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 mmHg (95% CI, 7.8-17.7 mmHg, P<0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP-day-SBP difference, 0.1 mmHg; 95% CI, -3.3 to 3.5 mmHg; P=0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mmHg 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.

Background: Our objective was to investigate the impact of both prevalent and incident hypertension on cognition in middle-aged individuals followed up for 10 years and to explore the extent to which blood pressure control by antihypertensive drugs could modify this relationship. Method: Three thousand, two hundred and one participants from the Vieillissement Santé Travail (Aging, Health and Work) (VISAT) cohort study, aged 32, 42, 52 and 62 years at baseline were followed up 5 and 10 years later. Blood pressure, antihypertensive medication use as well as memory and speed cognitive performances were assessed at baseline and follow-up. Linear mixed models were used for analyses. Results: At 10-year follow-up, compared with nonhypertensive participants, prevalent hypertensive individuals showed poorer global cognitive performances (&bgr; = −2.99 ± 0.96, P = 0.002 for participants aged 32 or 42 years at baseline and &bgr; = −5.94 ± 1.00, P < 0.001 for those aged 52 or 62). Patients with incident hypertension had poorer global cognitive performances over time compared with patients without hypertension. When considering prevalent hypertension and blood pressure control status by antihypertensive therapy, untreated and uncontrolled hypertension were associated with poorer cognitive performances than controlled and no hypertension (untreated hypertension compared with no hypertension: &bgr; = −5.51 ± 0.75, P < 0.001; uncontrolled hypertension compared with no hypertension: &bgr; = −6.13 ± 1.40, P < 0.001). Conclusion: Our findings showed that both prevalent and incident hypertension are associated with poorer global cognitive function in middle-aged individuals and suggested a potential preventive effect of antihypertensive therapy on cognition. Thus, for brain functioning, heightened efforts to detect hypertension and adequately treat it are of critical importance.

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 (approximate to 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.

Objective: Hyperkalemia can occur following unilateral adrenalectomy for primary aldosteronism due to hypoaldosteronism. We hereby report the cases of 4 male patients exhibiting prolonged failure of the renin-aldosterone (RA) axis in association with normal-to-high kalemia or labile blood pressure and, most significantly, a decrease in extracellular fluid volume (ECFV).Methods: Prior to surgery, all patients exhibited hypokalemic hypertension, with documented primary aldosteronism. Within a few weeks of undergoing unilateral adrenalectomy, the patients developed either mild hyperkalemia or labile blood pressure. Complementary investigations revealed a decrease in measured ECFV with inappropriate normal renal sodium excretion, low supine plasma renin activity, and insufficient orthostatic-related aldosterone production. The adrenocorticotropic hormone (ACTH) stimulation test demonstrated no glucocorticoid deficiency, along with responsive aldosterone secretion.Results: The discrepancy between the aldosterone response in the orthostatic position versus the ACTH stimulation test suggested that the aldosterone deficiency was largely due to RA axis depression. Recovery was confirmed between 3 and 18 months in all but one patient, the latter still requiring mineralocorticoid substitution 23 months later.Conclusion: Following unilateral adrenalectomy for primary aldosteronism, the occurrence of mild hyperkalemia prompted a functional evaluation of the RA system using an orthostatic stimulation test, rather than simply measuring baseline values and evaluating the glucocorticoid axis. In such cases, where RA depression is confirmed to cause latent hypovolemia, all treatments likely to further decrease plasma volume should be avoided, while mineralocorticoid substitution may be required.Abbreviations: ACTH = adrenocorticotropic hormone; AVS = adrenal vein sampling; BP = blood pressure; CT = computed tomography; ECFV = extracellular fluid volume; PA = primary aldosteronism; RA = renin-aldosterone

