Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA Correspondence to Lawrence R. Krakoff, MD, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1190 5th Avenue, New York, NY 10029, USA Tel: +1 212 241 1789; fax: +1 646 537 2965; e-mail: [email protected] Received March 12, 2017 Received in revised form March 17, 2017 Accepted May 18, 2017

Hypertension is a highly prevalent comorbidity of diabetes mellitus. It contributes substantially to morbidity and mortality in those patients. The present article represents the recommendations of the Austrian Diabetes Association for the treatment of hypertension in diabetic patients according to current scientific evidence.

OBJECTIVES The goal of this study was to investigate whether complex aortic atherosclerosis is associated with increased risk of vascular events in a non-selected population.BACKGROUND In selected high-risk patients, aortic atherosclerosis is associated with increased risk of vascular events.METHODS We describe the relationship between simple versus complex (>4-mm thick or mobile debris) aortic atherosclerotic plaques and vascular events during follow-up in a random sample of 585 persons (age greater than or equal to45 years) using 1993 to 2000 data from the Stroke Prevention: Assessment of Risk in a Community (SPARC), a prospective population-based longitudinal study.RESULTS At five-year median follow-up (range, 0.5 to 6.5 year), cardiac events (death, non-fatal myocardial infarction, coronary revascularization, heart failure associated with coronary artery disease) and cerebrovascular events (ischemic fatal and non-fatal strokes, transient ischemic attacks) had occurred in 95 subjects and 41 subjects, respectively. Age, male gender, prior coronary artery disease, higher pulse pressure, and diabetes were significant cardiovascular predictors. Age, prior myocardial infarction, and a history of atrial fibrillation were significant cerebrovascular predictors. Simple aortic plaques (253 persons) were not independently associated with either cardiac or cerebrovascular events. Complex plaques (44 persons) were marginally associated with cardiac events, adjusting for age and gender (hazard ratio [HR], 2.28; 95% confidence interval [CI], 1.11 to 4.68; p = 0.053 for two degrees of freedom [complex and simple plaques vs. no plaques]) but it not after adjusting for additional clinical risk factors (HR, 1.22; 95% CI, 0.57 to 2.62; p 0.64). Complex plaques were associated with cerebrovascular events only univariately.CONCLUSIONS Aortic atherosclerotic plaques are not associated with future cardiac or cerebrovascular events. Aortic atherosclerosis may not be an independent risk factor for vascular events in the general population. (C) 2004 by the American College of Cardiology Foundation.

BackgroundAccurate blood pressure measurement is critical to successful care of the hypertensive patient. The mercury manometer is rapidly being removed from clinical practice due to concerns about environmental contamination. The Accoson Greenlight 300™ device is the first non-automated mercury-free device for auscultatory blood pressure measurement to pass the International Protocol for validation of blood pressure measuring devices in adults. MethodsFifty-one patients were enrolled to obtain the 33 patients required to fill the three systolic blood pressure (SBP) ranges (low 90–129 mmHg, medium 130–160 mmHg, high 161–180 mmHg) and diastolic blood pressure (DBP) ranges (low 40–79 mmHg, medium 80–100 mmHg, high 101–130 mmHg). Nine sequential blood pressure measurements by two observers with the mercury manometer and the supervisor with the Greenlight 300™ were taken. The first two observer blood pressures were used to classify the SBP and DBP range. The readings were then analyzed in two phases to determine whether the device passed the International Protocol. ResultsThe device passed Phase 1 using 15 subjects. In Phase 2.1 (n = 33) for the 99 readings of SBP, 84 of 99 were within 5 mmHg, 95 of 99 were within 10 mmHg, and 98 of 99 were within 15 mmHg. For the 99 readings of DBP, 74 of 99 were within 5 mmHg, 90 of 99 were within 10 mmHg, and 96 of 99 were within 15 mmHg. In Phase 2.2 (n = 33) for SBP, 33 of 33 had 2 of 3 SBP within 5 mmHg and none had all three readings ≥ 5 mmHg. For DBP, 27 of 33 had 2 of 3 of their DBP within 5 mmHg and only three had all three readings ≥ 5 mmHg. ConclusionsThe Accoson Greenlight 300™ is the first electronic non-automated blood pressure measurement device to pass the International Protocol.

