Patrice Wendling

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep. The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic BP dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients with a dipper BP pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern. Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than were dippers (4.4%) or extreme dippers (4%). But nondippers were significantly less likely to be smokers (17%) than were dippers (25%) or extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in dipper, nondipper, and extreme-dipper patients, respectively. Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that adjusted for various covariates, including 24-hour BP and drug therapy, showed that cardiovascular risk was significantly higher in nondipper patients (relative risk 1.7) and in extreme-dipper patients (RR 2.2), compared with dipper patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, in a statement, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m

The evidence supports 24-hour blood pressure monitoring at least in patients at very high risk of being nondippers. DR. BAKRIS

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep. The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic BP dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients with a dipper BP pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern. Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than were dippers (4.4%) or extreme dippers (4%). But nondippers were significantly less likely to be smokers (17%) than were dippers (25%) or extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in dipper, nondipper, and extreme-dipper patients, respectively. Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that adjusted for various covariates, including 24-hour BP and drug therapy, showed that cardiovascular risk was significantly higher in nondipper patients (relative risk 1.7) and in extreme-dipper patients (RR 2.2), compared with dipper patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, in a statement, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m

The evidence supports 24-hour blood pressure monitoring at least in patients at very high risk of being nondippers. DR. BAKRIS

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep. The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic BP dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients with a dipper BP pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern. Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than were dippers (4.4%) or extreme dippers (4%). But nondippers were significantly less likely to be smokers (17%) than were dippers (25%) or extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in dipper, nondipper, and extreme-dipper patients, respectively. Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that adjusted for various covariates, including 24-hour BP and drug therapy, showed that cardiovascular risk was significantly higher in nondipper patients (relative risk 1.7) and in extreme-dipper patients (RR 2.2), compared with dipper patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, in a statement, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m

The evidence supports 24-hour blood pressure monitoring at least in patients at very high risk of being nondippers. DR. BAKRIS

CHICAGO — Despite its superior efficacy, the diuretic chlorthalidone is being underutilized in patients with hypertension, according to Dr. William J. Elliot.

The reason may be as simple as the lack of a convenient abbreviation.

Studies support the efficacy of chlorthalidone in reducing hypertension, yet the diuretic hydrochlorothiazide remains favored in clinical practice. One theory is that chlorthalidone is associated with more hypokalemia than is hydrochlorothiazide.

Dr. Elliott, a preventive medicine professor at Chicago's Rush University Medical Center, suggests chlorthalidone has fallen out of favor because hydrochlorothiazide can be abbreviated as HCTZ, while there is no standard abbreviation for chlorthalidone.

“In my opinion, the reason that people are not using chlorthalidone—a better diuretic—is because it unfortunately has to be written out, all 14 letters of it, whereas doctors can get by using only four letters of hydrochlorothiazide,” Dr. Elliot said at a press briefing at the annual meeting of the America Society of Hypertension.

He cited several studies favoring chlorthalidone, including a recent blinded, randomized, head-to-head comparison (Hypertension 2006;47:352–8) that showed a greater reduction in 24-hour mean systolic blood pressure at 8 weeks in patients receiving chlorthalidone 25 mg/day, compared with those receiving HCTZ 50 mg/day (−12.4 mm Hg vs. −7.4 mm Hg, P = .054).

The greater reduction with chlorthalidone, at half the dose, was thought to be primarily because of its effect on nighttime mean systolic blood pressure, which fell 13.5 mm Hg for chlorthalidone vs. 6.4 mm Hg for HCTZ.

In the Multiple Risk Factor Intervention Trial, patients given HCTZ by investigators had 44% more coronary heart disease and 16% more deaths after 5 years of follow-up, compared with control patients cared for in the community by primary care physicians (Circulation 1990;82:1616–28). Conversely, there was 58% less coronary heart disease and 41% fewer deaths in patients treated with chlorthalidone, compared with referred-care controls, Dr. Elliott said.

More recently, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial found fewer cardiovascular events with chlorthalidone than with an angiotensin-converting enzyme inhibitor, while the second Australian National Blood Pressure study found an inhibitor to be superior to HCTZ at reducing combined mortality and morbidity in men but not in women.

“I submit that we ought to be putting HCTZ on the list of 'do not use' abbreviations because it is an inferior product and ought to be replaced in general practice by chlorthalidone,” he said.

Cost is not a factor, as both drugs are generically available and can be found on the Wal-Mart $4 per month drug list, said Dr. Elliott, who disclosed possible conflicts of interest with Pfizer Inc., Novartis Pharmaceuticals Corp., AstraZeneca, Kos Pharmaceuticals Co., Abbott Laboratories, and KV Pharmaceutical.

Dr. Elliott recommends low-dose chlorthalidone 12.5 mg because of better efficacy and longer duration of action. He uses diuretics in hypertensive patients with chronic kidney disease, diabetes, or high risk of heart failure, but typically switches patients with severe late-stage kidney disease to loop diuretics taken twice daily.

Dr. John Flack, of Wayne State University, Detroit, agreed with Dr. Elliott's recommendation to use chlorthalidone over HCTZ. “One of the things that would really help is if a pharmaceutical company would have the courage to break the trend of simply putting HCTZ with everything,” Dr. Flack said.

