Hypertension artérielle résistante et maladie rénale chronique : Déterminants et risques associésL’hypertension résistante, définie par une pression artérielle au-dessus de la cible en dépit de la prise de trois antihypertenseurs à dose optimale dont un diurétique, est fréquemment associée à la maladie rénale chronique (MRC). Sa prévalence, ses déterminants et l’impact potentiel de la MRC sur son pronostic à long terme sont mal connus, notamment chez le sujet âgé. Dans l’étude des 3 cités, incluant 4262 personnes de plus de 65 ans traitées pour hypertension, la prévalence de l’hypertension apparemment résistante (HTAR) - la notion de traitement à dose optimale étant inconnue - était de 11,8% vs 5,2% chez ceux avec vs sans MRC (définie par une fonction rénale < 60 mL/min/1.73 m2). Nous avons montré que l’apparition d’une HTAR était plus fortement liée à la rapidité du déclin annuel de la fonction rénale qu’à son niveau, indépendamment des autres facteurs de risque : obésité, diabète, sexe masculin, antécédent cardiovasculaire. Comparé au groupe de référence (avec hypertension contrôlée et sans MRC), les personnes avec une HTAR et une MRC n’avaient pas de risque significativement plus élevé de mortalité toute cause, mais avaient deux fois plus de risque d’accident vasculaire cérébral (AVC), létal ou non, et de récurrence d’un AVC ou d’un événement coronaire, et trois fois plus de décès coronaire. Cependant, l’’hypothèse d’un effet aggravant de la MRC sur le pronostic de l’HTAR n’a pas été confirmé (interaction non significative).Dans la cohorte CKD-REIN, incluant plus de 3000 patients avec une MRC modérée ou avancée suivis en néphrologie (âge moyen, 70 ans, 60% d’hommes), nos résultats préliminaires montrent une prévalence élevée d’HTAR, 36,7%, et plusieurs facteurs de risque potentiellement modifiables : adhérence médiocre au traitement, absence de diurétique, consommation de sel en excès, obésité.Dans l’ensemble, ces travaux montrent l’importance de la MRC dans le développement de l’HTAR et des risques cardiovasculaires associés, et suggère des moyens de prévention au-delà des traitements médicamenteux. / Resistant hypertension and chronic kidney disease: Determinants and outcomesResistant hypertension defined as blood pressure above goal despite simultaneous use of 3 antihypertensive classes at optimal doses including a diuretic, is commonly associated with chronic kidney disease (CKD). Resistant hypertension prevalence and determinants, and the impact of CKD on its long term outcomes are poorly known, particularly in the elderly population.In the 3 Cities cohort, including 4262 community-dwelling elderly individuals, aged 65 years or older treated for hypertension, the prevalence of apparent treatment resistant hypertension (aTRH) – because of lack of information on optimal treatment dose – was 11.8% vs 5.2% in those with vs without CKD (defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2). We showed that new-onset aTRH was more strongly related to the speed of kidney function decline than kidney function level itself, independent of other risk factors: male sex, obesity, diabetes, and history of cardiovascular disease. Compared to the reference group (with controlled hypertension and no CKD), participants with aTRH and CKD had no significantly higher risk of all-cause mortality, but had a risk of fatal or non-fatal stroke and of recurrent stroke or coronary events more than twice as high, and of coronary death more than three times higher. However, the hypothesis that CKD may worsen the prognosis of aTRH was not confirmed (no significant interaction).In the CKDREIN cohort, which included more than 3000 nephrology outpatients with moderate or severe CKD (mean age, 70 years, 60% of men), our preliminary results showed a high prevalence of aTRH, 36,7% and several potentially modifiable risk factors : poor treatment adherence, lack of diuretic use, excess salt intake and obesity.Overall, this work shows the importance of CKD in the development of aTRH and associated cardiovascular outcomes, and suggests means for prevention beyond drug therapy.

No description available.

No description available.

No description available.

Arterial stiffness represented by carotid-femoral pulse wave velocity (PWV) is considered to be an independent cardiovascular risk factor. This study was focused on large artery properties investigation in specific forms of hypertension using applanation tonometer Sphygmocor (Atcor Medical). PWV was significantly higher in resistant hypertension patients when compared to moderate essential hypertension (EH) patients. This difference appears to be independent of clinical blood pressure (BP). Night-time BP appears to be a more accurate predictor of PWV in EH. In another study we demonstrated that primary hyperparathyroidism (PH) (both hypertensive or non-hypertensive forms) might be associated with higher PWV when compared to EH patients or to normotensive controls and that this difference is independent of age and clinical BP. Neither calcium serum level, nor parathyroid hormone has been associated with PWV. Specific treatment by parathyroidectomy (PTX) seems to be beneficial for PWV decrease, which might be mainly determined by improved BP control after surgery. Since PTX indications for asymptomatic forms of PH have been discussed, our data suggest the potential benefit to the extent of subclinical organ damage after surgical treatment in these patients. Similarly, we prooved higher PWV in...

