Una Martin

Falls are common during hospital admissions and may occur more frequently in patients who are taking antihypertensive medications, particularly in the context of normal to low blood pressure. The review and adjustment of these medications is an essential aspect of the post-fall assessment and should take place as soon as possible after the fall. Our aim was to investigate whether appropriate post-fall adjustments of antihypertensive medications are routinely made in a large National Health Service (NHS) Trust. Inpatient records over an eight-month period were captured from an electronic prescribing system to identify older adults (≥80 years old) with normal/low blood pressures (< 140 mmHg systolic) who had a documented inpatient fall as these patients were considered to be at high risk of further falls. Prescribed antihypertensive medication on admission was then compared with the post-fall (within 24 h after the fall) and discharge prescriptions. A total of 146 patients were included in the analysis. Of those, 120 patients (82%) were taking the same number of antihypertensive medications in the 24 h after the fall as they were before; only 19 patients (13%) had a reduction in the number of medications and seven patients (5%) had an increase in medications during that period. Only 9% of the antihypertensive classes assessed were either stopped or reduced in dose immediately post-fall. In addition, 11 new antihypertensives were prescribed at this time. At discharge, half of the patients (n = 73) remained on the same number of antihypertensive medication as on admission, 51 patients (35%) were on fewer antihypertensives and 22 (15%) were on more. Additionally, no changes were made to individual antihypertensives in 49% of prescriptions; 34% were stopped or reduced in dose but 38 new agents were started by the time of discharge. Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers (ACEi/ARB) were the class of medications most commonly stopped or reduced (51%). Antihypertensive prescriptions are frequently unchanged after an inpatient fall. Routine medication review needs to be part of post-fall assessments in hospital to reduce the risk of further falls.

Hypertension is a major risk factor for cardiovascular disease and prevalence varies by ethnic group. The diagnosis and management of blood pressure are informed by guidelines largely based on data from white populations. This study addressed whether accuracy of blood pressure measurement in terms of diagnosis of hypertension varies by ethnicity by comparing two measurement modalities (clinic blood pressure and home monitoring) with a reference standard of ambulatory BP monitoring in three ethnic groups. Cross-sectional population study (June 2010 - December 2012) with patients (40–75 years) of white British, South Asian and African Caribbean background with and without a previous diagnosis of hypertension recruited from 28 primary care practices. The study compared the test performance of clinic BP (using various protocols) and home-monitoring (1 week) with a reference standard of mean daytime ambulatory measurements using a threshold of 140/90 mmHg for clinic and 135/85 mmHg for out of office measurement. A total of 551 participants had complete data of whom 246 were white British, 147 South Asian and 158 African Caribbean. No consistent difference in accuracy of methods of blood pressure measurement was observed between ethnic groups with or without a prior diagnosis of hypertension: for people without hypertension, clinic measurement using three different methodologies had high specificity (75–97%) but variable sensitivity (33–65%) whereas home monitoring had sensitivity of 68–88% and specificity of 64–80%. For people with hypertension, detection of a raised blood pressure using clinic measurements had sensitivities of 34–69% with specificity of 73–92% and home monitoring had sensitivity (81–88%) and specificity (55–65%). For people without hypertension, ABPM remains the choice for diagnosing hypertension compared to the other modes of BP measurement regardless of ethnicity. Differences in accuracy of home monitoring and clinic monitoring (higher sensitivity of the former; higher specificity of the latter) were also not affected by ethnicity.

