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Background Cardiovascular diseases are the leading cause of death in women, killing sevenfold more women than breast cancer. Rates of hospital death for myocardial infarction in women, although decreasing, remains significantly higher than in men (more than double), especially among women under the age of 50. The occurrence of myocardial infarction in non-menopausal women is not unusual, and the incidence continues to rise. While women under the age of 60 accounted for less than 12% of patients with myocardial infarction admitted in 1995, they accounted for more than 25% in 2015. In addition to the traditional cardiovascular risk factors, women present specific ones linked to hormonal modifications, inflammatory high-risk profiles, and thrombophilia. Purpose We comprehensively and systematically collected all clinical and biological data and the results of morphological explorations in all women admitted for myocardial infarction under the age of 50 in high-volume French centres. To date, no systematic descriptive analysis has been carried out incorporating not only clinical, morphological, and extraordinary characteristics, but biological characteristics, in particular hormonal and immunological parameters. Methods This prospective, observational study included all women admitted for myocardial infarction under the age of 50 years at 30 centres in France from May 2017 to June 2019. Results The population comprised 314 women (mean age 44.9 years): 192 presented with ST-segment elevation myocardial infarction and 122 with non-ST-segment elevation myocardial infarction, 75% were current smokers, 35 had a family history of cardiovascular disease, 33% had a complication of pregnancy, and 55% reported recent emotional stress. Ten had a normal coronary angiogram. Independent predictors of premature MI, Conclusion The WAMIF study showed that most young women with acute myocardial infarction reported typical symptoms of chest pain, and modifiable cardiovascular risk factors, most commonly tobacco use. Gynaecological status, history of pregnancy complications, and non-compliance with non-indication of combined contraception were overrepresented, emphasizing the urge for a better cardiological and gynaecological network. The overall prognosis for these women was better than previously reported despite the high rate of emergency consultations in the year following the index myocardial infarction, highlighting the need for more comprehensive follow-up following the myocardial infarction. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): French Society of CardiologyGrants from Indusctries Biosensors Europe SA, AstraZeneca, Boston Scientific Corporation, Abbott Medical Devices, Terumo Corporation, Daiichi Sankyo, Inc., Hexacath, France, Biotronik SE & Co. KG.

Resumen El embarazo constituye un periodo de riesgo para las mujeres con patologia cardiovascular. Las complicaciones cardiovasculares son la primera causa de mortalidad indirecta de las mujeres en la etapa del parto en los paises del hemisferio norte. Las cardiopatias preexistentes al embarazo son la primera causa de descompensacion cardiaca: las mas frecuentemente observadas en estas pacientes son las enfermedades valvulares y las cardiopatias congenitas. Las patologias de alto riesgo materno son las valvulopatias estenosantes, la hipertension pulmonar, las protesis mecanicas, la insuficiencia cardiaca, las cardiopatias congenitas cianogenas y los aneurismas de la aorta. El manejo y tratamiento de estas pacientes necesitan adaptarse durante el embarazo, y el parto debe ser programado por un equipo multidisciplinar preparado. No hay que olvidar el riesgo fetal y neonatal, en particular la prematuridad espontanea o inducida, el riesgo de retraso de crecimiento intrauterino, de abortos de repeticion o de teratogenicidad. Es frecuente detectar enfermedades cardiacas subyacentes, desconocidas hasta ese momento, en el periodo del parto, deteccion que se asocia a una importante morbimortalidad materna. En caso de sintomatologia sugerente, soplos, antecedentes familiares de cardiopatia o antecedentes personales de quimioterapia o radioterapia, se puede recomendar realizar una deteccion precoz clinica y ecocardiografica.

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.

Can menopausal hormone therapy (HT) be used in hypertensive women? The group of experts of the French Society of Hypertension has carried out a review of the recent literature in order to answer this question, based on the most recent scientific publications. If use of oral HT is associated with a discreet increase in blood pressure, the transdermal route seems to be safer. The first results of major randomized trials of HT had alerted to an increase in cardiovascular events and breast cancer with the use of oral HT, generally, tipping the benefit-risk balance of the deleterious side. Complementary analyzes have shown the importance of the window of intervention (less than 10 years after the menopause) and the age of the woman to start the HT. On the contrary, they have shown a significant decrease of the coronary events. For woman suffering from hypertension and important climacteric symptoms, it is important to evaluate the whole cardiovascular risk in order to decide the possibility of prescribing a HT. Thus, the group of experts proposes a prescription assistance algorithm based on the stratification of cardiovascular risk, always favoring, when it is authorized, HT by transdermal route of administration.

Resume Contexte Les maladies cardiovasculaires (CV) restent la premiere cause de mortalite chez la femme. Une piste d’amelioration est de developper des parcours cardio-gynecologiques comme le circuit « cœur, arteres et femmes » au CHRU de Lille, destinee aux femmes a risque CV. Methode Cette etude observationnelle a evalue la pertinence du circuit a partir d’une population de 191 femmes hospitalisees pour bilan « vasculaire » (n = 55) ou « hypertension arterielle (HTA) » (n = 136) du 1er janvier au 31 decembre 2013. L’objectif a ete d’etudier leurs profils cliniques et leurs prises en charge. Resultats Toutes les femmes etaient a haut risque CV (38 % a tres haut risque). Âgees en moyenne de 52 ans, une femme sur 3 avait un antecedent d’hypertension ou de diabete gestationnel, 1 sur 2 etait menopausee. Les estro-progestatifs ont ete interrompus chez 12 femmes. Six sur 10 n’avaient pas de suivi gynecologique. Cent quatre-vingt-six femmes etaient hypertendues (HTA nocturne dans 73 % des cas ; non dipping dans 1 cas sur 2 ; 15 nouveaux diagnostics). Le depistage du syndrome d’apnee du sommeil etait positif 1 fois sur 2. Les traitements ont ete optimises, notamment la tritherapie chez les patientes atheromateuses, passant de 30 % a 46 % (p = 0,0005). Le courrier de synthese a ete transmis au gynecologue dans 18 % des cas. Conclusion Ce bilan a 1 an souligne l’utilite du circuit « cœur, arteres et femmes » avec un reajustement des prises en charge et une sensibilisation de tous a l’opportunite d’un suivi coordonne.