The most common reason for an outpatient physician visit is for the diagnosis and treatment of hypertension. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) VII, which is increasingly evidence-based, advises the clinician to use studies of the mean response and benefit derived from reduction in blood pressure (BP) from antihypertensive therapy and to translate this data into recommendations for the individual hypertensive patient. We believe that the increasingly aggressive approach to hypertension mandated by JNC VII calls into question the use of physician-measured BP. Ample evidence has shown that phycisians have not been adequately trained to measure BP and, therefore, rarely measure BP to the standards asked for by JNC VII or the American Heart Association (AHA) guidelines. In addition, the white coat effect dilutes the validity and usefulness of physician-measured BPs. Finally, in the evidenced-based studies used to derive the JNC VII guidelines, BPs were measured by nurses, other "trained observers," or automated devices, not physicians. Accurate BP measurement is critical to diagnosis and management of hypertension. We recommend, therefore, that for this purpose physicians should not measure BP themselves but should rely on BPs from well-trained and monitored observers or validated automated devices to improve the quality of care of the hypertensive patient.

Forty-three patients with mild essential hypertension were randomized into two double-blind studies: pinacidil vs. placebo or pinacidil vs. hydralazine. Pinacidil (62±18 mg/day) decreased office systolic and diastolic blood pressures from 145 to 137 mm Hg and from 98 to 89 mm Hg, respectively, after 6 weeks of therapy. Similarly, hydralazine (128±28 mg/day) reduced supine systolic blood pressure from 140 to 134 mm Hg and supine diastolic blood pressure from 93 mm Hg to 84 mm Hg. Significant tachycardia was not noted with either drug. Ambulatory blood pressure was monitored for 24 h during the placebo-washout and efficacy phases with both pinacidil and hydralazine. Mean 24-h blood pressure was 128 systolic and 81 diastolic with pinacidil and 121 systolic and 76 diastolic with hydralazine. Reduction in awake hypertensive diastolic blood pressure was significant for both pinacidil and hydralazine. Normal sleep diastolic blood pressure was not reduced by pinacidil but was reduced by hydralazine. Side-effects with both drugs included edema, headache, and palpitations. These data demonstrate that pinacidil is as effective an antihypertensive agent as hydralazine.

HIGH BLOOD PRESSURE IS A MAJOR PUBLIC HEALTH issue, affecting approximately 25% of US adults, or roughly 50 million Americans. The prevalence of high blood pressure increases dramatically with age, such that the lifetime risk of high blood pressure approaches 100%. Despite the availability of effective antihypertensive agents, rates of hypertension treatment and control have remained low and static over the last decade. Control of blood pressure begins with accurate measurement leading to appropriate diagnosis and treatment decisions. For more than 100 years, clinicians and researchers have used the mercury sphygmomanometer, a simple, gravitybased instrument, for blood pressure measurement. Because of its accuracy and reliability, the mercury sphygmomanometer is generally regarded as the gold standard against which all other devices for blood pressure measurement should be compared. In recent years, with the confluence of concern that mercury is contaminating the environment plus the development of electronic/digital equipment for blood pressure measurement, many health care institutions have replaced the mercury manometer with alternate equipment. Experience with the reliability of the mercury manometer has contributed to a lack of attention both to issues of accuracy and to regulation of nonmercury measurement devices. The effort to remove mercury manometers from health care facilities has created unanticipated problems and challenges to measuring blood pressure accurately. Recently the US Environmental Protection Agency (EPA) has identified mercury and mercury compounds as persistent bioaccumulative toxins. Most of the toxic effects of mercury are associated with mercury compounds, especially methyl mercury. Long-term exposure to mercury compounds has been associated with serious health problems, but the elemental mercury enclosed in manometers is quite stable and has rarely been reported to cause health problems. This same elemental mercury has been used in dental amalgam in fillings for years with no recognized toxicity. As part of EPA efforts, a memorandum of understanding regarding elimination of mercury waste was signed in 1998 between the EPA and the American Hospital Association. This memorandum created “Hospitals for a Healthy Environment,” a voluntary project requesting all hospitals to virtually eliminate mercury waste by 2005. The memorandum and the associated project have already led to mercury manometers being removed from many hospitals, health systems, and clinics. The controversy over mercury has led to an examination of several issues related to accurate blood pressure determination, involving both the instrument used and other issues of quality. These issues, recently discussed in a working meeting convened by the National Heart, Lung, and Blood Institute and the American Heart Association, should be of interest to clinicians, researchers, health care administrators, manufacturers, and policy makers.

