Background: Patients with diabetes mellitus (DM) have a high prevalence of atherosclerotic vascular lesions. It is therefore reasonable to assume that also the rate of renal artery stenosis (RAS) is higher. The presence of a RAS can have implications for the treatment of patients with diabetes mellitus and hypertension and renal impairment. Therefore it is important to be informed about the chance that a RAS is present among such patients.Methods: We prospectively studied the prevalence of atherosclerotic renal artery stenosis (RAS) among patients with diabetes mellitus. Patients were included if they were diagnosed with DM and hypertension with or without impairment of renal function. If causes of renal disease other than DM or hypertension were more probable on the basis of biochemical data, then such patients were excluded. A magnetic resonance angiography (MRA) of the renal arteries was made in 54 included successive patients.Results: Patient characteristics: mean age 59 +/- 8.5 years (range 35 to 80). Eight patients had DM 1 and 46 DM 2. Mean BMI was 31.4 +/- 5.6 kg/m(2). A RAS was present in 18 of the 54 (33%) patients, 3 patients had bilateral stenoses. Factors related to the presence of RAS were diastolic blood pressure, glomerular filtration rate and dyslipidaemia.Conclusion: In this group of diabetic patients with hypertension and or renal impairment the prevalence of RAS was 33%. (C) 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Background: Crossing the ankles in the sitting position has no effect on blood pressure (BP), but BP increases when legs are crossed at the knee level. The physiological mechanism responsible for this BP increase is a higher cardiac output (CO), but not a higher total peripheral resistance (TPR). Objective: The purpose of our study was to determine the effect and physiological mechanism of crossing the ankle over the knee on BP. Methods: Finger BP was measured continuously and noninvasively by the use of the Nexfin monitor by one trained investigator. Twenty five participants crossed their ankle over the knee with the lateral malleolus on the suprapatellar bursa in the sitting position. Differences in systolic BP (SBP), diastolic BP (DBP), mean BP (MAP), heart rate (HR), stroke volume (SV), CO and TPR were determined in the crossed position versus feet flat on the floor. Results: Except TPR, all hemodynamic parameters were significantly higher with the ankle crossed over the knee versus the uncrossed position: SBP 11.4 ± 5.3 mmHg (mean ± SD) (9.2–13.6; 95% CI), DBP 3.8 ± 2.5 mmHg (2.8 – 4.9), MAP 7.0 ± 3.9 mmHg (5.4 – 8.6), HR 1.7 ± 3.2 beats/min (0.4 – 3.0), SV 5.7 ± 3.7 ml (4.2 - 7.3), CO 0.5 ± 0.3 l/min (0.4 – 0.7). Conclusion: Our study shows that ankle crossing over the knee causes increases in BP, CO and SV, while TPR does not change. The working mechanism for the BP increase when the ankle is crossed over the knee seems to be comparable with the working mechanism of the BP increase when legs are crossed at knee level. All persons who measure BP should be aware of the influence of leg position and instruct patients to keep their feet flat on the floor during BP measurements. The position of legs should be mentioned in all guidelines and publications regarding BP.

Background. Patients with a renal artery stenosis (RAS) > 50% carry an increased risk for future cardiovascular (CV) events. Experimental literature on this topic suggests that this might as well be true for subjects with lower-grade RAS.Methods. Recruitment in this longitudinal cohort study was conducted from 1982 to 2002 in a Dutch University Hospital. Included in this study were 301 hypertensive patients clinically suspected of having RAS. Study participants were radiologically classified as having no, a low-grade (< 50% lumen narrowing) or high-grade (>= 50%) RAS. A predetermined composite CV end-point was defined as one of the following: myocardial infarction or 'objectified' angina pectoris, ischaemic stroke or death from any CV cause. Other end-points were the occurrence of CV complications, all-cause plus CV mortality and decline in renal function.Results. During a median follow-up of 8.2 years, the incidence of the composite end-point totalled 79 events. After full adjustment in Cox models, a significant risk increase in high-grade [hazard ratio (HR) 2.81; P = 0.002] and low-grade RAS (HR 2.32; P = 0.038) was observed. Other end-points did not differ significantly between study groups.Conclusion. Hypertensive subjects with RAS of any extent, compared with hypertensives without RAS, carry a substantially increased risk for future CV events. Therefore, even in patients with low-grade RAS, aggressive pharmacological treatment strategies should be adopted as a preventive measure.