While HCTZ is part of several fixed-dose combination drugs, chlorthalidone is available in only three combination products: clonidine (Clorpres), reserpine (Regroton), and atenolol (Tenoretic), Dr. Elliott said.

CHICAGO — Despite its superior efficacy, the diuretic chlorthalidone is being underutilized in patients with hypertension, according to Dr. William J. Elliot.

The reason may be as simple as the lack of a convenient abbreviation.

Studies support the efficacy of chlorthalidone in reducing hypertension, yet the diuretic hydrochlorothiazide remains favored in clinical practice. One theory is that chlorthalidone is associated with more hypokalemia than is hydrochlorothiazide.

Dr. Elliott, a preventive medicine professor at Chicago's Rush University Medical Center, suggests chlorthalidone has fallen out of favor because hydrochlorothiazide can be abbreviated as HCTZ, while there is no standard abbreviation for chlorthalidone.

“In my opinion, the reason that people are not using chlorthalidone—a better diuretic—is because it unfortunately has to be written out, all 14 letters of it, whereas doctors can get by using only four letters of hydrochlorothiazide,” Dr. Elliot said at a press briefing at the annual meeting of the America Society of Hypertension.

He cited several studies favoring chlorthalidone, including a recent blinded, randomized, head-to-head comparison (Hypertension 2006;47:352–8) that showed a greater reduction in 24-hour mean systolic blood pressure at 8 weeks in patients receiving chlorthalidone 25 mg/day, compared with those receiving HCTZ 50 mg/day (−12.4 mm Hg vs. −7.4 mm Hg, P = .054).

The greater reduction with chlorthalidone, at half the dose, was thought to be primarily because of its effect on nighttime mean systolic blood pressure, which fell 13.5 mm Hg for chlorthalidone vs. 6.4 mm Hg for HCTZ.

In the Multiple Risk Factor Intervention Trial, patients given HCTZ by investigators had 44% more coronary heart disease and 16% more deaths after 5 years of follow-up, compared with control patients cared for in the community by primary care physicians (Circulation 1990;82:1616–28). Conversely, there was 58% less coronary heart disease and 41% fewer deaths in patients treated with chlorthalidone, compared with referred-care controls, Dr. Elliott said.

More recently, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial found fewer cardiovascular events with chlorthalidone than with an angiotensin-converting enzyme inhibitor, while the second Australian National Blood Pressure study found an inhibitor to be superior to HCTZ at reducing combined mortality and morbidity in men but not in women.

“I submit that we ought to be putting HCTZ on the list of 'do not use' abbreviations because it is an inferior product and ought to be replaced in general practice by chlorthalidone,” he said.

Cost is not a factor, as both drugs are generically available and can be found on the Wal-Mart $4 per month drug list, said Dr. Elliott, who disclosed possible conflicts of interest with Pfizer Inc., Novartis Pharmaceuticals Corp., AstraZeneca, Kos Pharmaceuticals Co., Abbott Laboratories, and KV Pharmaceutical.

Dr. Elliott recommends low-dose chlorthalidone 12.5 mg because of better efficacy and longer duration of action. He uses diuretics in hypertensive patients with chronic kidney disease, diabetes, or high risk of heart failure, but typically switches patients with severe late-stage kidney disease to loop diuretics taken twice daily.

Dr. John Flack, of Wayne State University, Detroit, agreed with Dr. Elliott's recommendation to use chlorthalidone over HCTZ. “One of the things that would really help is if a pharmaceutical company would have the courage to break the trend of simply putting HCTZ with everything,” Dr. Flack said.

While HCTZ is part of several fixed-dose combination drugs, chlorthalidone is available in only three combination products: clonidine (Clorpres), reserpine (Regroton), and atenolol (Tenoretic), Dr. Elliott said.

CHICAGO — Despite its superior efficacy, the diuretic chlorthalidone is being underutilized in patients with hypertension, according to Dr. William J. Elliot.

The reason may be as simple as the lack of a convenient abbreviation.

Studies support the efficacy of chlorthalidone in reducing hypertension, yet the diuretic hydrochlorothiazide remains favored in clinical practice. One theory is that chlorthalidone is associated with more hypokalemia than is hydrochlorothiazide.

Dr. Elliott, a preventive medicine professor at Chicago's Rush University Medical Center, suggests chlorthalidone has fallen out of favor because hydrochlorothiazide can be abbreviated as HCTZ, while there is no standard abbreviation for chlorthalidone.

“In my opinion, the reason that people are not using chlorthalidone—a better diuretic—is because it unfortunately has to be written out, all 14 letters of it, whereas doctors can get by using only four letters of hydrochlorothiazide,” Dr. Elliot said at a press briefing at the annual meeting of the America Society of Hypertension.

He cited several studies favoring chlorthalidone, including a recent blinded, randomized, head-to-head comparison (Hypertension 2006;47:352–8) that showed a greater reduction in 24-hour mean systolic blood pressure at 8 weeks in patients receiving chlorthalidone 25 mg/day, compared with those receiving HCTZ 50 mg/day (−12.4 mm Hg vs. −7.4 mm Hg, P = .054).