Mercury sphygmomanometers are being removed from clinical practice in the United States due to environmental concerns about mercury toxicity. Accurate blood pressure measurement is central to high-quality hypertension management. In this study of 106 patients, the BpTRUTM device was compared to nurse blood pressure measurements that complied with all the JNC VII/American Heart Association guidelines in evaluation of a random casual blood pressure. The intermethod difference in systolic blood pressure was +1.8±5.1 mmHg, and for diastolic blood pressure it was 4.8±5.1 mmHg (both P<0.001). For the primary study end point of clinical decision-making, there was 92% (97/106) agreement between the hypertension nurse specialist and the BpTRU™ (kappa 0.8280, 95% confidence interval, 0.721–0.9350). The oscillometric blood pressure measurement with the BpTRU™ is recommended as a replacement for poorly performed auscultatory blood pressure measurement in clinical practice.

OBJECTIVE:Hypertension is estimated to cause 4.5% of current global disease burden and is as prevalent in many developing countries, as in the developed world. Blood pressure-induced cardiovascular risk rises continuously across the whole blood pressure range. Countries vary widely in capacity for management of hypertension, but worldwide the majority of diagnosed hypertensives are inadequately controlled. This statement addresses the ascertainment of overall cardiovascular risk to establish thresholds for initiation and goals of treatment, appropriate treatment strategies for non-drug and drug therapies, and cost-effectiveness of treatment.CONCLUSIONS:Since publication of the WHO/ISH Guidelines for the Management of Hypertension in 1999, more evidence has become available to support a systolic blood pressure threshold of 140 mmHg for even 'low-risk' patients. In high-risk patients there is evidence for lower thresholds. Lifestyle modification is recommended for all individuals. There is evidence that specific agents have benefits for patients with particular compelling indications, and that monotherapy is inadequate for the majority of patients. For patients without a compelling indication for a particular drug class, on the basis of comparative trial data, availability, and cost, a low dose of diuretic should be considered for initiation of therapy. In most places a thiazide diuretic is the cheapest option and thus most cost effective, but for compelling indications where other classes provide additional benefits, even if more expensive, they may be more cost effective. In high-risk patients who attain large benefits from treatment, expensive drugs may be cost effective, but in low-risk patients treatment may not be cost-effective unless the drugs are cheap.

Hypothesis:Accurate BP measurement is critical to decision making in the hypertensive patient. It often is poorly done because of time constraints. The BpTRU is an automated multiple BP measuring device that could replace the gold standard nurse (GSN) JNC VI-recommended multiple office BP measurement.