Contexte Le syndrome d’apnees du sommeil (SAS) est un facteur de risque cardiovasculaire reconnu. Chez la femme, sa frequence augmente au moment de la menopause. La presentation clinique feminine du SAS est atypique, a l’origine d’un retard diagnostique. L’objectif principal de l’etude a ete d’etudier le SAS chez les femmes menopausees a risque cardiovasculaire (RCV) eleve a tres eleve selon la stratification americaine specifique de la femme. Methode Etude observationnelle retrospective, sur une population de 91 patientes menopausees hospitalisees pour un bilan programme dans le centre d’excellence d’HTA-vasculaire au CHU de Lille entre le 1 er janvier 2013 et le 1 er janvier 2015. Toutes les femmes incluses ont eu un depistage de SAS par polygraphie ventilatoire ou polysomnographie. Les caracteristiques demographiques, antecedents, facteurs de risque cardiovasculaires (RCV) et reponses aux auto-questionnaires de depistage du SAS ont ete etudies. Le diagnostic de SAS etait pose devant un index apnees/hypopnees (IAH) > 5 (recommandations francaises). Resultats Le diagnostic de SAS etait confirme chez 73 % des patientes. La severite du SAS etait stratifiee en fonction de l’IAH en SAS leger (5 30) (24 %). Dans un cas sur 5, l’IAH etait non renseigne. Parmi ces SAS, un sur deux relevait d’un appareillage par pression positive continue. Chez les patientes ayant un SAS modere a severe et/ou appareille, l’absence de baisse de la pression arterielle (PA) nocturne etait retrouvee dans 49% des cas pour la pression systolique et dans 22% des cas pour la pression diastolique. Les patientes a « tres haut RCV » selon la classification de l’American Heart Association (AHA) avaient plus souvent un SAS (OR = 4,3, p = 0,0012). Il n’y avait pas d’autre difference significative retrouvee sur les autres variables etudiees, en particulier l’anciennete de la menopause. Conclusion Les patientes menopausees a RCV eleve a tres eleve sont a tres haut risque de SAS. Il est necessaire d’utiliser la stratification dediee au RCV chez ces patientes pour cibler prioritairement les femmes relevant d’un depistage du SAS, en s’aidant aussi de la mesure ambulatoire de la PA sur 24 heures pour la PA nocturne. Les auto-questionnaires de depistage, pas assez discriminants chez la femme, devront etre adaptes a leurs specificites cliniques. Ce sera un des objectifs a court terme du parcours de sante « cœur-arteres-femmes », au CHU de Lille.

Grandes pourvoyeuses de morbidite, les maladies cardiovasculaires (CV) sont la premiere cause de mortalite chez les femmes en France. En vivant au meme rythme que les hommes, les femmes ont adopte un mode de vie similaire avec, en particulier, un tabagisme precoce. D’apres l’etude de Framingham, ce sont plus de 80 % des femmes de plus de 45 ans qui ont au moins 2 facteurs de risque traditionnels. Certains d’entre eux ont un impact plus deletere sur le risque coronaire chez la femme (INTERHEART). Celles-ci sont de plus exposees a des facteurs de risque specifiques (notamment hormonaux) ou emergents, peu connus. Ces constats font de la femme une cible prioritaire de prevention et de recherche. Plusieurs scores de risque ont ete elabores pour guider les prises en charge mais les femmes sont sous-representees. Dans le score europeen, aucune femme francaise n’a ete incluse dans sa construction, sa validation externe a porte sur 12 femmes decedees. La seule utilisation des facteurs de risque traditionnels sous-estime aussi le risque CV feminin. Pres de 20 % des evenements coronaires chez la femme surviennent en l’absence de facteurs de risque majeurs utilises dans le score de Framingham. Celui-ci classe plus de 80 % des femmes a « bas risque » avant 70 ans, et meme jusqu’a 80 ans. Le score de Reynolds reclasse 43 % des femmes classees a risque « intermediaire » selon Framingham en « bas » ou « haut » risque. Ce score aurait des performances superieures au score de Framingham pour predire les evenements CV chez la femme. Toutefois, aucun des scores ne prend en compte le risque hormonal ni les facteurs psychosociaux. C’est pourquoi Mosca et al. ont propose, en 2011, une stratification innovante du risque CV feminin, incluant ces specificites. Compte tenu des enjeux humains et economiques des maladies CV chez la femme, il apparait essentiel de construire un score de risque qui leur soit specifique.