To establish the cause of primary aldosteronism (PA), it is essential to distinguish unilateral from bilateral adrenal aldosterone secretion, as adrenalectomy improves aldosterone secretion and controls hypertension and hypokalemia only in the former. Except in the rare cases of type 1 or 3 familial hyperaldosteronism, which can be diagnosed genetically and are not candidates for surgery, lateralized aldosterone secretion is diagnosed on adrenal CT or MRI and adrenal venous sampling. Postural stimulation tests and (131)I-norcholesterol scintigraphy have poor diagnostic value and (11)C-metomidate PET is not yet available. We recommend that adrenal CT or MRI be performed in all cases of PA. Imaging may exceptionally identify adrenocortical carcinoma, for which the surgical objectives are carcinologic, and otherwise shows either normal or hyperplastic adrenals or unilateral adenoma. Imaging alone carries a risk of false positives in patients over 35 years of age (non-aldosterone-secreting adenoma) and false negatives in all patients (unilateral hyperplasia). We suggest that all candidates for surgery over 35 years of age undergo adrenal venous sampling, simultaneously in both adrenal veins, without ACTH stimulation, to confirm the unilateral form of the hypersecretion. Sampling results should be confirmed on adrenal vein cortisol assay showing a concentration at least double that found in peripheral veins. Aldosterone secretion should be considered lateralized when aldosterone/cortisol ratio on the dominant side is at least 4-fold higher than contralaterally.

The purpose is to consider the practical management of etiological work up in hypertension, beyond national or international recommendations, leading to consider the prior practice of hormonal assays or renal, renovascular or adrenal imaging. The ease of access to imaging, difficulties to meet the requirements to obtain reliable hormonal assays explain the use of first-line imaging in clinical practice. The renal and adrenal CT angiography provides diagnostic orientation without allowing a formal conclusion. Incidentaloma prevalence in the general population, increasing with age, underlines the limitations of a decision based only on imaging. The discovery of adrenal morphological abnormalities justifies the realization of hormonal assays to determine their causal relationship with hypertension. The aldosterone/PRA ratio, in standardized conditions, has the best diagnostic performance to screen for primary aldosteronism and is the pivotal test of the etiological diagnosis of hypertension. The identification of a subclinical Cushing should be considered in patients with adrenal morphological abnormalities, particularly in case of metabolic syndrome. The abdominal CTscan is initially recommended in the diagnosis of pheochromocytoma, but the recommende boichemical testing is urine metanephrines whose result will lead to search a pheochromocytoma or an extra-abdominal paraganglioma. Many drug interactions must be considered in order to interpret hormonal measurements and avoid erroneous diagnosis. Finally, a genetic context and the possibility of endocrine causes with normal abdominal CT scan should be considered: extra-abdominal paraganglioma, parathyroid adenoma and Cushing's disease with pituitary adenoma, requiring a multidisciplinary decision. The efficiency of imaging as first-line in the screening of secondary hypertension is relative and confrontation with hormone assays will be critical to the diagnostic and therapeutic management. In young women, hormonal measurements precede imaging in the etiological investigation of hypertension.

The French Endocrinology Society (SFE) French Hypertension Society (SFHTA) and Francophone Endocrine Surgery Association (AFCE) have drawn up recommendations for the management of primary aldosteronism (PA), based on an analysis of the literature by 27 experts in 7 work-groups. PA is suspected in case of hypertension associated with one of the following characteristics: severity, resistance, associated hypokalemia, disproportionate target organ lesions, or adrenal incidentaloma with hypertension or hypokalemia. Diagnosis is founded on aldosterone/renin ratio (ARR) measured under standardized conditions. Diagnostic thresholds are expressed according to the measurement units employed. Diagnosis is established for suprathreshold ARR associated with aldosterone concentrations >550pmol/L (200pg/mL) on 2 measurements, and rejected for aldosterone concentration<240pmol/L (90pg/mL) and/or subthreshold ARR. The diagnostic threshold applied is different if certain medication cannot be interrupted. In intermediate situations, dynamic testing is performed. Genetic forms of PA are screened for in young subjects and/or in case of familial history. The patient should be informed of the results expected from medical and surgical treatment of PA before exploration for lateralization is proposed. Lateralization is explored by adrenal vein sampling (AVS), except in patients under 35 years of age with unilateral adenoma on imaging. If PA proves to be lateralized, unilateral adrenalectomy may be performed, with adaptation of medical treatment pre- and postoperatively. If PA is non-lateralized or the patient refuses surgery, spironolactone is administered as first-line treatment, replaced by amiloride, eplerenone or calcium-channel blockers if insufficiently effective or poorly tolerated.

