Cardiovascular disease (CVD) is the most common cause of death in industrialized nations. Type 2 diabetes is a CVD risk factor that confers risk similar to a previous myocardial infarction in an individual who does not have diabetes. In addition, the most common cause of chronic kidney disease (CKD) is diabetes. Together, diabetes and hypertension account for more than two-thirds of CVD risk, and other risk factors such as dyslipidemia contribute to the remainder of CVD risk. CKD, particularly with presence of significant albuminuria, should be considered an additional cardiovascular risk factor. There is no consensus on how to assess and stratify risk for patients with kidney disease across subspecialties that commonly treat such patients. This paper summarizes the results of a consensus conference utilizing a patient case to discuss the integrated management of hypertension, kidney disease, dyslipidemia, diabetes, and heart failure across disciplines.

Cost-containment measures in healthcare provision include the implementation of therapeutic and generic drug substitution strategies in patients whose condition is already well controlled with pharmacotherapy. Treatment for hypertension is frequently targeted for such measures. However, drug acquisition costs are only part of the cost-effectiveness equation, and a variety of other factors need to be taken into account when assessing the impact of switching antihypertensives. From the clinical perspective, considerations include maintenance of an appropriate medication dose during the switching process; drug equivalence in terms of clinical effectiveness; and safety issues, including the diverse adverse-event profiles of available alternative drugs, differences in the 'inactive' components of drug formulations and the quality of generic formulations. Patients' adherence to and persistence with therapy may be negatively influenced by switching, which will also impact on treatment effectiveness. From the economic perspective, the costs that are likely to be incurred by switching antihypertensives include those for additional clinic visits and laboratory tests, and for hospitalization if required to address problems arising from adverse events or poorly controlled hypertension. Indirect costs and the impact on patients' quality of life also require assessment. Substitution strategies for antihypertensives have not been tested in large outcome trials and there is little available clinical or economic evidence on which to base decisions to switch drugs. Although the cost of treatment should always be considered, careful assessment of the human and economic costs and benefits of antihypertensive drug substitution is required before this practice is recommended.

The aim of this study is to assess the effect of hospital admission on 24-h ambulatory blood pressure (ABP) in hypertensive subjects. Treated or untreated hypertensive adults with open-angle glaucoma underwent inpatient and outpatient 24-h ABP monitoring in a random order 4 weeks apart. Awake ambulatory hours, awake in-bed hours and sleep hours were reported by participants. The nighttime-to-daytime ABP dip (%) and the sleeping-to-awake dip (ambulatory and in-bed) were determined using the two ABP recordings. A total of 40 subjects were analyzed (mean age 65.7 ± 8.4 (s.d.) years, n=19 men). Daytime systolic BP (SBP) was lower in the hospital than in the outpatient setting (mean difference 4.3 ± 10.4 mm Hg, P=0.01), as was the awake ambulatory SBP (mean difference 5.0 ± 11.1 mm Hg, P=0.008). No differences were detected in 24 h, nighttime or sleeping SBP or in any of the respective diastolic outpatient vs. inpatient ABP measurements. The nighttime SBP dip (vs. daytime) was larger in the outpatient setting (8.9 ± 7.5% and 5.2 ± 4.7%, respectively; P=0.003). Sleeping SBP dip (vs. awake ambulatory and awake in-bed) was also larger in the outpatient setting (11.1 ± 7.3 and 7.8 ± 5.9%, respectively; P=0.02) with no difference in diastolic ABP. These data suggest that inpatient 24-h ABP monitoring does not reflect the usual BP level during routine daily life, nor does it represent the usual diurnal pattern of an individual. Relying on the 24-h ABP monitoring performed in the hospital environment may lead to an underestimation of ABP and an overdiagnosis of non-dippers. Therefore, 24-h ABP monitoring for decision making regarding diagnosis and treatment of hypertension should be performed only in the routine daily conditions of each individual.