Systolic (SBP) and diastolic (DBP) blood presures are well known to exhibit a circadian rhythm. We examined whether this factor would affect the assessment of BP control rates during the hours of 0700 to 1900. 55,809 BP measurements in 9,111 patients in the Mayo Clinic Hypertension Continuity Clinic Database from 1997-2001 were analyzed by the time of day the BP was measured: 0700-0900, 0900-1100, 1100-1300, 1300-1500, 1500-1700, and 1700-1900. BPs were measured by strict JNC VI standards. BP control rates (BP <140/90 mm Hg) were tabulated according to each time period. To control for the possibility that patient selection was not independent of time of day, the data were further analyzed after subtracting each patient's overall mean SBP and DBP; then the residuals were subjected to analysis of variance by the same time periods. Overall visit-based control rates were 40.9%. In each time block the control rates were: 43.9%, 40.2%, 39.6%, 43.0%, 37.5%, and 31.8% respectively (P <.0001 for the significance of variation). Logistic regression controlling for age and sex showed that the time of day effects remained significant. Residuals of SBP within patients were subjected to one way ANOVA and the results were −0.8, −0.6, +0.4, −1.0, +2.4 and +4.7 mm Hg respectively (P <0.0001) showing that hourly patterns were not all due to patient selection. See Figure 1 below. These differences in BP control rates by time of day have some significance for assessment of the individual patient in practice. These findings are very significant for epidemiologic studies. To avoid bias in population studies of longitudinal changes or in between-population comparisons of BP control rates, time of day of BP measurement should be standardized.

Hypertensive leg ulcers (Martorell's ulcers) are a unique form of lower extremity ischaemic leg ulcer. First described by Martorell, and Hines and Farber in the 1940s, these ulcers are defined by pain disproportionate to the size of the ulcer, specific location on the lower extremity, female-to-male predominance, association with long-standing, often poorly, controlled hypertension, and healing response to specific antihypertensive agents. We present a case of Martorell's hypertensive ischaemic leg ulcer and a concise review of the 104 previous cases in the world's English literature. Hypertensive ischaemic leg ulcers will be more commonly recognised with a renewed appreciation of the existence of this clinical entity.

We categorized blood pressure (BP) status (normotension [NTN] or hypertension [HTN]) in a population-based sample of 495 adults ≥45 years old by home, and office measurements of BP (conventional), and by 24-hour ambulatory BP monitoring (ABPM). Categorization using conventional measures of BP was determined by the average of two random-zero measurements obtained at home plus four measures obtained in the office. HTN was defined as systolic (S) BP ≥ 140 mm Hg or diastolic (D) BP ≥ 90 mm Hg (JNC VI criteria). Categorization using ABPM was determined by the average of readings measured every 10 minutes during the awake period (AP), and separately on the average of readings measured every 10 minutes during the asleep period (SP) (JNC VI criteria). HTN during the AP was defined as average SBP ≥ 135 mm Hg or average DBP ≥ 85 mm Hg. HTN during the SP was defined as average SBP ≥ 120 mm Hg or average DBP ≥ 75 mm Hg. Of 209 subjects categorized as HTN by conventional measurement, 30 (14%) were categorized as NTN by average AP BP. Of 286 subjects categorized as NTN by conventional measurement, 71 (25%) were categorized as HTN by average AP BP and 70 (24%) were categorized as HTN by average SP BP. Of 245 subjects classified as NTN by average AP BP, 47 (19%) were categorized as HTN by average SP BP. Compared to conventional measurement, ABPM identifies more individuals at risk from elevated BP. Conventional BP is associated with high rates of both white coat NTN (24%) and white coat HTN (14%). These observations argue for more routine use of 24-hour ABPM to determine individual risk from elevated BP.

At the community level, the effect of national programs in increasing hypertension awareness, prevention, treatment, and control is unclear. This study evaluated the degree of detection and control of high blood pressure in a random population-based sample of Olmsted County, Minnesota, residents >/=45 years old, of whom 636 subjects among 1245 eligible residents agreed to participate. Home interview and home and office measurements of blood pressure were used to estimate awareness, treatment, and control rates for hypertension in the community. Mean blood pressures (+/-SD) were 138/80+/-20/12 mm Hg for men and 137/76+/-23/11 mm Hg for women. The overall prevalence of hypertension was 53%. The percentage of subjects with treated and controlled hypertension was 16.6%. Thirty-nine percent of subjects were unaware of their hypertension. Despite clinical trial evidence of reduced morbidity and mortality with antihypertensive therapy, recently reported national data suggest a leveling-off trend for treatment and control of hypertension. This population-based study supports these observations and suggests that at a community level, hypertension awareness and blood pressure control rates are suboptimal, presumably because of decreased attention to the detection and control of hypertension.