L’objectif du traitement antihypertenseur pendant les 6 premiers mois de grossesse est d’éviter les complications maternelles associées à une hypertension artérielle sévère sans être délétère sur le développement du fœtus.

Objective: The DENERHTN trial confirmed the BP lowering efficacy of renal denervation (RDN) added to a standardised stepped-care antihypertensive treatment (SSAHT) for resistant hypertension (RH) at 6 months. There was large between-patient variability in the BP response to RDN and SSAHT. The presence of aortic abdominal calcification (AAC), which has been related to arterial stiffness, may impact BP response to both RDN and SSAHT. Design and method: Patients with confirmed RH to 4-week treatment with indapamide 1.5 mg/day, ramipril 10 mg/day (or irbesartan 300 mg/day), and amlodipine 10 mg/day on daytime ABPM (> = 135/85 mmHg) were randomly assigned to RDN+SSAHT, or the same SSAHT alone (control group). After randomisation, spironolactone 25 mg/day, bisoprolol 10 mg/day, prazosin 5 mg/day, and rilmenidine 1 mg/day were sequentially added from months 2 to 5, in both groups if home BP was > = 135/85 mmHg. AAC were delineated blind to the randomization with a semiautomatic segmentation software from the aortic hiatus to the iliac bifurcation on each pre-randomization abdominal CT angiogram. Results: Of the 106 randomised patients, 42/53 in the RDN group and 48/53 in the control group were analyzed because of missing endpoints (age: 54.6+/-10.6 years, males: 61.1%, type 2 diabetes: 22.2%, daytime ambulatory BP: 154/93 mmHg). 78.9% of patients had AAC. Median (IQR) AAC volume was 451 (34–2225) mm3 in all patients. Increasing tertiles of AAC were significantly associated with increasing age, male sex, Caucasian ethnicity, smoking, diabetes, hypercholesterolemia, prior cardiovascular events and obstructive sleep apnea (Table). Higher AAC was associated higher levels of ambulatory and central pulse pressure and pulse wave velocity at baseline. However, at 6-month follow-up, the change in daytime ambulatory SBP/DBP and number of controlled patients did not significantly differ according to tertiles of AAC. Figure. No caption available. Conclusions: In these highly selected patients with RH, AAC were associated with arterial stiffness and cardiovascular risk factors. The presence AAC on CT-angiogram did not impact the BP response in patients treated with RDN+SSAHT or SSAHT alone.