Hypertension in children and adolescents has been gaining ground in cardiovascular medicine, mainly due to the advances made in several areas of pathophysiological and clinical research. These guidelines arose from the consensus reached by specialists in the detection and control of hypertension in children and adolescents. Furthermore, these guidelines are a compendium of scientific data and the extensive clinical experience it contains represents the most complete information that doctors, nurses and families should take into account when making decisions. These guidelines, which stress the importance of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, should act as a stimulus for governments to develop a global effort for the early detection and suitable treatment of high pressure in children and adolescents. J Hypertens 27:1719-1742 Q 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

In children and adolescents, the diagnosis of hypertension is based on office, home and ambulatory blood pressure (BP) measurements. Different normalcy tables for each method have provided 95th percentiles of BP as thresholds for hypertension diagnosis. This study assessed the differences in BP thresholds among these methods when applied in the pediatric population. The most widely used office, home and ambulatory BP normalcy tables were compared in terms of the 50th and 95th percentiles by gender and age. The range of office BP change with increasing age is wider than for home or ambulatory BP in boys and girls, apart from systolic BP in boys. Percentiles of home BP are consistently lower than that of daytime ambulatory BP. There is a trend for office BP to be lower than home or daytime ambulatory BP in the younger age subgroups. This difference is progressively eliminated with increasing age, apart from systolic BP in boys. In conclusion, in children and adolescents, the relationship between office, home and ambulatory BP thresholds provided by the widely used normalcy tables is not the same as in the adults. These findings should be taken into account when evaluating BP measurements in children and adolescents in clinical practice.

Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

Ambulatory arterial stiffness index (AASI) is a novel index derived from the linear relationship between 24-h ambulatory systolic and diastolic blood pressure (BP) measurements. This study investigated whether 'home arterial stiffness index' (HASI) based on self-home BP measurements is similar to AASI. A total of 483 hypertensive subjects underwent 24-h ambulatory and 6-day home BP monitoring. AASI and HASI were defined as one minus the respective regression slope of diastolic on systolic BP. Mean HASI (0.66+/-0.17) was higher than 24-h (0.33+/-0.15) daytime (0.50+/-0.18) and nighttime AASI (0.37+/-0.19, P<0.001 for all comparisons vs. HASI) and was weakly correlated with 24-h (r=0.14, P<0.01) daytime (r=0.14, P<0.01) and nighttime AASI (r=0.09, P=0.05). Compared to 24-h AASI, HASI was less closely associated with age (r=0.46 and 0.10 respectively, P<0.001 for difference), systolic home BP (r=0.30 and 0.09, P<0.001) and pulse pressure (r=0.52 and 0.20, P<0.001), as well as with 24-h ambulatory systolic BP (r=0.21 and 0.05, P<0.05) and pulse pressure (r=0.56 and 0.25, P<0.001). No satisfactory agreement was observed between HASI and 24-h (agreement 63%, kappa 0.02) daytime (agreement 65%, kappa 0.1) or nighttime AASI (agreement 63%, kappa 0.03) in detecting subjects at the top quartile of the respective distributions. HASI appears to be similar but also has important differences from AASI and is less closely associated with markers of arterial stiffness. These data do not support the view that home BP measurements can replace ambulatory monitoring in the assessment of the arterial stiffness index.

Hypertension in children and adolescents has gained ground in cardiovascular medicine, thanks to the progress made in several areas of pathophysiological and clinical research. These guidelines represent a consensus among specialists involved in the detection and control of high blood pressure in children and adolescents. The guidelines synthesize a considerable amount of scientific data and clinical experience and represent best clinical wisdom upon which physicians, nurses and families should base their decisions. They call attention to the burden of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers, to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Several studies compared blood pressure (BP) at home (HBP) with ambulatory BP (ABP), but using different devices, which contribute to differences in measured BP. A novel dual-mode device allowing ABP and HBP monitoring (Microlife WatchBPO3) was validated according to the European Society of Hypertension International Protocol and used to compare the two methods. In the validation study, 33 subjects were assessed with simultaneous BP measurements taken by 2 observers (connected mercury sphygmomanometers) 4 times, sequentially with 3 measurements taken using the tested device. Absolute observer-device BP differences were classified within 5/10/15 mm Hg zones. Measurements with