The new guidelines of the Joint American Committee for the diagnosis and treatment of high blood pressure emphasize the importance of improving the detection of the disease, and optimizing the treatment. The new classification of high blood pressure includes < 120/89 mmHg as optimum blood pressure goal, and for patients with diabetes or existing cardiac disease the blood pressure goal should be reduced to 130/85 mmHg. In this sense, the report also focuses on the need of accomplishing a diagnostic and therapeutic target of the global cardiovascular risk of the patient, taking into account other pathological situations.

Treatment recommendations for hypertension as outlined in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) are constantly evolving and being refined as new information on the disease becomes evident. Uncontrolled hypertension is a major antecedent of stroke, heart failure, coronary heart disease, and end-stage renal disease. The increasing incidences of both cardiovascular and renal diseases fuel the need for improved control of hypertension. In fact, according to the National Health and Nutrition Examination Survey (NHANES), about 69% of Americans whose blood pressure is greater than 140/90 mm Hg are aware of it, about half are getting treatment for it, and only about one-quarter are adequately controlled. These observations fuel the need for improved patient management guidelines.

HomeHypertensionVol. 29, No. 2Limited Echocardiography for Hypertensive Left Ventricular Hypertrophy Free AccessResearch ArticleDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticleDownload EPUBLimited Echocardiography for Hypertensive Left Ventricular Hypertrophy Sheldon G. Sheps and Edward D. Frohlich Sheldon G. ShepsSheldon G. Sheps Mayo Clinic, Rochester, Minn, and Ochsner Clinic, New Orleans, La. and Edward D. FrohlichEdward D. Frohlich Mayo Clinic, Rochester, Minn, and Ochsner Clinic, New Orleans, La. Originally published1 Feb 1997https://doi.org/10.1161/01.HYP.29.2.560Hypertension. 1997;29:560–563Echocardiographic assessment of left ventricular (LV) mass has provided the best noninvasive information to permit diagnostic, therapeutic, and prognostic assessment of hypertensive heart disease1234567 (Table 1). Reversal of hypertension-induced LV hypertrophy (LVH) occurs with all pharmacological (and some nonpharmacological) antihypertensive treatment, although few data are yet available to demonstrate that such reversal is associated with a reduced risk of LVH. However, one recent report suggested that patients who had changes of reversal of LVH (by electrocardiography [ECG]) were at substantially reduced risk compared with those who did not demonstrate diminished LVH.9 However, the cost of echocardiography has limited its utility in patients with hypertension. A less time-consuming and less-expensive LVH screening echocardiogram would be of great value; such a procedure is referred to as a limited echocardiogram.10TechnologyEchocardiography has been used as a standard procedure for the calculation of LV muscle mass for more than 25 years.11 Primary measurements of LV dimensions are made according to American Society of Echocardiography standards using the leading edge method of interface recognition and by identifying end diastole and end systole at the QRS onset and nadir of posterior systolic motion of the interventricular septum.121314 Adequate M-mode images for calculation of LV mass can be obtained in approximately 90% of patients in an experienced echo laboratory.151617 Assessment of the degree of LVH should include measurements of the posterior wall and septal thickness and calculation of LV mass index. However, even in patients with good-quality studies, there is significant intrareader and interreader variability of LV mass.15 For instance, in the Treatment of Mild Hypertension Study, the variance between the two readers was 23.8% (49.2g), and the intrareader variance was approximately 8.5%. Temporal variability of LV mass measurements in hypertensive patients and normotensive subjects was also highly variable.181920LVH can also be assessed by methods that are simpler or more complex than conventional echocardiography. Less complex and less expensive are ECG methods; but classic ECG criteria, although accurate when positive, are highly insensitive, identifying only 20% of patients with true LVH.212223 At the other extreme of the technology spectrum, the most