Objective: Predictive factors associated with normal blood pressure (BP) values after unilateral adrenalectomy for primary aldosteronism are not clearly identified. Arterial stiffness could play a role in the persistence of hypertension. The aim was to evaluate the predictive value of arterial stiffness assessed before surgery on BP after surgery. Design and method: From 2009–2013, in a French multicentre open-labelled prospective study, 96 patients with primary aldosteronism due to unilateral adrenal adenoma with an indication for surgery were recruited (age 48 ± 12; 47.6% of women; SBP/DBP: 150 ± 21/91 ± 15 mmHg; kalemia: 3.4 ± 0.5). Plasma aldosterone concentration (PAC) was conventionally measured (Normal values: 40–175 ng/l), either direct renin concentration (DRC) (4.2–59.7 mU/l) or plasma renin activity (PRA) (>0.4 ng/ml/h). Aortic pulse wave velocity (PWV) was assessed before surgery (Complior ®) They underwent an ABPM before and 3 to 6 months after surgery (Spacelab's ®) Normal BP values were defined as mean 24-hour-SBP/DBP<130/80 mmHg between 3 to 6 months after adrenalectomy Results: BP and PWV were available for 82 patients. At baseline, mean PAC was 368 ± 244 pg/ml, DRC was 4.4 ± 4.2 mU/L (n = 58) and PRA was 0.19 ± 0.18 ng/ml/h. Six months after surgery, office SBP/DBP was 131/81 mmHg. Mean 24-hour-SBP/DBP decreased (from 144 ± 15/91 ± 9 before to 131 ± 15/84 ± 11 mmHg). 40 of them who underwent ABPM at 12 months had 24-hour-SBP/DBP 125 ± 15/81 ± 9 mmHg. No patient needed potassium supplementation after surgery (vs 56% before). 64.7% of women and 35.3% of men had 24h-SBP/DBP<130/80 mmHg at 6 months (p = 0.07) and 68.8% vs 31.3% at 12 months (n = 40) (p = 0.03). SBP/DBP was higher for men than for women after 6 months (p = 0.01/0.001) and 1 year (p = 0.04/0.05). Mean PWV was 10.5 ± 3.6 m/s among patients with mean 24h-SBP/DBP<130/80mmHg vs 10.3 ± 2.3 m/s for patients with 24h-SBP/DBP>130/80mmHg (p = 0.96). 52.9% of patients with PWV<10m/s (median value) and 47.1% of patients with PWV values>10 m/s had 24h-SBP/DBP<130/80 mmHg (p = 0.91). No significant association between initial PWV and SBP or DBP after surgery was found. Conclusions: In our multicentre study, arterial stiffness reflected by PWV measured pre-operatively does not predict a benefit of adrenalectomy on blood pressure values. More women than men had normal BP values after surgery.

In the first 6 months of pregnancy, the primary goal of antihypertensive treatment is to prevent the complications of severe hypertension.Initiation of antihypertensive drug treatment is recommended in pregnant women with severe hypertension (blood pressure > 160/110 mmHg). Initiation of antihypertensive drug treatment should also be considered in pregnant women at high cardiovascular risk (diabetes, chronic kidney disease, personal history of cardiovascular disease) with moderate hypertension (blood pressure between 140-159/90-109 mmHg). A systolic blood pressure goal < 160 and a diastolic blood pressure goal between 85 and 100 mmHg is recommended in pregnancy. Labetalol, nifedipine, nicardipine and alphamethyldopa should be considered preferential antihypertensive drugs in pregnancy.Salt restriction, physical exercise and weight loss have not demonstrated any effect in the prevention of preeclampsia and serious maternal complications of hypertension.

About 77.9 million (1 in 4) American adults have high blood pressure. High blood pressure is the primary cause of left ventricular hypertrophy (LVH), which represents a strong predictor of future heart failure and cardiovascular mortality. Previous studies have shown an altered metabolic profile in hypertensive patients with LVH. The goal of this study was to identify blood metabolomic LVH biomarkers by 1H NMR to provide novel diagnostic tools for rapid LVH detection in populations of hypertensive individuals. This cross-sectional study included 48 hypertensive patients with LVH matched with 48 hypertensive patients with normal LV size, and 24 healthy controls. Two-dimensional targeted M-mode echocardiography was performed to measure left ventricular mass index. Partial least squares discriminant analysis was used for the multivariate analysis of the H-1 NMR spectral data. From the H-1 NMR-based metabolomic profiling, signals coming from methylene (-CH2-) and methyl (-CH3) moieties of aliphatic chains from plasma lipids were identified as discriminant variables. The -CH2-/-CH3 ratio, an indicator of the mean length of the aliphatic lipid chains, was significantly higher (P<0.001) in the LVH group than in the hypertensive group without LVH and controls. Receiver operating characteristic curve showed that a cutoff of 2.34 provided a 52.08% sensitivity and 85.42% specificity for discriminating LVH (AUC= 0.703, P-value<0.001). We propose the -CH2-/-CH3 ratio from plasma aliphatic lipid chains as a biomarker for the diagnosis of left ventricular remodeling in hypertension.