The greater reduction with chlorthalidone, at half the dose, was thought to be primarily because of its effect on nighttime mean systolic blood pressure, which fell 13.5 mm Hg for chlorthalidone vs. 6.4 mm Hg for HCTZ.

In the Multiple Risk Factor Intervention Trial, patients given HCTZ by investigators had 44% more coronary heart disease and 16% more deaths after 5 years of follow-up, compared with control patients cared for in the community by primary care physicians (Circulation 1990;82:1616–28). Conversely, there was 58% less coronary heart disease and 41% fewer deaths in patients treated with chlorthalidone, compared with referred-care controls, Dr. Elliott said.

More recently, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial found fewer cardiovascular events with chlorthalidone than with an angiotensin-converting enzyme inhibitor, while the second Australian National Blood Pressure study found an inhibitor to be superior to HCTZ at reducing combined mortality and morbidity in men but not in women.

“I submit that we ought to be putting HCTZ on the list of 'do not use' abbreviations because it is an inferior product and ought to be replaced in general practice by chlorthalidone,” he said.

Cost is not a factor, as both drugs are generically available and can be found on the Wal-Mart $4 per month drug list, said Dr. Elliott, who disclosed possible conflicts of interest with Pfizer Inc., Novartis Pharmaceuticals Corp., AstraZeneca, Kos Pharmaceuticals Co., Abbott Laboratories, and KV Pharmaceutical.

Dr. Elliott recommends low-dose chlorthalidone 12.5 mg because of better efficacy and longer duration of action. He uses diuretics in hypertensive patients with chronic kidney disease, diabetes, or high risk of heart failure, but typically switches patients with severe late-stage kidney disease to loop diuretics taken twice daily.

Dr. John Flack, of Wayne State University, Detroit, agreed with Dr. Elliott's recommendation to use chlorthalidone over HCTZ. “One of the things that would really help is if a pharmaceutical company would have the courage to break the trend of simply putting HCTZ with everything,” Dr. Flack said.

While HCTZ is part of several fixed-dose combination drugs, chlorthalidone is available in only three combination products: clonidine (Clorpres), reserpine (Regroton), and atenolol (Tenoretic), Dr. Elliott said.

CHICAGO — Bedtime dosing of valsartan is more efficient than morning dosing in controlling blood pressure and improving renal function in hypertensive patients with or without diabetes, Ramon Hermida, Ph.D., said at the annual meeting of the American Society of Hypertension.

Dr. Hermida suggests this time-dependent effect is not unique to valsartan, but may be class related for angiotensin II receptor blockers.

Dr. Hermida randomized 204 untreated hypertensive patients to receive valsartan 160 mg/day upon awakening or at bedtime. Blood pressure was measured at 20-minute intervals from 7:00 a.m. to 11:00 p.m., and at 30-minute intervals at night for 48 hours before and after 12 weeks. Urine was collected in the first 24 hours of BP monitoring. Mean age was 52 years, and 97 had type 2 diabetes mellitus.

Bedtime dosing was significantly more efficient than morning dosing in reducing nocturnal BP in patients with or without diabetes, said Dr. Hermida, of the University of Vigo (Spain). The diurnal/nocturnal BP ratio was unchanged after taking valsartan on awakening, but significantly increased by 5.3% if taken before bedtime. Urinary albumin excretion was significantly reduced by 23% from baseline in patients without diabetes and by 31% in those with diabetes only after bedtime administration.

This reduction was independent of the significant decrease in 24-hour or diurnal mean BP post treatment. It was highly correlated with the decrease in nocturnal BP, and mainly correlated with the increase in diurnal/nocturnal BP ratio, said Dr. Hermida, who disclosed no conflicts of interest. When analyzed separately, the decrease in urinary albumin excretion associated with the increase in diurnal/nocturnal BP ratio was statistically significant for patients both with and without diabetes.

CHICAGO — Bedtime dosing of valsartan is more efficient than morning dosing in controlling blood pressure and improving renal function in hypertensive patients with or without diabetes, Ramon Hermida, Ph.D., said at the annual meeting of the American Society of Hypertension.

Dr. Hermida suggests this time-dependent effect is not unique to valsartan, but may be class related for angiotensin II receptor blockers.

Dr. Hermida randomized 204 untreated hypertensive patients to receive valsartan 160 mg/day upon awakening or at bedtime. Blood pressure was measured at 20-minute intervals from 7:00 a.m. to 11:00 p.m., and at 30-minute intervals at night for 48 hours before and after 12 weeks. Urine was collected in the first 24 hours of BP monitoring. Mean age was 52 years, and 97 had type 2 diabetes mellitus.

Bedtime dosing was significantly more efficient than morning dosing in reducing nocturnal BP in patients with or without diabetes, said Dr. Hermida, of the University of Vigo (Spain). The diurnal/nocturnal BP ratio was unchanged after taking valsartan on awakening, but significantly increased by 5.3% if taken before bedtime. Urinary albumin excretion was significantly reduced by 23% from baseline in patients without diabetes and by 31% in those with diabetes only after bedtime administration.