precise index of LV geometry can be obtained by the three-dimensional imaging technologies. Thus, ECG-gated magnetic resonance imaging, computed tomography, and three-dimensional echocardiography also provide LV mass and volume with great precision242526 but at a higher cost and with varied availability. Patients with marked obesity and severe chronic obstructive lung disease may provide poor images, and subcostal imaging may yield a more useful study instead of the standard approach. Transesophageal echocardiography, which provides excellent cardiac images, can be used in selected circumstances for assessment of LVH, but this procedure is not recommended routinely.Recommendations for the Use of Limited EchocardiographyThe use of the limited echocardiogram for assessment of LVH risk is appropriate in untreated hypertensive patients with stage 1 blood pressure levels (systolic pressure 140 to 159 mm Hg and/or diastolic pressure 90 to 99 mm Hg) and no other evidence of LVH or other cardiovascular risk factors, and a standardized, high-quality procedure is feasible. It should not be obtained routinely in all patients with hypertension, nor should it be used for therapy selection because all classes of antihypertensive agents will diminish LV mass, providing that blood pressure is controlled. Identification of increased LV mass in an individual having hypertension of lesser stages of severity (eg, "high normal," stage 1 primarily and stage 2 rarely) is extremely valuable in helping the clinician decide whether to initiate antihypertensive drug therapy. However, in patients with stages 2 through 4 blood pressure levels (systolic pressure ≥160 mm Hg and/or diastolic pressure ≥100 mm Hg) or those with LVH and/or other cardiovascular risk factors associated with stage 1 or 2 hypertension, identification of echocardiographic evidence of increased LV mass is unnecessary because in these patients, vigorous control of pressure with antihypertensive therapy is already necessary.Follow-up limited echocardiograms in patients whose LV mass is already known is not indicated if blood pressure has not been controlled successfully. In such patients, further and more aggressive management with optimal control of pressure is clearly required. Office, ambulatory, and self blood pressure measurements (at work and home) would indicate whether blood pressure has been successfully reduced and controlled. Finally, one should not consider reduction of LV mass as a substitute for prevention of cardiovascular disease events when assessing the success of an antihypertensive agent.Indications and situations when limited echocardiography is and is not indicated are presented in Tables 2 and 3, respectively.Cost ConsiderationsWhen a more targeted approach to the management of hypertensive patients at higher risk is being considered, the availability of limited echocardiography would allow carefully selected hypertensive patients to undergo useful risk stratification, possibly without increasing the aggregate amount of financial and technical resources used. Although some younger patients with hypertension may be undergoing a more comprehensive echocardiographic procedure for other specific clinical indications, it may be more appropriate and cost-effective to obtain limited echocardiograms for these younger patients when the primary clinical issue is assessment of LVH.One recent report indicated that in asymptomatic patients with hypertension and a normal clinical cardiac examination, a limited echocardiographic study rarely misses significant LVH.17 Moreover, any further clinically relevant information would be provided by a more comprehensive echocardiographic study in less than 10% of patients.17 When the expense of long-term antihypertensive drug therapy, especially for newer drugs, is being considered, it may be more cost conserving to use limited echocardiography as part of a screening strategy for initiating antihypertensive drug treatment.2728The more comprehensive and costly M-mode, 2-D, and Doppler echocardiographic evaluations may be warranted in the following patients: (1) hypertensive patients with chest pain, unexplained dyspnea, or other cardiac symptoms to assess LV systolic or diastolic function; (2) patients with systolic or diastolic murmurs to help define their cause or significance; and (3) patients with comorbid cardiac problems. More comprehensive echocardiographic examination may also be of