De bloeddruk is een van de factoren die het cardiovasculaire risicoprofiel van een patiënt bepaalt. Daarom is het van belang een juiste bloeddrukmeting uit te voeren. Richtlijnen geven aan dat de bloeddruk aan de blote bovenarm gemeten dient te worden. In de praktijk wordt de bloeddruk uit tijdgebrek vaak over een laag kleding gemeten. De vraag luidt of deze laag kleding invloed heeft op de uitkomst van de bloeddrukmeting.

signed to answer the question whether antihypertensive treatment reduces strokes (both fatal and non-fatal strokes) without increasing total mortality. A total of 3845 patients were assigned to active treatment or placebo. About 90% had a history of hypertension, 65% of which were being treated. At the start of the study all antihypertensive treatment was stopped and the subjects were randomized to either indapamide 1.5 mg with or without perindopril 2-4 mg or to identical looking placebo. After about 2 years the trial was discontinued for ethical reasons as there was less death from any cause in the intervention group. Blood pressure decreased with 30/13 mmHg in the treatment versus 1517 mmHg in the placebo group. There was a 30% decrease of all strokes (p = 0.06) but a significant reduction in fatal strokes (p < 0.05). Unexpected was the 21% reduction in all-cause mortality (p < 0.02). The 23% reduction in the rate of cardiovascular death was not significant (p < 0.06). Heart failure and total cardiovascular events decreased (p < 0.001). There were fewer adverse effects in the treatment group (p = 0.001). In our opinion HYVET proves that antihypertensive medication should not be stopped when patients pass the age of 80 years. However, it remains to be established whether treatment should be started in new patients who present themselves with hypertension above the age of 80 years.

In this issue of the Journal, attention is given to some aspects of blood pressure (BP) measurement by oscillometry. In fact the oscillometric principle is a very old one and some of our elderly colleagues may remember the application in the oscillogram, used when a patient was suspected of having one-sided leg ischaemia. In such cases, oscillations in BP were different between the two legs, i.e. the affected leg showed oscillations with a smaller amplitude. When BP is measured oscillations are visible from suprasystolic to infradiastolic BP, but the oscillations show varying amplitude, as can be seen in figure 1, a well-known registration from the work of Geddes' group. H i s T o r Y

The 'Hypertension in the very elderly trial' (HYVET) was designed to answer the question whether antihypertensive treatment reduces strokes (both fatal and non-fatal strokes) without increasing total mortality. A total of 3845 patients were assigned to active treatment or placebo. About 90% had a history of hypertension, 65% of which were being treated. At the start of the study all antihypertensive treatment was stopped and the subjects were randomized to either indapamide 1.5 mg with or without perindopril 2-4 mg or to identical looking placebo. After about 2 years the trial was discontinued for ethical reasons as there was less death from any cause in the intervention group. Blood pressure decreased with 30/13 mmHg in the treatment versus 15/7 mmHg in the placebo group. There was a 30% decrease of all strokes (p = 0.06) but a significant reduction in fatal strokes (p < 0.05). Unexpected was the 21% reduction in all-cause mortality (p < 0.02). The 23% reduction in the rate of cardiovascular death was not significant (p < 0.06). Heart failure and total cardiovascular events decreased (p < 0.001). There were fewer adverse effects in the treatment group (p = 0.001). In our opinion HYVET proves that antihypertensive medication should not be stopped when patients pass the age of 80 years. However, it remains to be established whether treatment should be started in new patients who present themselves with hypertension above the age of 80 years.

Background: Home blood pressure (HBP) measurement is considered to reflect BP during the day better than office BP (OBP). But in some patients HBP is higher than OBP. This is called masked hypertension (MH).Objective: To examine whether MH occurs in healthy volunteers and apparently well-controlled hypertensives. Methods: 57 treated hypertensive patients and V healthy volunteers (27/22 men) participated. Mean age (SD) was 61 13 and 29 13 years, respectively. Patients were instructed to measure their BP twice daily for three days (3 readings each) with the Omron 705 CP device after at least 01 minutes rest in a comfortable sitting position. In the outpatient department, OBP was measured four times, in duplicate, every ten minutes by the physician using the same device and under similar conditions.Results: Mean HBP of the treated hypertensive group was 146/84 +/- 18/10 mmHg, significantly higher than OBP 136/79 +/- 19/10 (p < 0.001). For the healthy volunteer group mean HBP was 123/70 +/- 15/8) mmHg and the OBP was 117/69 +/- 16/10). Of 57 patients, 16 (28%) were classified as MH. The use of antihypertensive drugs was similar in the MH patients and the uncontrolled hypertensives. Logistic regression analysis showed that age tended to be a weak predictor for MH while gender, BMI and upper arm circumference were not.Conclusion: This study demonstrates that MH occurs frequently in apparently well-controlled hypertensives, but not in healthy volunteers. However, in healthy volunteers HBP can be relevantly higher than OBP, although both values generally remain within the normotensive range.