This reduction was independent of the significant decrease in 24-hour or diurnal mean BP post treatment. It was highly correlated with the decrease in nocturnal BP, and mainly correlated with the increase in diurnal/nocturnal BP ratio, said Dr. Hermida, who disclosed no conflicts of interest. When analyzed separately, the decrease in urinary albumin excretion associated with the increase in diurnal/nocturnal BP ratio was statistically significant for patients both with and without diabetes.

CHICAGO — Bedtime dosing of valsartan is more efficient than morning dosing in controlling blood pressure and improving renal function in hypertensive patients with or without diabetes, Ramon Hermida, Ph.D., said at the annual meeting of the American Society of Hypertension.

Dr. Hermida suggests this time-dependent effect is not unique to valsartan, but may be class related for angiotensin II receptor blockers.

Dr. Hermida randomized 204 untreated hypertensive patients to receive valsartan 160 mg/day upon awakening or at bedtime. Blood pressure was measured at 20-minute intervals from 7:00 a.m. to 11:00 p.m., and at 30-minute intervals at night for 48 hours before and after 12 weeks. Urine was collected in the first 24 hours of BP monitoring. Mean age was 52 years, and 97 had type 2 diabetes mellitus.

Bedtime dosing was significantly more efficient than morning dosing in reducing nocturnal BP in patients with or without diabetes, said Dr. Hermida, of the University of Vigo (Spain). The diurnal/nocturnal BP ratio was unchanged after taking valsartan on awakening, but significantly increased by 5.3% if taken before bedtime. Urinary albumin excretion was significantly reduced by 23% from baseline in patients without diabetes and by 31% in those with diabetes only after bedtime administration.

This reduction was independent of the significant decrease in 24-hour or diurnal mean BP post treatment. It was highly correlated with the decrease in nocturnal BP, and mainly correlated with the increase in diurnal/nocturnal BP ratio, said Dr. Hermida, who disclosed no conflicts of interest. When analyzed separately, the decrease in urinary albumin excretion associated with the increase in diurnal/nocturnal BP ratio was statistically significant for patients both with and without diabetes.

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep.

The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic blood pressue dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients who had a dipper blood pressue pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern.

Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than dippers (4.4%) or extreme dippers (4%).

However, the nondippers were significantly less likely to be smokers (17%) than were the dippers (25%) or the extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in the dipper, the nondipper, and the extreme-dipper patients, respectively.

Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that was adjusted for various covariates, including 24-hour blood pressue and drug therapy, showed that the cardiovascular risk was significantly higher in the nondipper patient group (relative risk 1.7) and also in the extreme-dipper patient group (RR 2.2), compared with the dipper group of patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep.

The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic blood pressue dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients who had a dipper blood pressue pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern.

Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than dippers (4.4%) or extreme dippers (4%).

However, the nondippers were significantly less likely to be smokers (17%) than were the dippers (25%) or the extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in the dipper, the nondipper, and the extreme-dipper patients, respectively.

Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that was adjusted for various covariates, including 24-hour blood pressue and drug therapy, showed that the cardiovascular risk was significantly higher in the nondipper patient group (relative risk 1.7) and also in the extreme-dipper patient group (RR 2.2), compared with the dipper group of patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep.

The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic blood pressue dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients who had a dipper blood pressue pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern.

Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than dippers (4.4%) or extreme dippers (4%).

However, the nondippers were significantly less likely to be smokers (17%) than were the dippers (25%) or the extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in the dipper, the nondipper, and the extreme-dipper patients, respectively.

Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that was adjusted for various covariates, including 24-hour blood pressue and drug therapy, showed that the cardiovascular risk was significantly higher in the nondipper patient group (relative risk 1.7) and also in the extreme-dipper patient group (RR 2.2), compared with the dipper group of patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m

TORONTO — Serogroup 22 is emerging as an important cause of pediatric meningitis, Dr. Carrie L. Byington and her associates reported in a poster at the Pediatric Academic Societies annual meeting.

Serogroup 22 appears to have a greater propensity to cause meningitis than other vaccine or nonvaccine serotypes, according to an analysis of 300 cases of pediatric invasive pneumococcal disease (IPD) among patients under age 18 years in Utah.

Serogroup 22 is not included in the licensed 7-valent pneumococcal conjugate vaccine (PCV-7) or in higher-valent vaccines under investigation.

Of the 300 cases of pediatric IPD that occurred from 1997 to 2005 at Primary Children's Medical Center in Salt Lake City, 52 were meningitis with or without bacteremia.

During the period prior to the licensure of the PCV-7 vaccine from 1997 to 2000, serotypes 14 (24%), 19F (16%), and 6B (12%) most often caused meningitis.

During the post-PCV-7 period from 2001 to 2005, serogroup 22 (19%), 14 (11%), 18C (11%), and 3 (7%) were the most common groups.

When analyzed by serogroup, 7 of 11 serogroup 22 isolates (64%) were recovered in blood and cerebrospinal fluid from children with meningitis, reported Dr. Byington, professor of pediatrics and associate chair for clinical research at the University of Utah, also in Salt Lake City, and her associates.