OBJECTIVE:To study the prevalence of different causes of hypertension in young adults referred to a hypertension center in the south west of France.METHODS:We conducted a retrospective overview of patients younger than 40years old hospitalized consecutively in the Hypertension department of Toulouse University Hospital between 2012 and 2014. Clinical data about gender, age, anthropomorphic parameters and blood pressure measurement by 24h Ambulatory Blood Pressure Monitoring (ABPM) were recorded. Biological data concerned dosages of kalemia, renin and aldosterone in the supine or after 15min of seating. Recorded radiological examinations were renal artery ultrasound and abdominal CT scan.RESULTS:One hundred and forty-eight detailed medical records were analyzed, 69 women and 79 men. Among the 69 women, the causes of secondary hypertension were primary aldosteronism (n=7), fibromuscular dysplasia (n=5) and renal disease (n=4). Oral contraceptives were involved in 13 women. In addition, essential hypertension concerned 40 women (58%). Among the 79 men, the causes of secondary hypertension were primary aldosteronism (n=10), fibromuscular dysplasia (n=3), left main renal artery entrapment by a diaphragmatic crura (n=2), renal disease (n=1), pheochromocytoma (n=3) and coarctation of the aorta (n=2). In addition, essential hypertension concerned 58 men (73%).CONCLUSIONS:In our population, the prevalence of secondary hypertension is close to 33% (42% of females and 27% of males), with the following main causes: primary aldosteronism for 11.5%; fibromuscular dysplasia for 5.4%. Oral contraceptives were involved in the hypertension of 19% of the females.

PURPOSE:To describe pharmacists' interventions made at patients hospital discharge from Department of Hypertension.METHODS:This is a single-center and prospective study over an 8-week period. At hospital discharge, the pharmacist compared pre-admission and inpatient medications with discharge orders and written instructions. Pharmacists' interventions were then classified in 4 categories. All variances and discrepancies were discussed with the prescribing physician when possible.RESULTS:Over the 8-week period, 154 cases were analyzed. Pharmacists' interventions at discharge underwent 48 times on 21% of the patients (n=33) but none was clinically relevant. Among these 48 cases, 40% (n=19) were rated as "inappropriate administration", 27% (n=13) were classified as "incomplete prescription", 19% (n=9) were "variances" and 4% (n=2) were due to "omission prescription". In 10% of the cases (n=5), discrepancies appeared without any possible further analysis as no discussion with the prescriber occurred.CONCLUSION:One fifth of all patients analyzed was the subject of a pharmacists' intervention. The complementary action of the pharmacist improves the consistency of the prescriptions and strengthens patient safety.

Aldosterone-producing adenoma is classically treated by unilateral adrenalectomy. Severe hyperkalemia, related to adrenal insufficiency, have been already reported after surgery. We describe here 4 male patients who, despite subnormal kalemia, developed a failure of the renin-aldosterone (RA) axis, resulting in a decrease in extracellular fluid volume (ECFV) following surgery PA diagnosis was established according to French recommendations. Unilateral adrenalectomy was performed in all. Postoperative explorations included ECFV measurement using inulin, and RA axis functionally test by orthostatic and ACTH stimulation.Abstract P1-10 – TablePatient1234ECFV (mL/kg) N:180-210108165166167Plasma potassium (mmol/L)4.94.64.54.2Plasma renin (mUI/L) N:2.8-39.95.53.119.410.5Plasma aldosterone (ng/L): Supine N:10-10515102116 1-hour orthostatism N:34-273<11143114 Post ACTH41354812 Abstract P1-10 – Table A decrease in ECFV with low renin level, and insufficient orthostatism-induced aldosterone production were depicted. The ACTH test demonstrated no glucocorticoid deficiency, along with responsive aldosterone secretion. The discrepancy in aldosterone response in orthostatic position versus ACTH stimulation test suggested that hypoaldosteronism primarily results from the lack of angiotensin 2 stimulation as a result of hyporeninism. Following unilateral adrenalectomy for PA, the occurrence of normal-to-high kalemia prompted an evaluation of the RA system using ortho-static stimulation test rather than simply measuring baseline values and evaluating the glucocorticoid axis. When confirmed, RA axis depression causes latent hypovolemia, meaning that all treatment likely to further decrease plasma volume should be avoided, while this may at times require mineralo-corticoid substitution.