Cardiovascular diseases remain the first cause of death in women. To improve women's health cardiologists and gynaecologists should work together on women's specific cardiovascular risk factor.Our study evaluated a care pathway named "heart, arteries and women". One hundred and ninety-one women were included for vascular (n=55) or hypertensive (n=136) explorations from January the first to December the 31st of 2013. We studied their clinical presentation and medical management.All women were at high cardiovascular risk (38% of them at very high risk). The average age was 52 years old. A woman on three had experienced high blood pressure or diabetes during pregnancy. One on two was postmenopausal woman. We stopped twelve estrogen-progesterone contraceptions; 60% didn't have gynaecological follow-up; 146 had high blood pressures (73% at night, 50% had no dipping blood pressure profile and 15 were newly diagnosed for hypertension). Sleep apnoea syndrome was suspected in half women. Medical therapies were optimized especially for women with atheroma in which 30 to 46% were properly treated (P=0.0005). Only 18% of the gynecologists received conclusive reports.At one year, our care pathway "heart, arteries and women" allowed to optimize medical therapy and clinical management. Everyone should be aware of this program.

Resume Ce cas clinique illustre une cause rare d’hypertension arterielle secondaire d’une adolescente de 17 ans, dont le bilan a permis la decouverte d’une nephropathie par reflux vesico-ureteral (NRVU) bilateral. Cette pathologie se complique frequemment d’hypertension arterielle et d’insuffisance renale. La prise en charge tres precoce de ces enfants est fondamentale. Les donnees recentes de la litterature pronent plutot pour un suivi medical rapproche que pour une cure chirurgicale.

Introduction Plus de 50 % des patients souffrant d’hypertension refractaire (HR) sont aussi porteurs d’un syndrome d’apnees obstructives du sommeil (SAOS). Cependant, il existe tres peu de donnees concernant le profil metabolique de ces patients et l’effet de la pression positive continue (PPC) sur leur pression arterielle (PA). Methodes Nous avons realise une etude multicentrique, comparative (presence ou non de SAOS), randomisee, en simple insu, chez 62 patients (60 ± 10 ans ; 77 % d’hommes, IMC, 29,6 ± 3,9 kg/m 2 ) avec HR (PA systolique (PAS) des 24 h diurne/PA diastolique (PAD) : 145 ± 13/85 ± 10 mmHg, 3,7 medicaments antihypertenseurs). Le critere de jugement principal etait l’influence du SAOS sur le taux sanguin de leptine a baseline des patients HR. Les patients HR porteurs d’un SAOS ( n = 37) ont ensuite ete randomises pour etre traites par 3 mois de PPC sham ( n = 18) suivis par 6 mois de PPC efficace ou seulement par 6 mois de PPC efficace ( n = 19) afin d’evaluer l’effet de la PPC sur la PA et les marqueurs metaboliques, comme criteres secondaires. Resultats Au total, 37 patients SAOS avec HR (60 % des 62 patients inclus) etaient surtout des hommes (87 vs. 64 % chez les patients non SAOS, p = 0,038), porteurs d’un syndrome metabolique (84 vs. 60 %, p = 0,036). Leur taux sanguin de leptine etait significativement inferieur compare a celui des patients HR non SAOS (9 [6 ; 15] vs. 17 [6 ; 29] ng/mL, p = 0,041). En intention de traiter, 3 mois de PPC diminuait significativement la PAS nocturne de 6,4 mmHg ( p = 0,033) et la frequence cardiaque de 6,0 mmHg ( p = 0,010) de ces patients HR + SAOS. Six mois de traitement par PPC efficace diminuait aussi la PA nocturne et ameliorait la chute nocturne de la PA. Le taux sanguin de leptine etait significativement reaugmente apres 6 mois de PPC efficace. Conclusion Il est primordial de rechercher la presence d’un SAOS chez les patients avec HR et de demarrer le traitement par PPC le plus tot possible. Car, en plus de son interet sur la somnolence, la PPC est aussi efficace sur la diminution de la PA nocturne chez les patients apneiques souffrant d’HR. Clinical trial registration : NCT00746902 .

Masked hypertension (MH) is defined by a normal office blood pressure (BP) and a high ambulatory BP. MH is characterized by high prevalence and poor cardiovascular prognosis. The aim of this study was to evaluate the usefulness of routine MH screening, using 24-h blood pressure monitoring (BPM), among patients with peripheral arterial disease (PAD).Between 2011 and 2013, 54 patients with PAD were included in the Hypertension and Vascular Medicine Unit of the Lille Hospital. They had normal office BP (140/90mmHg). A 24 h-BPM device was set on each patient. MH diagnosis was established if the BP average over 24 hours was ≥ 130/80 mmHg and/or the daytime average ≥ 135/85 mmHg and/or the nighttime average ≥ 120/70 mmHg.MH prevalence was about 42.6% (23 patients). It was significantly more frequent in diabetic patients (odds ratio: 3.8 [1.1-12.8]), in patients with known hypertension (odds ratio: 5 [1.5-16.9]) or with high normal office BP (140/90 mmHg but ≥ 130/85 mmHg) (odds ratio: 5.6 [1.7-18.2]). By multivariate analysis, only known hypertension and high normal office BP were associated with masked hypertension.The high prevalence of MH in patients with PAD shows us the importance of a careful screening of MH in this population, especially in diabetic patients, in patients with known hypertension or with a high normal office BP.