When compared with other non-PCV serotypes that caused meningitis (types 3, 7, 15, and 33), serogroup 22 was more likely to be associated with meningitis (64% vs. 20%), with a relative risk of 3.8.

Serogroup 22 also was more often associated with meningitis than the PCV-7 vaccine serogroups 14, 19F, and 6B (64% vs. 42%), with a relative risk of 2.14.

The findings may be related to the fact that individual serotypes of Streptococcus pneumoniae have differing propensities to colonize and cause invasive disease, Dr. Byington said in an interview.

“For example, in Utah, we have not documented a single pediatric isolate of serotype 1 that has resulted in colonization,” she said. “Rather, all isolates of serotype 1 have been from children with invasive disease, specifically complicated pneumonia.

“As we continue our surveillance, we undoubtedly will learn more about serogroup 22 and its propensity to cause IPD.”

Although meningitis cases nationally have declined significantly since the PCV-7 vaccine was approved, the trend was not significant in the Utah data.

Meningitis made up 20% of invasive pneumococcal disease cases in the prelicensure period (25/127) and 16% (27/173) in the postlicensure period, Dr. Byington and her associates reported

The gains experienced by the rest of the United States were not seen in Utah because prior to the introduction of PCV-7, Utah had a high proportion of invasive pneumococcal disease caused by nonvaccine serotypes, Dr. Byington explained.

“This mismatch may then have allowed for more rapid serotype replacement than what has been seen in other parts of the U.S., including the emergence of serogroup 22,” she said.

It is hoped that these pneumococcal serogroup data may inform future vaccine design, Dr. Byington and her associates concluded.

TORONTO — Serogroup 22 is emerging as an important cause of pediatric meningitis, Dr. Carrie L. Byington and her associates reported in a poster at the Pediatric Academic Societies annual meeting.

Serogroup 22 appears to have a greater propensity to cause meningitis than other vaccine or nonvaccine serotypes, according to an analysis of 300 cases of pediatric invasive pneumococcal disease (IPD) among patients under age 18 years in Utah.

Serogroup 22 is not included in the licensed 7-valent pneumococcal conjugate vaccine (PCV-7) or in higher-valent vaccines under investigation.

Of the 300 cases of pediatric IPD that occurred from 1997 to 2005 at Primary Children's Medical Center in Salt Lake City, 52 were meningitis with or without bacteremia.

During the period prior to the licensure of the PCV-7 vaccine from 1997 to 2000, serotypes 14 (24%), 19F (16%), and 6B (12%) most often caused meningitis.

During the post-PCV-7 period from 2001 to 2005, serogroup 22 (19%), 14 (11%), 18C (11%), and 3 (7%) were the most common groups.

When analyzed by serogroup, 7 of 11 serogroup 22 isolates (64%) were recovered in blood and cerebrospinal fluid from children with meningitis, reported Dr. Byington, professor of pediatrics and associate chair for clinical research at the University of Utah, also in Salt Lake City, and her associates.

When compared with other non-PCV serotypes that caused meningitis (types 3, 7, 15, and 33), serogroup 22 was more likely to be associated with meningitis (64% vs. 20%), with a relative risk of 3.8.

Serogroup 22 also was more often associated with meningitis than the PCV-7 vaccine serogroups 14, 19F, and 6B (64% vs. 42%), with a relative risk of 2.14.

The findings may be related to the fact that individual serotypes of Streptococcus pneumoniae have differing propensities to colonize and cause invasive disease, Dr. Byington said in an interview.

“For example, in Utah, we have not documented a single pediatric isolate of serotype 1 that has resulted in colonization,” she said. “Rather, all isolates of serotype 1 have been from children with invasive disease, specifically complicated pneumonia.

“As we continue our surveillance, we undoubtedly will learn more about serogroup 22 and its propensity to cause IPD.”

Although meningitis cases nationally have declined significantly since the PCV-7 vaccine was approved, the trend was not significant in the Utah data.

Meningitis made up 20% of invasive pneumococcal disease cases in the prelicensure period (25/127) and 16% (27/173) in the postlicensure period, Dr. Byington and her associates reported

The gains experienced by the rest of the United States were not seen in Utah because prior to the introduction of PCV-7, Utah had a high proportion of invasive pneumococcal disease caused by nonvaccine serotypes, Dr. Byington explained.

“This mismatch may then have allowed for more rapid serotype replacement than what has been seen in other parts of the U.S., including the emergence of serogroup 22,” she said.

It is hoped that these pneumococcal serogroup data may inform future vaccine design, Dr. Byington and her associates concluded.

TORONTO — Serogroup 22 is emerging as an important cause of pediatric meningitis, Dr. Carrie L. Byington and her associates reported in a poster at the Pediatric Academic Societies annual meeting.

Serogroup 22 appears to have a greater propensity to cause meningitis than other vaccine or nonvaccine serotypes, according to an analysis of 300 cases of pediatric invasive pneumococcal disease (IPD) among patients under age 18 years in Utah.

Serogroup 22 is not included in the licensed 7-valent pneumococcal conjugate vaccine (PCV-7) or in higher-valent vaccines under investigation.

