypertension. Fifty consecutive patients (29 M, 21 F, mean age 56⫾ 12 years) were studied. All the subjects were on treatment with aceinhibitors and oral anti-diabetic drugs. Apo E 3/4 was found in 10 patients, the E 2/3 was found in 4 patients whereas the E 3/3 was observed in 36 patients. The lipid profile was as follows in the E 3/4 patients: total cholesterol 189.5⫾23 mg/dl, HDL 49⫾20 mg/dl, LDL 109⫾20 mg/dl, tryglicerides 154 ⫾76 mg/dl, whereas in the other group total cholesterol was 207⫾32 mg/dl, HDL was 53⫾14 mg/dl, LDL was 207⫾32 mg/dl and tryglicerides were 160⫾73 mg/dl. Sphygmomanometric and ambulatory blood pressures, the length of known diabetic disease and the glycemic profile were similar between the 10 patients with the E 3/4 and the other group of 40 subjects (4 with E 2/3 and 36 with E 3/3 genotype ). However, the E 3/4 patients showed higher microalbuminuria than the other group (Mann Withney U test: 10,8⫾ 32,82 mg/dl vs 0.3⫾ 0,48 p⬍.05). In conclusion, the renal damage in type 2 diabetic patients, expressed by microalbuminuria seems to be related with the Apo E polymorphism, being the E 3/4 heterozigosity an increased risk factor. Key Words: ApoE, hypertension, diabetes

AJH–May 2003–VOL. 16, NO. 5, PART 2

P-569 IMPROVEMENT OF RISK FACTOR MANAGEMENT AMONGST HYPERTENSIVE PATIENTS BY EDUCATING FAMILY PRACTITIONERS: THE ISRAELI BLOOD PRESSURE CONTROL (IBPC) PROGRAM Dov Gavish, Eyal Leibovitz, Chaim Yosefi, Dror Dicker, Reuven J Viskoper. Internal Medicine, Wolfson Medical Center, Holon, Israel; Internal Medicine, Barzilai Medical Center, Ashkelon, Israel; Internal Medicine, Rabin Medical Center (Golda Campus), Petah-Tikwa, Israel. The IBPC program was designed to improve risk factor control amongst hypertensive patients, without allocating patient treatment to specialized risk factor clinics. The program started in August 2000, and it was headed by authoritative figures in risk factor control in Israel. Family practitioners, each caring for 1000 to 5000 patients, were asked to join the program and register data of hypertensive patients. Each physician was allocated a small budget for program related expenses. The organizing committee scheduled meetings every 2 months, to report on the progress of the program, and to review the treatment guidelines. Each physician received the data analysis concerning his clinic, and a comparison to the other centers. After one year, the participants filled the follow-up data regarding the same patients. A total of 4742 patients from 30 centers were recruited for the registry. After 1 year, systolic and diastolic BP dropped by 5.2% (from 142⫾16 mmHg to 135⫾14 mmHg, p⬍0.001, and from 85⫾11 to 80⫾8 mmHg p⬍0.001 respectively). 46.5% had controlled BP (according JNC VI) at follow-up compared to 31.6% at baseline (p⬍0.001). 88% of the clinics had more patients reach the JNC VI goals than they did at baseline, and 78% had more than 35% of their patients achieve the goals (compared to 30% at baseline, p⬍0.001). LDL-c reduced from 134⫾35 mg/dL at baseline to 126⫾49 mg/dL (p⬍0.001) at follow-up, and 42.6% had LDL-c levels below the ATP-III recommended goals(compared to 31.5% at baseline, p⬍0.001). 94% of the clinics had more patients reach the ATP III goals than they did at baseline, and 66.6% pf the clinics had more than 35% of their patients achieve the goals (compared to 33% at baseline, p⬍0.001). The changes in blood pressure and lipid levels were achieved by enhancing adherence to perscribed treatment, increasing the number and dosage of BP and lipid lowering medications and improving lifestyle. The estimated 10year risk according to ATP 3 risk charts was reduced from 18.0 (6% 10-year risk) to 17.4 points (5% 10-year risk) in females (p⬍0.001) and from 16.9 points (25-30% 10-year risk) to 13.8 points (12-16% 10-year risk) in males (p⬍0.001). We demonstrated that a physician education program can improve the quality of treatment in high risk patients in the community. Key Words: community, risk factor control, physician education program

P-570 ASSESSMENT OF CARDIOVASCULAR RISK FACTOR AWARENESS AND ACCENTUATION OF EARLY DETECTION AMONG AFRICAN-AMERICAN COLLEGE STUDENTS T Kristopher Harrell, Nancy N Horton, Deborah S King, Marion R Wofford. Schools of Pharmacy and Medicine, University of Mississippi Medical Center, Jackson, MS; School of Healthcare Administration, Jackson State University, Jackson, MS. Mississippi dubiously ranks first in the nation in the number of deaths due to cardiovascular disease (CVD). Mississippi also ranks first in prevalence rates of obesity (24.3%) and diabetes (8.8%), which are clearly associated risks for the development of CVD. While overall CVD mortality rates have been declining, Mississippi African-American rates of death have not been improving at the same rate. The most disturbing data are those for younger African-Americans, who have a three to four times greater risk of CVD death than their white counterparts.