This study investigated the relationship of ethnicity to the differences between blood pressure (BP) measured in a clinic setting and by ambulatory blood pressure monitoring (ABPM) in individuals with a previous diagnosis of hypertension (HT) and without a previous diagnosis of hypertension (NHT). A cross-sectional comparison of BP measurement was performed in 770 participants (white British (WB, 39%), South Asian (SA, 31%), and African Caribbean (AC, 30%)) in 28 primary care clinics in West Midlands, United Kingdom. Mean differences between daytime ABPM, standardized clinic (mean of 3 occasions), casual clinic (first reading on first occasion), and last routine BP taken at the general practitioner practice were compared in HT and NHT individuals. Daytime systolic and diastolic ABPM readings were similar to standardized clinic BP (systolic: 128 (SE 0.9) vs. 125 (SE 0.9) mm Hg (NHT) and 132 (SE 0.7) vs. 131 (SE 0.7) mm Hg (HT)) and were not associated with ethnicity to a clinically important extent. When BP was taken less carefully, differences emerged: casual clinic readings were higher than ABPM, particularly in the HT group where the systolic differences approached clinical relevance (131 (SE 1.2) vs. 129 (SE 1.0) mm Hg (NHT) and 139 (SE 0.9) vs. 133 (SE 0.7) mm Hg (HT)) and were larger in SA and AC hypertensive individuals (136 (SE 1.5) vs. 133 (SE 1.2) mm Hg (WB), 141 (SE 1.7) vs. 133 (SE 1.4) mm Hg (SA), and 142 (SE 1.6) vs. 134 (SE 1.3) mm Hg (AC); mean differences: 3 (0–7), P = 0.03 and 4 (1–7), P = 0.01, respectively). Differences were also observed for the last practice reading in SA and ACs. BP differences between ethnic groups where BP is carefully measured on multiple occasions are small and unlikely to alter clinical management. When BP is measured casually on a single occasion or in routine care, differences appear that could approach clinical relevance.

Many thanks for your comments about our recent article.1 We are happy to give a definition of ‘white-coat’ effect. This phenomenon refers to the transient rise in blood pressure triggered by a visit to the doctor’s office, caused by an alerting reaction. The difference between blood pressure measured in the …

Background Inter-arm difference in blood pressure of >10 mmHg is associated with peripheral vascular disease, but it is unclear how much of the difference in sequential right and left arm blood pressure measurements might be due to a 'white-coat' effect. Aim To use ambulatory blood pressure monitoring (ABPM) to better understand the clinical significance of inter-arm differences in blood pressure. Design and setting Retrospective study in a teaching hospital in Birmingham. Method Anonymised clinical data collected from 784 patients attending a single hospital-based hypertension clinic were retrospectively analysed. Each participant had blood pressure measured sequentially in both arms, followed by ABPM over the subsequent 24 hours. Results Data were available for 710 (91%) patients, of whom 39.3% (279) had a blood pressure difference of 10 mmHg or more between each arm. Compared to daytime systolic ABPM, the difference was 25.1 mmHg using the arm with the highest reading, but only 15.5 mmHg if the lower reading was taken (mean difference 9.6 mmHg (95% confidence interval [CI] = 9.0 mmHg to 10.3 mmHg)). However, differences between mean right (20.7 mmHg) or left (19.9 mmHg) arm blood pressure and daytime systolic ABPM were very similar. Conclusion Compared with ABPM, use of the higher of the left and right arm readings measured sequentially appears to overestimate true mean blood pressure. As there is no significant difference in the extent of disparity with ABPM by left or right arm, this is unlikely to be due to arm dominance and may be due to the 'white-coat' effect reducing blood pressure on repeated measurement. Where a large inter-arm blood pressure difference is detected with sequential measurement, healthcare professionals should re-measure the blood pressure in the original arm.

Blood pressure (BP) lowering in people who have had a stroke or transient ischaemic attack (TIA) leads to reduced risk of further stroke. However, it is not clear what the target BP should be, since intensification of therapy may lead to additional adverse effects. PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting, and whether more intensive therapy is associated with adverse effects on quality of life. This is a randomised controlled trial (RCT) in patients with a past history of stroke or TIA. Patients will be randomised to two groups and will either have their blood pressure (BP) lowered intensively to a target of 130 mmHg systolic, (or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg) compared to a standard group where the BP will be reduced to a target of 140 mmHg systolic. Patients will be managed by their practice at 1-3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months. 610 patients will be recruited from approximately 50 general practices. The following exclusion criteria will be applied: systolic BP <125 mmHg at baseline, 3 or more anti-hypertensive agents, orthostatic hypotension, diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness. The primary outcome will be change in systolic BP over twelve months. Secondary outcomes include quality of life, adverse events and cardiovascular events. In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals understanding and views of BP management. The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care, and help determine whether or not further research is required before recommending such targets for this population. ISRCTN29062286