This study investigated the optimal schedule for home blood pressure (HBP) monitoring that has the greatest prognostic ability and provides the most reliable assessment of HBP. The Didima study assessed the value of HBP (duplicate morning and evening measurements, 3 days) in predicting cardiovascular events in the general population (662 adults, 8.2+/-0.2 years follow-up). Criteria for the optimal monitoring schedule were stabilization of mean HBP, its variability (standard deviation (s.d.)) and hazard ratios (HRs) of cardiovascular events per 1 mm Hg HBP increase. By averaging more readings (1-12), there was a progressive decline in average HBP and its s.d. and increase in HR, with most of these benefits achieved on the second day (8 readings) and little additional benefit obtained on the third day (12 readings). The first day gave higher and more unstable HBP values (higher s.d.) with less prognostic ability (lower HR). The first HBP readings per occasion gave higher values but with similar prognostic ability as the second readings taken 1 min later. There was little difference in average HBP between morning and evening readings with no prognostic superiority of morning readings. In conclusion, by averaging more readings the average HBP and its variability are reduced and the prognostic ability improved. Any aspect of HBP monitoring (first or second readings, morning or evening) has similar prognostic ability. The first day gives higher and unstable values with lower prognostic ability and should be better discarded. These data validate the HBP monitoring schedule proposed by the European Society of Hypertension.

Masked hypertension is defined as low clinic and elevated out-of-clinic pressure (blood pressure, BP) assessed either by patients at home or by ambulatory monitoring. This study compared the cardiovascular status and psychometric characteristics of masked, white coat and sustained hypertensives. Three groups of consecutive subjects with masked (n=100, age 59+/-11 years), white coat (n=100, 60+/-10 years) and sustained hypertension (n=100, 60+/-11 years) diagnosed by ambulatory BP monitoring were compared. Masked hypertensives had higher educational level, exercised more frequently, received fewer drugs and sensed more responsibilities at work than at home. Their left ventricular hypertrophy indexes fall in-between those with white coat and sustained, the latter having the highest values. The estimated total cardiovascular risk was intermediate between white coat and sustained, whereas their cardiovascular morbidity and renal disease was higher than that of white coat and similar to sustained. Psychological profile analysis showed lower score for type-A personality and their mood behaviour in the hypomania-euthymia range compared with white coat and sustained hypertensives. The cardiovascular risk of masked hypertensives is higher than that of white coat and similar to sustained. Masked hypertensives have higher educational level, better physical training and different personality/mood pattern than white coat and sustained.

It is common practice to coadminister proton pump inhibitors with aspirin to diminish the risk of upper gastrointestinal bleeding. This is the first study that investigated the potential impact of a proton pump inhibitor on aspirin effects on platelet aggregation. Twenty-four hypertensive subjects eligible for treatment with low-dose enteric-coated aspirin (LDECA) for primary prevention of cardiovascular disease were randomized to receive 100 mg LDECA or 100 mg LDECA plus 30 mg lansoprazole for 4 weeks. Then, participants were crossed over to the alternative regimen for another 4 weeks. Salicylic, gastrin, and pepsinogen I blood level counting were used to ensure adherence to treatment. Platelet aggregation was evaluated by light transmittance aggregometry and PFA100. The LDECA administration reduced arachidonic acid (P < 0.001), collagen (P < 0.01), and epinephrine (P < 0.001) tests. These changes paralleled an increase in collagen/epinephrine duration (P < 0.001) but not in collagen/adenosine diphosphate duration and platelet count. No significant difference was found in any of these platelets' function tests with LDECA alone versus LDECA plus lansoprazole. A significant increase in salicylic levels was observed in patients on LDECA as well as in those on LDECA plus lansoprazole, whereas gastrin and pepsinogen I levels were increased only when lansoprazole was added. These data suggest that the concomitant use of the lansoprazole at 30-mg daily does not influence the long-term effect of LDECA on platelet aggregation. Furthermore, they might imply that an interaction of LDECA with other proton pump inhibitors on platelet aggregation is unlikely.