Of the 300 cases of pediatric IPD that occurred from 1997 to 2005 at Primary Children's Medical Center in Salt Lake City, 52 were meningitis with or without bacteremia.

During the period prior to the licensure of the PCV-7 vaccine from 1997 to 2000, serotypes 14 (24%), 19F (16%), and 6B (12%) most often caused meningitis.

During the post-PCV-7 period from 2001 to 2005, serogroup 22 (19%), 14 (11%), 18C (11%), and 3 (7%) were the most common groups.

When analyzed by serogroup, 7 of 11 serogroup 22 isolates (64%) were recovered in blood and cerebrospinal fluid from children with meningitis, reported Dr. Byington, professor of pediatrics and associate chair for clinical research at the University of Utah, also in Salt Lake City, and her associates.

When compared with other non-PCV serotypes that caused meningitis (types 3, 7, 15, and 33), serogroup 22 was more likely to be associated with meningitis (64% vs. 20%), with a relative risk of 3.8.

Serogroup 22 also was more often associated with meningitis than the PCV-7 vaccine serogroups 14, 19F, and 6B (64% vs. 42%), with a relative risk of 2.14.

The findings may be related to the fact that individual serotypes of Streptococcus pneumoniae have differing propensities to colonize and cause invasive disease, Dr. Byington said in an interview.

“For example, in Utah, we have not documented a single pediatric isolate of serotype 1 that has resulted in colonization,” she said. “Rather, all isolates of serotype 1 have been from children with invasive disease, specifically complicated pneumonia.

“As we continue our surveillance, we undoubtedly will learn more about serogroup 22 and its propensity to cause IPD.”

Although meningitis cases nationally have declined significantly since the PCV-7 vaccine was approved, the trend was not significant in the Utah data.

Meningitis made up 20% of invasive pneumococcal disease cases in the prelicensure period (25/127) and 16% (27/173) in the postlicensure period, Dr. Byington and her associates reported

The gains experienced by the rest of the United States were not seen in Utah because prior to the introduction of PCV-7, Utah had a high proportion of invasive pneumococcal disease caused by nonvaccine serotypes, Dr. Byington explained.

“This mismatch may then have allowed for more rapid serotype replacement than what has been seen in other parts of the U.S., including the emergence of serogroup 22,” she said.

It is hoped that these pneumococcal serogroup data may inform future vaccine design, Dr. Byington and her associates concluded.

TORONTO — Outpatient medication errors in the treatment of pediatric attention- deficit/hyperactivity disorder are numerous, but few of them seem to result in patient harm, Dr. David Bundy said at the annual meeting of the Pediatric Academic Societies.

An analysis of a national error-reporting database identified 361 outpatient medication errors involving ADHD medications for children aged 3–17 years from 2003 to 2005 in the U.S. Pharmacopeia MEDMARX database, which contains information on more than 1.1 million adverse drug events reported voluntarily by hospitals and health care systems.

Four medications accounted for 98% of all reports: methylphenidate (157 or 43%), dextroamphetamine alone and combined with amphetamine (149 or 41%) bupropion (28 or 8%), and atomoxetine (22 or 6%).

Methylphenidate errors were more likely to involve prescribing errors compared with dextroamphetamine/amphetamine (Adderall; 36% vs. 15%), and less likely to involve dispensing problems (49% vs. 67%).

Because more dextroamphetamine/amphetamine errors occurred during the dispensing phase, those errors were significantly more likely to reach patients than were errors involving methylphenidate (85% vs. 74%), said Dr. Bundy of Johns Hopkins University, Baltimore. Dextroamphetamine/amphetamine errors were three times more likely than were methylphenidate errors to involve the wrong dosage form (22% vs. 8%).

Overall, 297 errors reached patients but did not cause harm, 10 errors reached the patient and required monitoring to confirm no harm and/or intervention to preclude harm, and 2 errors occurred that may have contributed to or resulted in temporary harm and required intervention. There were no deaths related to the errors.

Dr. Bundy suggested that ADHD medications themselves may have properties predisposing them to certain types of errors. He described an ADHD “medication bingo” that includes an array of dosages and formulations, including Adderall XR (5, 10, 15, 20, 25, 30 mg); Adderall (5, 7.5, 10, 12.5, 15, 20, 30 mg); methylphenidate (Concerta) (18, 27, 36, 54 mg); and three formulations of methylphenidate (Ritalin), including Ritalin SR and Ritalin LA.

Although few errors involving ADHD medications appear to be harmful to patients' health, the impact on school performance and behavior may be important, said Dr. Bundy, who disclosed no related conflicts of interest. Moreover, pediatric ADHD outpatient medications are associated with 3.5 million ambulatory visits annually in children under 15 years of age—second only to asthma as a cause of ambulatory care visits for a chronic disease.

Dispensing errors are common, and there are no checks and balances afterward to identify errors, the investigators found. Efforts aimed at reducing ADHD medication errors must include not only physician-based systems, but also dispensing/pharmacy systems, Dr. Bundy said.