AIMS:To study the influence of postural changes on aldosterone to renin ratio (ARR) in patients with suspected secondary hypertension and to evaluate the sensitivity and specificity of the recommended seated ARR compared to supine and upright ARR for primary aldosteronism screening.METHODS:Fifty-three hypertensive patients were prospectively hospitalized for secondary hypertension exploration (age: 51 ± 12, 66% males). After withdrawal of drugs interfering with renin angiotensin system, plasma aldosterone and direct renin concentration were measured in the morning, at bed after an overnight supine position, then out of bed after 1 hour of upright position and finally 2 hours later after 15 minutes of seating. Minimal renin value was set at 5 μUI/mL.RESULTS:Referring to ARR cut-off of 23 pg/μUI, the sensitivity of seated ARR was 57.1% and specificity was 92.3%. The negative and positive predictive values were 95.1% and 45.2% respectively. Compared to these results, a cut-off of 19 improved sensitivity to 85.7% with a specificity of 89.7%. Negative and positive predictive values were 98.3% and 41.1% respectively. Seated ARR mean value was lower than supine and upright ARR mean values, due to an overall increase in renin at seating compared to the supine position by factor 1.9 while aldosterone just slightly increased by factor 1.2. Seated ARR correlated to supine and upright ARR: correlation coefficients (r) 0.90 and 0.93 respectively (P<0.001).CONCLUSIONS:Current recommended measurement of ARR in the seating position is fairly correlated to supine and upright ARR. A suggested cut-off value of 19 instead of 23 pg/μUI increased the discriminating power of this test.

Background Chronic hypertension, particularly midlife high blood pressure, has been associated with an increased risk for cognitive decline and dementia. In this context, antihypertensive drugs might have a preventive effect, but the association remains poorly understood.Objectives The aim of this systematic review was to examine all published findings that investigated this relationship and discuss the mechanisms underlying the potential benefits of antihypertensive medication use.Methods A literature search was conducted using MEDLINE, Embase, and the Cochrane Library for publications from 1990 onwards mentioning hypertension, antihypertensive drugs, cognitive decline, and dementia.Results A total of 38 relevant publications, corresponding to 18 longitudinal studies, 11 randomized controlled trials, and nine meta-analyses were identified from the 10,251 articles retrieved in the literature search. In total, 1,346,176 subjects were included in these studies; the average age was 74 years. In the seven longitudinal studies assessing the effect of antihypertensive medication on cognitive impairment or cognitive decline, antihypertensive drugs appeared to be beneficial. Of the 11 longitudinal studies that assessed the effect of antihypertensive medication on incidence of dementia, only three did not find a significant protective effect. Antihypertensive medication could decrease the risk of not only vascular dementia but also Alzheimer's disease. Four randomized controlled trials showed a potentially preventive effect of antihypertensive drugs on the incidence of dementia or cognitive decline: SYST-EUR (Systolic Hypertension in Europe Study) I and II, with a 55 % reduction in dementia risk (3.3 vs. 7.4 cases per 1,000 patient years; p < 0.001); HOPE (Heart Outcomes Prevention Evaluation), with a 41 % reduction in cognitive decline associated with stroke (95 % confidence interval [CI] 6-63); and PROGRESS (Perindopril Protection against Recurrent Stroke Study), with a 19 % reduction in cognitive decline (95 % CI 4-32; p = 0.01). Meta-analyses have sometimes produced conflicting results, but this may be due to methodological considerations. The lack of homogeneity across study designs, patient populations, exposition, outcomes, and duration of follow-up are the most important methodological limitations that might explain the discrepancies between some of these studies.Conclusion Antihypertensive drugs, particularly calcium channel blockers and renin-angiotensin system blockers, may be beneficial in preventing cognitive decline and dementia. However, further randomized controlled trials with longer periods of follow-up and cognition as the primary outcome are needed to confirm these findings.