Cardiovascular (CV) diseases are the primary cause of death of women. Since they kill 10 times more than breast cancer, preventive measures should be implemented. According to U.S. recommendations, a woman is either at "CV risk" or at "optimal health status" if she has no risk factors and a perfectly healthy lifestyle. Some risk factors are more deleterious to women (smoking, diabetes, stress, depression, atrial fibrillation); or specific to women (preeclampsia, gestational diabetes, contraception, menopause, headaches). The lifestyle plays a key role for them. The blood pressure measurement is the most frequent opportunity to detect women at risk. CV tests should be performed to all symptomatic women and for those over the age of 45 who want to start practicing sport. The cardiologist can play a key role to improve women's CV health by integrating their hormonal risks. Women themselves can also make a powerful contribution to prevention by adopting a healthy lifestyle. From those recommendations concerning women's CV health, there is a great opportunity to initiate a health path for women at high cardiovascular risk. The objectives of the specific path "heart, arteries and women" of University hospital of Lille will be to improve professional practice, awareness of women, educate public authorities and within a few years reduce the epidemic of CVD of French women.

Hypertensive patients with altered circadian blood pressure (BP) profile experience greater repercussion of hypertension on target organs and a higher risk of cardiovascular events, compared with those with physiological variations in BP. It has been demonstrated in animal models, that circadian variations in BP depend on several regulatory systems, in particular the nitric oxide-cGMP pathway. eNOS298 Glu/Asp polymorphism is a functional variant and may alter the amount of NO generated or eNOS activity. The objective of the present study was to find out whether eNOS298 gene polymorphism affects circadian BP regulation in 110 healthy subjects and 155 never-treated hypertensive patients recruited at Hypertension Units in Grenoble, Toulouse and Lille (France).

The cardiovascular reactivation to a recently described videogame task i.e. a maze test was evaluated in the time and frequency-domain using finger blood pressure (BP) measurement in 25 subjects on no medication, including 6 subjects with mild hypertension. Prior to BP measures subjects completed the items of the State-Trait Anger Expression Inventory questionnaire corresponding to the trait anger and anger expression scales. The BP recording session was divided into resting, test and recovery periods. A detrending procedure was applied to each recording prior to the fast Fourier transform. Systolic BP (SBP) and heart rate (HR) were increased during the test. The mid-frequency (MF, 0.1 Hz) components of SBP and HR variability were also elevated during the stressful period. In resting conditions SBP levels of subjects with low trait anger was lower than in subjects with high trait anger (128 +/- 4 mmHg, n = 14 versus 148 +/- 4 mmHg, n = 11, P0.01, Student t test). Nevertheless the average SBP increase due to the stress was of similar magnitude in these two subgroups (14 mmHg). A significant negative relationship was observed between anger-out expression score and the MF SBP variation (r = 0.46, P0.05). A significant negative relation was found between anger-in mode of expression and the HR peak during the test (r = 0.43, P0.05). In conclusion, our data suggest that individuals who are often in anger-provoking situations (high trait anger) should have heightened BP. Two different patterns of cardiovascular responses (SBP variability and HR levels) were observed for the outward and inward mode of expression of anger. This may reflect a different psychological control of HR levels and BP variability.

Therapeutic inertia (TI) is a recent concept still unknown by many physicians. In chronic diseases such as hypertension, it is defined as the tendency of physicians not to increase or change antihypertensive medications when the target blood pressure is not reached. Acting on TI could improve blood pressure control in France.This was a single-center prospective pilot study conducted by hypertension specialist physicians at the University Cardio-Vascular Center in Lille (France). It was conducted between March and June 2011. Data was collected from 161 hypertensive patients (mean age: 61.64±11.18 years; 98 (60.9%) male; 75 secondary prevention patients). Each physician completed a questionnaire on therapeutic inertia. TI was defined as a consultation in which treatment change was indicated (systolic blood pressure [BP]≥140 and/or diastolic BP≥90mmHg in all patients), but did not occur, with absence of an adapted justification of this choice. We considered as an adapted justification: a white coat effect demonstrated by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring; scheduled reassessment of the BP by ABPM; recent change in antihypertensive treatment (less than 4 weeks); hospitalization needed for complete evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage in patients with grade 1 or 2 hypertension. Our study aimed to evaluate rates of TI, to identify factors associated with TI, and to test the TI questionnaire.Therapeutic inertia as defined in this study occurred in 11 consultations (8.3%) of the 133 hypertensive patients having uncontrolled BP above or equal to 140 and/or 90mmHg. Significant factors associated with TI were older age (Z=2.35, P0.05) and sleep apnea syndrome (χ(2)=8.33, P0.05). The absence of ambulatory blood pressure monitoring before the consultation (χ(2)=4.28, 0.1P0.05) and the number of consultations (Z=1.92, 0.1P0.05) exhibited a significant trend to be associated with TI.Although the rate of TI was low in our study conducted in a specialized center, a well-accepted definition of therapeutic inertia would be useful for further study. The feasibility of using the questionnaire tested with this study shows that this measurement tool could help physicians become more aware of TI, both in the hospital and primary care setting. Further multicenter studies are needed for validation.

Both white coat effect (the tendency of blood pressure to rise during a medical visit) and talking effect were analyzed in 42 patients with essential hypertension. Blood pressure was measured during the clinic visit and over the subsequent 24-hour ambulatory period, with the physician performing 49 +/- 4 measurements for each patient. Three silent periods and two talking periods (stress and relaxation) were randomly allocated in a crossover design and studied, using analysis of variance. During the initial 11-minute silent period, systolic/diastolic blood pressures increased by 6 mm Hg/5 mm Hg. During the subsequent talking periods, these variations were significantly greater: +22 mm Hg/+17 mm Hg. Measures of systolic/diastolic blood pressure were higher during stressful talking than during relaxed talking. The talking and its emotional contents seemed to explain 70% of the white coat phenomenon. To minimize the white coat phenomenon in the clinic, physicians, nurses, and clinicians are advised to measure blood pressure during an initial period of silence.