Dispensing errors accounted for more than half of the reported errors (218 or 60%), whereas nearly one-quarter (84 or 23%) occurred during prescribing, and more than 1 in 10 (45 or 12%) during administration. The most common type of error was improper dose or quantity (131 or 36%) followed by wrong dosage form (51 or 14%), prescribing error (43 or 12%), omission error (39 or 11%), and wrong patient (32 or 9%).

Limitations of the study included the lack of a denominator, which made an incidence calculation impossible; no verification of report accuracy or completeness; underreporting and reporting bias; a nonrepresentative sample; and a lack of information from patients.

“ADHD-related medication error incidence is significant … so the importance of judicious use of ADHD medications is magnified,” Dr. Bundy said in an interview.

Few errors seem harmful to patients' health, but the impact on behavior and performance at school may be important. DR. BUNDY

TORONTO — Outpatient medication errors in the treatment of pediatric attention- deficit/hyperactivity disorder are numerous, but few of them seem to result in patient harm, Dr. David Bundy said at the annual meeting of the Pediatric Academic Societies.

An analysis of a national error-reporting database identified 361 outpatient medication errors involving ADHD medications for children aged 3–17 years from 2003 to 2005 in the U.S. Pharmacopeia MEDMARX database, which contains information on more than 1.1 million adverse drug events reported voluntarily by hospitals and health care systems.

Four medications accounted for 98% of all reports: methylphenidate (157 or 43%), dextroamphetamine alone and combined with amphetamine (149 or 41%) bupropion (28 or 8%), and atomoxetine (22 or 6%).

Methylphenidate errors were more likely to involve prescribing errors compared with dextroamphetamine/amphetamine (Adderall; 36% vs. 15%), and less likely to involve dispensing problems (49% vs. 67%).

Because more dextroamphetamine/amphetamine errors occurred during the dispensing phase, those errors were significantly more likely to reach patients than were errors involving methylphenidate (85% vs. 74%), said Dr. Bundy of Johns Hopkins University, Baltimore. Dextroamphetamine/amphetamine errors were three times more likely than were methylphenidate errors to involve the wrong dosage form (22% vs. 8%).

Overall, 297 errors reached patients but did not cause harm, 10 errors reached the patient and required monitoring to confirm no harm and/or intervention to preclude harm, and 2 errors occurred that may have contributed to or resulted in temporary harm and required intervention. There were no deaths related to the errors.

Dr. Bundy suggested that ADHD medications themselves may have properties predisposing them to certain types of errors. He described an ADHD “medication bingo” that includes an array of dosages and formulations, including Adderall XR (5, 10, 15, 20, 25, 30 mg); Adderall (5, 7.5, 10, 12.5, 15, 20, 30 mg); methylphenidate (Concerta) (18, 27, 36, 54 mg); and three formulations of methylphenidate (Ritalin), including Ritalin SR and Ritalin LA.

Although few errors involving ADHD medications appear to be harmful to patients' health, the impact on school performance and behavior may be important, said Dr. Bundy, who disclosed no related conflicts of interest. Moreover, pediatric ADHD outpatient medications are associated with 3.5 million ambulatory visits annually in children under 15 years of age—second only to asthma as a cause of ambulatory care visits for a chronic disease.

Dispensing errors are common, and there are no checks and balances afterward to identify errors, the investigators found. Efforts aimed at reducing ADHD medication errors must include not only physician-based systems, but also dispensing/pharmacy systems, Dr. Bundy said.

Dispensing errors accounted for more than half of the reported errors (218 or 60%), whereas nearly one-quarter (84 or 23%) occurred during prescribing, and more than 1 in 10 (45 or 12%) during administration. The most common type of error was improper dose or quantity (131 or 36%) followed by wrong dosage form (51 or 14%), prescribing error (43 or 12%), omission error (39 or 11%), and wrong patient (32 or 9%).

Limitations of the study included the lack of a denominator, which made an incidence calculation impossible; no verification of report accuracy or completeness; underreporting and reporting bias; a nonrepresentative sample; and a lack of information from patients.

“ADHD-related medication error incidence is significant … so the importance of judicious use of ADHD medications is magnified,” Dr. Bundy said in an interview.

Few errors seem harmful to patients' health, but the impact on behavior and performance at school may be important. DR. BUNDY

TORONTO — Outpatient medication errors in the treatment of pediatric attention- deficit/hyperactivity disorder are numerous, but few of them seem to result in patient harm, Dr. David Bundy said at the annual meeting of the Pediatric Academic Societies.

An analysis of a national error-reporting database identified 361 outpatient medication errors involving ADHD medications for children aged 3–17 years from 2003 to 2005 in the U.S. Pharmacopeia MEDMARX database, which contains information on more than 1.1 million adverse drug events reported voluntarily by hospitals and health care systems.

Four medications accounted for 98% of all reports: methylphenidate (157 or 43%), dextroamphetamine alone and combined with amphetamine (149 or 41%) bupropion (28 or 8%), and atomoxetine (22 or 6%).

Methylphenidate errors were more likely to involve prescribing errors compared with dextroamphetamine/amphetamine (Adderall; 36% vs. 15%), and less likely to involve dispensing problems (49% vs. 67%).