Background and objective: Treatment with angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) during pregnancy can cause severe foetal abnormalities. This study aimed to identify the proportion of women of childbearing age taking ACE inhibitors or ARBs on referral to a tertiary Hypertension Clinic. Design: Retrospective cohort study. Methods: A cohort of female patients aged 16–45 years was identified from approximately 1500 new referrals from January 2004 to October 2006, excluding those not taking antihypertensive medication. ACE inhibitors and ARBs were grouped together for the purposes of the study. Contraceptive status was established where possible. Results: Forty seven of 101 (47%) women aged 16–45 years were taking an ACE inhibitor (35) an ARB (11) or both (1) of whom 26 (55%) were aged 16–40 years. In this younger group, eight were using no contraception and three were using barrier methods only. Conclusions: Many GPs continue to prescribe ACE inhibitors and ARBs to women of childbearing age. A quarter of women in the study were taking these agents and were 40 years or less; of these many were not using reliable contraception. These women are at risk of foetal malformation and poor perinatal outcomes if they become pregnant. The British Hypertension Guidelines may put younger women at risk if general practitioners are unaware of potential foetotoxic and teratogenic consequences of prescribing ACE inhibitors and ARBs to women of child bearing age.

Case 1 A 64 year old woman was referred to a hypertension clinic with a blood pressure of 180/110 mm Hg. Her biochemical profile was normal (serum creatinine concentration 102 µmol/l, urea 6.4 mmol/l, potassium 4.2 mmol/l, sodium 139 mmol/l). Treatment started with amlodipine 5 mg, and when she was reviewed, six weeks later, her blood pressure was 165/95 mm Hg. Perindopril 4 mg was added, and one week later her blood pressure was 144/70 mm Hg. However, her renal function showed some deterioration, with slight rises in serum creatinine concentration (110 µmol/l) and urea concentration (9.3 mmol/l). A month later the patient's blood pressure control remained good (140/70 mm Hg), but there was further deterioration in renal function (creatinine of 143 µmol/l, urea 10.4 mmol/l). A further month later, she was normotensive (139/71 mm Hg) with no further change in renal function (creatinine 143 µmol/l, urea 11 mmol/l). In view of the deterioration in her renal function, she was investigated with a renal ultrasound scan followed by enhanced renal magnetic resonance angiogram. A short tight stenosis of the left renal artery was diagnosed. A nuclear medicine renal scan showed that the left kidney was contributing 15% of overall function, so angioplasty of the left renal artery was performed. After the procedure, the patient's blood pressure decreased further and stabilised at 138/83 mm Hg, and her treatment was reduced to amlodipine monotherapy. Summary points Monitoring of renal function and electrolytes before and during treatment of hypertension may provide an alert to underlying problems and help to prevent serious adverse effects Early changes in biochemical parameters may be important and indicate the need for more frequent monitoring The evidence base for the effectiveness of monitoring strategies is still limited

The aim of this study was to examine the effect of the cadioselective B(1)-adrenoceptor blocker nebivolol on glycaemic control, lipid profile and markers of oxidative stress in patients with type 2 diabetes over a 6-month period. Twenty-six patients with mild to moderate hypertension (140-160 mmHg systolic, 90-105 mmHg diastolic) confirmed on 24-h blood pressure monitoring, were treated with nebivolol 5 mg daily for 6 months. Total serum cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) subfractions, lipid hydroperoxides (LHPs) and total antioxidant capacity (TAC) were measured before and after 6 months of treatment. Nebivolol, as expected, reduced mean daytime systolic and diastolic pressures on ambulatory monitoring (149 +/- 9 to 140 +/- 13 mmHg, P = 0.02 and 84 +/- 7 to 77 +/- 9 mmHg, P < 0.001). There were no significant changes in serum cholesterol or triglycerides following treatment but a significant increase in HDL cholesterol was noted (1.12 +/- 0.19 to 1.25 +/- 0.36 mmol/L, P = 0.008). Patients showed a highly significant reduction in TAC from 501 +/- 57 to 422 +/- 29 trolox equivalent (P < 0.001). Baseline LHPs were very high and showed no significant change over the 6-month period (18.7 +/- 7.4 and 18.7 +/- 10.9 micromol/L). The LDL score increased significantly from 1.7 +/- 0.7 to 2.3 +/- 0.7 (P = 0.0002) at 6 months suggesting a change to a more atherogenic lipid profile. Neither weight nor glycaemic control changed during treatment. Nebivolol appears to be lipid neutral and may even have a positive effect on HDL cholesterol. Despite this it may promote the formation of potentially atherogenic LDL subfractions possibly as a result of reduced antioxidant defences. Further studies are needed to clarify the changes observed in parameters of oxidative stress.