The response to the maze test was studied in 31 subjects on no medication, including seven subjects with mild essential hypertension. Beat-by-beat finger blood pressure (BP) was measured with a Finapres device. Pulse interval from which heart rate (HR) was derived was obtained from the BP signal. A period of 5 min baseline was used to define resting levels of systolic BP and HR using 20-s averaged values for the calculation of the 95% confidence limit of the two variables. The average test duration was 10 min. During this period a series of video-displayed mazes had to be solved with easy mazes preceding difficult ones. No subject had been exposed to the test before. The maximal BP elevation associated with the test was 27 mmHg. The HR response averaged 11 beats/min. Significant elevations were observed for half the test duration. No significant relationship between these two responses was observed and some subjects exhibited isolated systolic BP or HR responses. When indices obtained during this active mental stress were compared to resting values, positive correlations were observed. When the resting standard deviation (SD) of systolic BP was higher the systolic response was greater. A similar relationship was observed for HR. In addition, when the systolic BP level at rest was higher, the systolic BP reactivity index was greater. However, systolic BP or HR at baseline were not predictive of the systolic BP or HR responses. This study demonstrates the applicability of a new test to assess cardiovascular reactivity. The main advantage of non-invasive continuous BP measurement with the Finapres is the ability to provide variability indices in addition to the peak responses.

Short-term fluctuations in blood pressure (BP) and heart rate (HR) were analysed in a group of twelve males with essential hypertension. Indirect finger BP was measured by a Finapres device. The effect of a 7-day administration of a cardioselective beta-adrenoceptor blocker, acebutolol (400 mg/day), was studied in a double-blind, randomized, placebo-controlled cross-over study. Compared with placebo, acebutolol caused a significant decrease in BP and HR. In addition, the standard deviation (SD) of BP and HR were reduced after acebutolol in the standing position. Spectral analysis of fluctuations in BP showed a reduction in the variability underlying the SD changes of BP and HR. This reduction predominated in the mid frequency (MF) region corresponding to Mayer waves. This effect was marked for HR since the MF component for standing HR after acebutolol was 46% the placebo level. The average reduction in MF component for standing Systolic BP (SBP) was 36%. No significant correlation was found between the Mayer wave reduction and the systolic, diastolic BP or HR lowering effect of acebutolol. No significant changes in the gain of the transfer function between MF SBP and HR fluctuations in the standing position were observed. The reduced MF component of HR and BP variability after acebutolol could be due to a peripheral cardiac and non-cardiac sympatholytic effect of chronic beta-adrenoceptor blockade.

This clinical case illustrates the management difficulties encountered during gestational hypertension and its impact on maternal and foetal outcome. Typically, preeclampsia occurs at the end of the second trimester. If blood pressure remains high early during pregnancy, a secondary cause of hypertension such as renal artery fibromuscular dysplasia should be explored. A renal vascular etiology can be safely ruled out with a duplex ultrasound. In this particular case of renal vascular hypertension in a patient with a single kidney, angioplasty appeared to be the sole solution and was efficient.

A 24-year-old African who had been living in France for few years first consulted at our institution for severe systemic hypertension. He had no prior medical or surgical history. The patient was strictly asymptomatic. Except for systemic hypertension at both arms, the basic physical examination was normal with no cardiac murmur and no pulse deficit. A 24-hour ambulatory blood pressure monitoring performed before the consultation confirmed the presence of systemic hypertension with a mean blood pressure at 155/90mmHg during the day and also during the night under anti-hypertensive treatment. Ankle-brachial index measurement was low at 0.8 at both legs. Subsequently, a trans-thoracic echocardiography (TTE) and an aortic CT-scanner were performed. The TTE did not find any abnormalities including no aortic dilatation or no ventricular hypertrophy. The CT-scanner revealed a partial aortic coarctation. The patient underwent aortic surgery and recovered in few days with quite normal blood pressure under medical treatment. In conclusion, systematic ankle-brachial index is useful and recommended in every patient at first visit for systemic hypertension. Its safety and simplicity make it an essential tool in the management of systemic hypertension especially in populations with no systematic screening of aortic coarctation in childhood. It was in the present case very useful for the final diagnosis and treatment. In addition, it is an efficient tool to screen patients with asymptomatic peripheral artery disease and it can help for stratification of cardiovascular risk.

L’examen de reference pour 1’exploration des arteres renales est l’angiographie conventionnelle, examen invasif remplace par l’imagerie volumique grâce aux progres en resolution spatiale et temporelle.