value in distinguishing physiological from pathological hypertrophy in athletes.Economic Information About Limited EchocardiographyThe Medicare claims data analyzed initially by the American Medical Association for 1992 through 1994 were reviewed and the following noted: (1) The volume of 2-D, M-mode echocardiograms (CPT code 93307) increased over that period from 3 191 922 to 3 596 686; (2) the volume of limited echocardiograms (CPT code 93308) declined for the same period from 53 131 to 43 110 (Figure); (3) in 1994, essential hypertension was one of the top eight diagnostic codes listed on claims that included 2-D, M-mode echocardiography (CPT code 93307), and 7% of the claims for that procedure had an associated diagnosis of essential hypertension (ICD-6 code 401); and (4) on a line-item basis for echocardiography performed in 1994, essential hypertension was listed as one of the top eight diagnostic codes, representing 4% of the diagnoses identified as justifying this procedure (these data are consistent with limited echocardiographic Medicare data from 1986 to 1993).The foregoing data, although interesting, must be cautiously interpreted before any conclusions are drawn regarding the actual current use of limited and/or 2-D, M-mode echocardiography for the evaluation of hypertensive LVH. Since justification for this procedure may have been considered disallowable, an alternative diagnosis may have been selected. Other potentially useful data sets (eg, the Uniform Hospital Discharge Data Set, or UHDDS) have not been evaluated to delineate further the precise utilization of these procedures in the overall hypertensive population and to support or refute the Medicare claims data findings. The only known and available data are presented in this report.Medicare has two data files that have been of particular value. The American College of Cardiology has analyzed the 1986-1993 Medicare procedure files, which include 100% of actual claims (submitted by physicians through the Part B Medicare Annual Data (BMAD) files) (Table 4). In addition, the Medicare beneficiary file has proved useful. The latter file consists of a 5% longitudinal sampling of all beneficiaries capturing code ICD-9 diagnostic aligned with each procedure code; this is required by the Health Care Financing Administration as a means of justifying the procedure. The CPT codes used to identify echocardiographic services have been in a state of flux for years and have undergone coding changes. Before 1990, two coding systems existed, one for radiology (70000 series) and the other for cardiology (93300 series). At the same time, evolution of the technology led to consolidation of the codes (2-D, M-mode, etc). These issues have obviously complicated the data.Possible explanations for the reduction in the frequency of utilization of limited echocardiograms during the later period include: (1) A general awareness developed that a more limited procedure was not broadly appreciated by the physicians interested in the study; (2) greater third-party reimbursement was available by ordering 2-D, M-mode, and Doppler echocardiograms; and (3) with the broadened interest of physicians in hypertensive heart disease, those who were concerned about that problem may have ordered the more costly procedure without considering a less-expensive alternative. This possibility seems likely, especially when one considers that the concept of limited echocardiography had not been recommended broadly in peer-reviewed cardiovascular journal articles.In conclusion, echocardiography is a safe, sensitive, and accurate tool for assessment of cardiac function in patients with hypertension. Despite some limitations, the determination of LV mass by echocardiography is a powerful predictor of cardiovascular risk. Limited echocardiography has been used less frequently in recent years. A limited echocardiogram for the detection of increased LV mass in carefully selected hypertensive patients would be appropriate in a targeted approach to the detection of patients at increased risk as part of a program to reduce their morbidity and mortality by the use of antihypertensive medications in addition to lifestyle changes. The overall effect could be a reduction in the cost of the lifetime management of hypertension in those selected patients.Download figureDownload PowerPoint Figure 1. Annual volumes of limited echocardiographic procedures from Medicare data. Table 