Arterial stiffness represented by carotid-femoral pulse wave velocity (PWV) is considered to be an independent cardiovascular risk factor. This study was focused on large artery properties investigation in specific forms of hypertension using applanation tonometer Sphygmocor (Atcor Medical). PWV was significantly higher in resistant hypertension patients when compared to moderate essential hypertension (EH) patients. This difference appears to be independent of clinical blood pressure (BP). Night-time BP appears to be a more accurate predictor of PWV in EH. In another study we demonstrated that primary hyperparathyroidism (PH) (both hypertensive or non-hypertensive forms) might be associated with higher PWV when compared to EH patients or to normotensive controls and that this difference is independent of age and clinical BP. Neither calcium serum level, nor parathyroid hormone has been associated with PWV. Specific treatment by parathyroidectomy (PTX) seems to be beneficial for PWV decrease, which might be mainly determined by improved BP control after surgery. Since PTX indications for asymptomatic forms of PH have been discussed, our data suggest the potential benefit to the extent of subclinical organ damage after surgical treatment in these patients. Similarly, we prooved higher PWV in...

Made available in DSpace on 2011-05-04T12:42:04Z (GMT). No. of bitstreams: 0 Previous issue date: 2010 / A hipertensão arterial é um dos mais importantes fatores de risco para o desenvolvimento das complicações cardiovasculares, cerebrovasculares e renais. Embora seja facilmente detectável, o controle dos níveis tensionais constitui um enorme desafio da saúde pública. O objetivo desta tese foi analisar dados longitudinais de uma coorte de pacientes hipertensos resistentes. Em estudos longitudinais, o principal foco de interesse é na mudança ocorrida ao longo do tempo; seja ela avaliada como tempo até o evento ou como medidas repetidas tomadas durante o período de acompanhamento. O presente trabalho foi organizado em três artigos onde foram apresentadas essas duas abordagens. No primeiro artigo, foi realizada uma Análise de Sobrevida, tendo como desfecho eventos cardiovasculares fatais e não fatais, em mulheres hipertensas da coorte. Foi verificado que para atingir o objetivo de diminuir a morbidade e a mortalidade cardiovascular nessa população, as decisões deveriam ser baseadas no controle da pressão devigília obtida na Monitorização Ambulatorial da Pressão Arterial (MAPA) e não no controle dapressão de consultório. No segundo artigo, foram usadas as medidas da pressão arterial (PA) obtidas na MAPA em sua forma resumida usual (médias de PA 24h, vigília e noturna). Ospacientes hipertensos pseudorresistentes apresentaram trajetória ascendente, indicando a necessidade de acompanhamento desses pacientes a intervalos inferiores a um ano. Além disso, não foi observada redução dos valores do índice de massa corporal e da circunferência da cintura nesses pacientes. O terceiro artigo abordou a evolução temporal dos valores do descenso noturnopressórico nos pacientes da coorte, além de estimar as probabilidades brutas de transição entre as categorias do descenso noturno, em MAPAs sucessivas. Apesar de não ultrapassar o limite de normalidade de 10 por cento, houve uma queda acentuada nos valores percentuais do descenso noturnodos pacientes dippers ao longo do tempo. A probabilidade estimada de permanência no estado dipper foi de 52 por cento, enquanto que no estado non dipper esse valor foi de 46 por cento. Nesses dois artigos foram usados Modelos Aditivos Generalizados Mistos, que incorporam efeitos aleatórios, umavez que a variação intra-paciente foi expressiva. A incorporação de métodos estatísticos mais sofisticados faz jus à qualidade e custo de coleta das informações longitudinais. Com base nesses três artigos, concluiu-se que o uso da MAPA é primordial no acompanhamento de pacientes hipertensos resistentes, pois permite detectar as variações ao longo do tempo na evolução clínica. / Hypertension is one of the most important risk facotors for cardiovascular, cerebrovascular and renal diseases. While it is easy to detect, blood pressure control is a major public health challenger. The objective of this thesis was to examine longitudinal data fron a cohort of resistant hypetensive patients. In longitudinal studies, the main focus of interest is on changes over time, either evalueated as time-to -event or as repeated measures taken durin the foloow-up. this thesis was organized in tree articles which presented these two approaches. In the fist article, in the suvival approach, we modeled the time free of fatal and nonfatal cardiovasculr event, in hypertensive women of the cohort. It was found that to achieve the goal of decreasing cardiovasculr morbidity and mortality in this population, decisions should be based on the control of daytime Ambulatory Blood Pressure (ABP) and not on the control of office blood pressure. In the second article, it was used blood pressure (BP) measurementes from ABPM in its usual summary form (mean 24h, daytime ande nighttime). Pseudoresistant hypetensive patients showed an upward trend, indicating th need to monitor them more than once a year. Moreover, there was no reduction in body mass index and waist circunference values in these patientes. the third paper dealt with the evolution of nocturnal blood pressure values in these cohort patients, as well as estimated the crude probabilities of trnsitions between the nocturnal dip categories in sucessive ABPM. Although the limit of normality of 10% was not excessd, a sharp drop in nocturnal dip values was observed on dippers patients oves time. the maindtenance probbiliy in dippes status was estimted in 52% whereas in non dipper status figured in 46%. In these two articles generalized additive mixed models that incorporte random effects were used, since the intr-patient vrition was significant. the incorpotation of moro sophisticated statistical methods is justified by the quality and cost of longitudinal informations. Based on these three articles, it was conclued tht the use of ABPM is essentil in monitoring patients with resistant hypertension, since it allows to detect chnges over time in the clinical outcome.