Created in 2004, the HTA vasc healthcare network intensified detection, multi-disciplinary management and follow up of atheromatous cardiovascular disease and complicated hypertension in the Nord Pas de Calais region. The participating doctors gave their patients a Patient Dossier, as a function of predefined inclusion criteria (patients at elevated cardiovascular risk, as defined by the Haute Autorité de Santé (Higher Authority of Health) stratification. The dossier was presented in the form of a file containing all the information needed to optimise multi-disciplinary management, while at the same time reinforcing therapeutic compliance by patients. Therapeutic education workshops were organised, in order to complement the existing service. In parallel, HTA vasc set up a pilot medical education programme for vascular rehabilitation in six hospitals in the region. HTA vasc also established partnerships with other healthcare networks in the region. A patients' association 'Notre Coeur, Nos Artères', (Our Hearts, Our Arteries) was created in September 2006. About 250 healthcare professionals had joined the network by the end of January 2006, an increase of almost 40% over the year. More than two thirds were independent doctors, and they included cardiologists, neurologists, nephrologists, diabetologists, general practitioners, radiologists, cardiovascular surgeons, rehabilitation doctors, paramedics and pharmacists. More than 260 patients received a follow up dossier. The results of a survey carried out in May 2006 showed a high level of satisfaction: 82% of patients considered the Patient Dossier to be useful and appropriate; 78% of the healthcare professionals stated that the network was of help in the management of patients. HTA vasc received the scientific support of the Sociétés Françaises de Médecine Vasculaire, d' Hypertension Artérielle (French Societies of Vascular Medicine and Hypertension), and the Vascular Group of the Société Française de Cardiologie, with an external audit of the tools and activities undertaken in the region.

Diagnosis of renal artery stenosis (RAS) should be discussed in numerous clinical situations including refractory high blood pressure (HBP), HBP in a polyvascular patient, degradation of renal function following renin angiotensin inhibitor or flash pulmonary edema. Ultrasound-doppler coupled with gadolinium-enhanced MR or CT angiography has proven adequate for most patients with RAS. Digital subtraction angiography should be limited to revascularisation procedures. Functional testing are not sensitive or specific enough because the degree of renin activation differs widely among patients with RAS. Renal percutaneous angioplasty induces a light to moderate decrease in blood pressure, has no effect on renal function but allows to reduce the number of anti-hypertensive drugs. Stenting completed angioplasty is worthwhile in most patients with atherosclerotic RAS. ACE inhibitors decrease mortality and increase renal function in patients with RAS.

Metabolic syndrome (MetS) was defined by association of abdominal obesity, hypertension, glucose intolerance and/or dyslipidemia. The objective of this study was to compare the new International Diabetes Federation (IDF) definition and the National Cholesterol Education Program Adult Treatment Panel III (NCEP) definition and their association with cardio-vascular disease in hypertensive patients.Two hundred and thirty hypertensive patients were hospitalized successively for cardio-vascular disease exploration and hs-CRP measurement. The stratification of cardio-vascular risk was made according to the French recommendations. The IDF definition and the NCEP definition were compared according frequency of resistant hypertension and cardio-vascular disease extension.In our study, high cardio-vascular risk hypertension represented 68.5% of patients. Diabetes was present in 23.5% of them and obesity in 45.5%. Patients with cardio-vascular disease represented 60% of our study population. Prevalence of MetS was 38.5% according to the NCEP definition and 59% according to the IDF definition. The NCEP definition was allowed to select subjects with widespread vascular disease and resistant hypertension whereas the IDF definition did not. These results could be explained by lower waist circumference and glycaemia cuts offs according to the IDF criteria. When diabetic's patients were excluded, MetS was not associated with increase of resistant hypertension frequency. Moreover, hs-CRP was independently associated to the extension of the cardiovascular disease and smoking remained the most powerfully factor associated to the cardio-vascular disease extension.In hypertensive patients, the NCEP definition seems more adapted to the diagnosis of MetS than the IDF one. Abdominal obesity could be the indispensable element to the MetS diagnosis but according to the NCEP waist circumference cut off. The use of this syndrome seems to be relevant to select the patients presenting an intermediate cardio-vascular risk in order to adapt treatment.

Usefulness of magnetic resonance angiography in the screening of renal artery stenosis in hypertensive patients: proposition of a diagnostic algorithm: a study on 245 patients. Different non-invasive techniques, including Duplex, spiral angioscan, and magnetic resonance angiography (MRA) are available for the diagnosis of renal artery stenosis (RAS). The aim of this study was to assess the diagnostic performances of MRA and the MRA-Duplex couple in the diagnosis of RAS. Between September 2003 and January 2005, 245 patients benefited from a renal MRA for the assessment of hypertension etiology. The MRA-Duplex couple was performed in 228 patients. Renal arteriography was performed in case of abnormalities observed with MRA and/or Duplex (n=41). The sensitivity and specificity of MRA were respectively at 100% and 23%. The sensitivity was notably higher in the right renal artery (100 vs. 73%). The sensitivity and specificity of Duplex were respectively at 71 and 85%. The concordance between the two exams was disappointing (kappa at 0.39 for the right side and 0.62 for the left side), leading to the interest of the MRA-Duplex association for excluding the presence of RAS (sensitivity and negative predictive value=100%). However, using the MRA-Duplex couple led to a high number of false positive cases, due to MRA, leading to 11 angiograms out of 41 exams, without any significant RAS. In case of suspicion of RAS, the MRA-Duplex couple permits to exclude definitely the diagnosis of RAS. In case of discordance between the 2 exams, it would be useful to require a spiral angioscan and/or redo a Duplex exam using contrast agents, prior to angiography with a therapeutic goal. These management modalities might be useful to avoid the number of normal angiograms, with an inherent risk of complications and cost excess.