1. Summary of Epidemiological Studies Relating Echocardiographic Left Ventricular Mass With Long-term PrognosisReferenceType of Cohort (n)Follow-upEnd-point EventsTotalRelative Risk with LVHLevy et al2GP (1911)4 yearsCAD70Men: 1.67*Women: 1.60*Levy et al3GP (3220)4 yearsCVD208Men: 1.49†Women: 1.57†All deaths124Men: 1.73†Women: 2.12†Casale et al5HTN (140)4.8 yearsCVD14Men: 3.83Koren et al6HTN (280)10.2 yearsCVD40All: 2.17CVD death11All: 14.00All deaths19All: 3.50Ghali et al7HTN, mostly black, had angio (785)4 yearsCardiac deathNACAD: 2.73‡No CAD: 2.80‡All death80CAD: 2:14‡No CAD: 4.14‡LVH indicates echocardiographic left ventricular hypertrophy; GP, general population; CAD, coronary artery disease; CVD, cardiovascular disease; HTN, hypertensive; and angio, coronary angiography. Table and references from Lauer8 with permission.*Relative risks for each increment of 50 g/m of left ventricular mass after adjusting for age, systolic pressure, smoking, and ratio of total to high-density lipoprotein cholesterol.†Relative risks for each increment of 50 g/m left ventricular mass after adjusting for age, blood pressure, antihypertensive treatment, ratio of total to high-density lipoprotein cholesterol, number of cigarettes smoked per day, diabetes, body mass index, and electrocardiographic LVH.‡Adjusted for age, sex, and hypertension. Table 2. Indications For Limited Echocardiography• Untreated hypertensive patients with stage 1 blood pressure levels (140-159/90-99 mm Hg), having no other evidence of LVH or no other cardiovascular risk factors.• When evidence of LVH requires further clarification (eg, suspected false positive electrocardiographic voltage changes, electrocardiograph with left atrial abnormality).• To minimize overuse of more costly echocardiographic procedures when only left ventricular mass and wall thickness measurements are desired. Table 3. Situations In Which Limited Echocardiography Is Not Indicated• Not a routine procedure for all patients with hypertension.• Untreated hypertensive patients with stage 1 blood pressure levels (140-159/90-99 mm Hg) having electrocardiographic evidence of left ventricular hypertrophy or other cardiovascular risk factors. These patients should be treated vigorously to achieve effective control of pressure.• To select antihypertensive therapy.• Patients with stages 2 through 4 blood pressure levels (>160/<100 mm Hg) with left ventricular hypertrophy (or other risk factors).• For follow-up once increased left ventricular mass is established. Table 4. Echo Trend Data 1986-1993: Volume Only, Includes Coding ChangesCodeDescription1986198719881989199019911992199393300*2D131 004130 658123 56855 11316 6908737076620*2D137 015124 97766 06425 38718922071093307M-mode212 724257 874253 459876 9911 546 9161 920 3432 218 0492 410 97376627*M-mode165 877164 01799 34541 6531585870093309*2D/M-mode196 897287 761489 519238 46054 716136914076629*2D/M-mode51 56194 152193 94160 54818397500Total895 0781 059 4391 225 8961 298 1521 623 6381 922 9542 218 0712 410 973Change18%16%6%25%18%15%9%Follow-up93305*2D22 42499438561370073528010076625*2D652129641833257111200933082D/M-mode24 80817 78920 77026 20454 38846 35335 76135 51276628*2D/M-mode68282589288836028900Total60 58133 28534 05230 52155 16246 65435 77135 512Change−45%2%−10%81%−15%−23%−1%Source: Medicare claims data, 1986-1993. Percent change 1987-1993: complete echo, 126%; limited echo, 7%.*Codes deleted in 1990.The authors gratefully acknowledge guidance from Drs Henry R. Black, Richard E. Devereux, Tonette Krousel-Wood, Daniel Levy, Philip R. Liebson, Barry M. Massie, Franz H. Messerli, Jack P. Segal, Clarence Shub, and James V. Talano. Each individual is an eminent authority in one or more of the following fields: cardiovascular medicine, hypertensive diseases, echocardiography, cardiovascular epidemiology, or healthcare analysis.FootnotesCorrespondence to Sheldon G. Sheps, MD, Division of Hypertension, Mayo Clinic, West 9, 200 First St SW, Rochester, MN 55905. E-mail [email protected] References 1 Frohlich ED, Apstein C, Chobanian AV, Devereux RB, Dustan HP, Dzau V, Fauad-Tarazi F, Horan MJ, Marcus M, Massie B, Pfeffer MA, Re RN, Roccella EJ, Savage D, Shub C. The heart in hypertension. N Engl J Med.1992; 327:998-1008.CrossrefMedlineGoogle Scholar2 Levy D, Garrison RI, Savage DD, Kannel WB, Castelli WP. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. 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