It is illusory to think that one year is long enough to establish all the truths that will guide our clinical practice in vascular medicine. On the contrary, one year was long enough to contradict what the preceding twelve months had set out to demonstrate. Consequently, promising trials in the treatment of abdominal aortic aneurysms by endoprostheses have been the object of contradictory debate with regards to the long-term benefits. In fundamental research, circulating progenitors of endothelial cells have been shown to be a marker of atherosclerosis, but is it a better marker than LDL-cholesterol values? The demonstration that these progenitors are of value in the treatment of essential ischaemia of the lower limbs is awaited. Finally, ximelagatran, a direct thrombin antagonist, seemed to have all the qualities of an ideal anticoagulant: easy to use, safe... until the report of raised hepatic enzymes, the clinical relevance of which remains to be determined. In the good news section: the Systolic Pressure Index, an unquestioned marker of arterial disease. Its reduction was known to be correlated with the prevalence of cardiovascular complications. However, it has now been shown that an increase in the index is also associated with cardiovascular complications, a real U-shaped curve. Renal arterial stenosis should be considered in patients with left ventricular failure presenting with flash pulmonary oedema. In the absence of cardiac pathology, BNP would seem to be a good biological marker of haemodynamically significant renal arterial stenosis. Finally, should superficial femoral artery stenosis be treated by an active stent. To date, there is no formal proof.

A 20-year-old woman consulted for severe hypertension which revealed aneurismal stenosing fibrodysplasia of the renal arteries. The diagnosis was established by duplex Doppler which visualized tight stenosis of the distal portion of the right renal artery and the proximal portion of the left, associated with aneurismal lesions downstream from the strictures (1.8 cm on the right and 1.3 cm on the left). The lesions were highly suggestive of fibrodysplasia and were confirmed by magnetic resonance angiography. Endoluminal revascularization was undertaken because of the severe hypertension and the presence of arterial lesions. Revascularization was unsuccessful and severe hypertension persisted. Surgery was performed in two stages. The first procedure consisted in resection of the left aneurismal lesion with aortorenal internal saphene bypass. Secondarily, exclusion of the right aneurysm was performed with cure of the stricture by extracorporal renal surgery with anastomosis of the renal artery to the aorta and the renal vein to the vena cava. Clinical outcome was favorable. Angioscan and duplex Doppler controls at three and six months confirmed the anatomic success of the revascularization. Aneurysm of the renal artery, like renal artery stenotic dysplasia, is a rare but probably underestimated condition due to insufficient screening. This diagnosis should be entertained in hypertensive young women. There is risk of rupture of the aneurysm. Aneurysmal lesions can be associated with renal artery stenosis which usually involves a short segment of the artery, as in our case. Renal aneurysms should be treated when one of the following elements is present: aneurysm measuring more than 20 mm, progressing aneurysm, dissection, discovery in a patient with a renal risk (single kidney, renal insufficiency), desire for pregnancy, severe hypertension recently discovered in a young subject associated with dysplastic stenosis, isolated aneurysm associated with recent severe hypertension, as reported here.

The wealth of information in vascular pathology merits close examination. The French Cardiology Society vascular group turned its attention to arteries, veins, hypertension and a more fundamental investigation to analyse the results from some illuminating studies which appeared in 2004, despite some pertinent therapeutic doubts. Examination of the trials discussed here shows the importance, as much in vascular pathology as elsewhere, of founding our practice on evidence based medicine.

The indication of renal atherosclerotic artery stenosis revascularisation is always debated in clinical practices when arterial hypertension is stabilized by the treatment, especially if the stenosis is discovered fortuitously. The clinician needs clinical and morphological markers which will indicate or not the revascularisation in the situation of "nephronic protection". The benefits of angioplasty have been studied on the blood pressure, the creatinine clearance, the glomerular function analyzed by scintigraphy, the renal length and more recently on the mean cortical thickness (MCT). The follow-up of these studies is generally inferior to 2 years. In this work, we tried to estimate the clinic and morphologic evolution 5 years after a unilateral artery stenosis angioplasty. From a group of 249 patients who had a renal angioplasty between January 1995 and January 2000 (T0), 29 patients with refractory hypertension and with a unilateral atherosclerotic renal artery stenosis on spiral computed tomographic angiography (TCA) performed at T0 [17 M; 12 W; medium age 68.6 +/- 10 years] were included. The TCA performed at 5 years (T5) eliminated a new renal arterial stenosis or restenosis. We have analyzed 29 revascularized kidneys (kidney S) and 29 controlateral kidneys (kidney C), the blood pressure and renal function. The renal length (mm) was at T0: kidney C=99.4 +/- 13.5; kidney S=93.5 +/- 10.8 and at T5: kidney C=99.4 +/- 12.6; kidney S=94.2 +/- 10.7. MCT (mm) was at T0: kidney C=7 +/- 1.2; kidney S=6.6 +/- 1.1 and at T5: kidney C=6.2 +/- 1.2; kidney S5=6 +/- 1. The cortical atrophy got worse while the renal length and creatinine clearance were stable: only diastolic blood pressure was controlled (78.8 mmHg +/- 11.9). In spite of small strength, this study arguments the fact that the angioplasty isn't sufficient to control the arterial hypertension in an atheromatous context, not allowing to slow the evolution of distal cortical lesions with however a stability of creatinine clearance.

This case-report emphasizes an uncommon cause of hypertension in an adolescent: reflux nephropathy. Reflux nephropathy is a frequent hypertension and renal failure etiology. Medical treatment is unknown from cardiologist.

According to ANAES guidelines (2000) adapted from the international guidelines, kidney function should be regularly monitored in hypertensive patients in order to detect vascular nephropathy at an early stage and prevent kidney failure which is a major cardiovascular factor. The PHENOMEN survey was conducted between January and July 2001 on a representative sample of 16,358 patients suffering from hypertension being followed by a General Practitioner (GP). The population included patients from all 22 administrative regions in France.To determine the prevalence of renal involvement in patients with hypertension (both treated and untreated); to compare the GP's subjective evaluation of the extent of renal involvement with a more objective assessment made according to ANAES guidelines.Kidney function was evaluated by measuring plasma creatinine levels to derive a value for the creatinine clearance rate (CCR) using the Cockeroft-Gault formula.Out of the 16,358 patients included, plasma creatinine levels could be measured in 11,586 (76%) [53% men; 47% women, mean age = 63 +/- 12 years]: mean plasma creatinine = 90 +/- 49 mumol/l, i.e. a mean CCR of 83 +/- 32 ml/min. For 8,650 of the patients (75%), kidney function had been monitored in the preceding twelve months. The physicians defined their patient's kidney function as normal in 10,080 (87%) of cases whereas in reality, 4,411 of 8,650 (51%) were suffering from some degree of renal insufficiency (RI): in 2,422 (28%), RI was mild (or = 60 CCR80 ml/min): in 1,903 (22%) RI was moderate (or = 30 CCR60 ml/min). A minority of patients (44 i.e. 1%) showed severe RI (CCR30 ml/min).Most GPs apply ANAES guidelines and order plasma creatinine assays. However, there is a discrepancy between how the physician "perceives" the seriousness of the renal insufficiency and a more objective measure based on the CCR figure. It would seem that the CCR derivative is insufficiently exploited despite the widespread availability of converters. Thus, the PHENOMEN survey has revealed that the extent of renal involvement in patients with hypertension still tends to be underestimated by GPs despite the major implications of this complication in terms of therapeutic strategy and global cardiovascular risk.

Diltiazem is an antihypertensive belonging to the class of heart rate-slowing calcium channel blockers; its antihypertensive efficacy has been demonstrated for a long time. Controlled trials have also demonstrated that it does not interfere with lipid parameters. This open multicentre trial was designed to verify the absence of any action of diltiazem on lipid parameters as well as its effect on the heart rate of hypertensive patients. The patients included had to take one capsule of diltiazem 300 mg sustained release formulation, developed by Laboratoires Synthélabo, in the morning for 6 months. A lipid assessment and an electrocardiogram were performed before and at the end of the trial. One hundred and forty-six patients were included: 81 underwent a complete lipid assessment (7 parameters) before and after treatment and 69 underwent an electrocardiogram at rest to the same study times. Total cholesterol (p = 0.0007), LDL cholesterol (p = 0.005) and apoprotein A1 (p = 0.0002) were significantly decreased. Blood pressure decreased progressively throughout the study and was "controlled" (supine diastolic blood pressureor = 90 mmHg) after six months of treatment in 77% of patients. Heart rate decreased significantly at the end of the study; no pathological variation of PR, QRS and Qt intervals was observed. The effect on heart rate, also studied in patient subgroups defined by their baseline values, was more marked when the baseline heart rate was increased. The investigators considered the safety to be good at each visit, in 80% of cases. Sixteen patients dropped out of the trial because of adverse effects or intercurrent disease. The adverse effects most frequently reported were oedema of the lower limbs (7.5%), headache (4.8%) and hot flushes (2.7%). No harmful effect of diltiazem on lipid parameters was observed during this open trial; some lipid parameters even decreased at the end of treatment. Clinically, diltiazem lowered blood pressure and decreased heart rate. The reduction of heart rate was more marked in the case of high baseline heart rate. Safety was satisfactory.

To define the prevalence of cardiovascular risk (CVR) levels in a population of hypertensive patients (whether treated or not) monitored by General Practitioners, using the stratification system proposed by the ANAES in 2000.Between January and July 2001, a nation-wide survey was carried out based on a representative sample of 8,177 General Practitioners spread evenly throughout all of the 22 administrative regions in France. The evaluation of CVR levels took into account blood pressure readings as well as CVR factors and indicators.This survey covered 16,358 patients (53.2% men, 46% women; mean age = 62.5 +/- 11.9 years; BMI = 27.3 +/- 4.5 kg/m2) with a mean history of hypertension of 7 +/- 7 years. The most common CVR factors were dyslipidemia (59.5%), smoking (19%) and diabetes (16%). Concomitant target organ damage was recorded in 17% and heart disease in 21.8%. One patient in four had more than three CVR factors; respectively 56.5%, 30.9% and 12.5% of the patients had mild, moderate or severe hypertension. More than 50% of the patients were classified as being at "high" or "very high" CV risk. The distribution of risk levels was similar throughout the country with a North-South gradient of the high/very high levels. Only 17% of the patients being treated had completely normal blood pressure (140/190 mmHg), although 19% more count as normal if the limit values are included.The main objective of this large-scale, nation-wide epidemiological survey was to evaluate how well CVR is being managed in a representative sample of patients with high blood pressure. In general, none of the risk factors is adequately controlled, especially in populations considered as being at high CVR. Moreover, the notion of CVR has only been partially assimilated by General Practitioners.

This clinical case illustrates the diagnosis of a secondary cause of hypertension in a patient with Von Recklinghausen's disease. The hypertension resulted from a complex malformation of the right renal artery and dysplasic stenosis of the left inferior polar artery treated successfully by simple angioplasty. This case illustrates the high proportion of vascular (renal artery dysplasia, coarctation of the aorta) and endocrine (pheochromocytoma) causes of hypertension in patients with neurofibromatosis.