Because more dextroamphetamine/amphetamine errors occurred during the dispensing phase, those errors were significantly more likely to reach patients than were errors involving methylphenidate (85% vs. 74%), said Dr. Bundy of Johns Hopkins University, Baltimore. Dextroamphetamine/amphetamine errors were three times more likely than were methylphenidate errors to involve the wrong dosage form (22% vs. 8%).

Overall, 297 errors reached patients but did not cause harm, 10 errors reached the patient and required monitoring to confirm no harm and/or intervention to preclude harm, and 2 errors occurred that may have contributed to or resulted in temporary harm and required intervention. There were no deaths related to the errors.

Dr. Bundy suggested that ADHD medications themselves may have properties predisposing them to certain types of errors. He described an ADHD “medication bingo” that includes an array of dosages and formulations, including Adderall XR (5, 10, 15, 20, 25, 30 mg); Adderall (5, 7.5, 10, 12.5, 15, 20, 30 mg); methylphenidate (Concerta) (18, 27, 36, 54 mg); and three formulations of methylphenidate (Ritalin), including Ritalin SR and Ritalin LA.

Although few errors involving ADHD medications appear to be harmful to patients' health, the impact on school performance and behavior may be important, said Dr. Bundy, who disclosed no related conflicts of interest. Moreover, pediatric ADHD outpatient medications are associated with 3.5 million ambulatory visits annually in children under 15 years of age—second only to asthma as a cause of ambulatory care visits for a chronic disease.

Dispensing errors are common, and there are no checks and balances afterward to identify errors, the investigators found. Efforts aimed at reducing ADHD medication errors must include not only physician-based systems, but also dispensing/pharmacy systems, Dr. Bundy said.

Dispensing errors accounted for more than half of the reported errors (218 or 60%), whereas nearly one-quarter (84 or 23%) occurred during prescribing, and more than 1 in 10 (45 or 12%) during administration. The most common type of error was improper dose or quantity (131 or 36%) followed by wrong dosage form (51 or 14%), prescribing error (43 or 12%), omission error (39 or 11%), and wrong patient (32 or 9%).

Limitations of the study included the lack of a denominator, which made an incidence calculation impossible; no verification of report accuracy or completeness; underreporting and reporting bias; a nonrepresentative sample; and a lack of information from patients.

“ADHD-related medication error incidence is significant … so the importance of judicious use of ADHD medications is magnified,” Dr. Bundy said in an interview.

Few errors seem harmful to patients' health, but the impact on behavior and performance at school may be important. DR. BUNDY

CHICAGO — Few adults with diabetes and prediabetes are adhering to American Diabetes Association nutrition and activity recommendations, and even fewer with undiagnosed diabetes are doing so.

After adjustment for age, gender, and race, a logistic regression analysis of 6,446 U.S. adults revealed that only a small proportion of those with diabetes (40.2%), undiagnosed diabetes (31.5%), prediabetes (40.7%), and normal glucose (41.4%) were meeting at least three out of five American Diabetes Association (ADA) dietary recommendations.

Similarly, the proportion of adults reporting physical activity of 150 minutes or more per week was low at 19.6%, 24.6%, 21.4%, and 26.3%, respectively, Dr. Yiling J. Cheng of the division of diabetes translation at the Centers for Disease Control and Prevention, and colleagues reported in a poster at the annual scientific sessions of the ADA.

The investigators analyzed self-reported dietary and physical activity information from adults aged 20–79 years in the National Health and Nutrition Examination Survey (NHANES) 1999–2004 database. The cohort included 1,333 adults with self-reported diagnosed diabetes, 180 with undiagnosed diabetes defined by a fasting glucose of 126 mg/dL or more, 1,459 adults with prediabetes defined by a fasting glucose between 110 and 125 mg/dL, and 3,474 adults with a normal fasting glucose of less than 100 mg/dL.

The median age was 43 years; 62% were women, 72% were non-Hispanic white, 11% black, and 13% Hispanic.

The 2002 ADA guidelines used in the study recommend the following:

▸ Carbohydrate and monosaturated fat together provide 60%–70% of total energy intake.

▸ Saturated fats contribute less than 10% of energy intake.

▸ Dietary cholesterol is less than 300 mg/day.

▸ Total fat intake is less than 30% of daily energy.

▸ Daily sodium intake is no more than 2,400 mg.

▸ Thirty minutes or more of physical activity 5 or more days per week.

The best adherence was observed for cholesterol, with 64.4% of those with diabetes, 53.4% with undiagnosed diabetes, 61.9% with prediabetes, and 65.2% with normal glucose levels meeting the daily target. Conversely, adherence to the total daily fat intake was poor at 31%, 24.5%, 30%, and 33.2%, respectively.

The study did not evaluate obstacles to adherence, but lack of knowledge, reluctance to change, and socioeconomic status are known barriers. How the guidelines are translated to the general public also may play a role, Dr. Cheng said. For example, it's hard for patients to know what 2,000 mg of sodium looks like without further knowledge.

“These recommendations seem to be quantified, but hard to be practiced or followed by the general population,” Dr. Cheng said in an interview. “A layman's recommendation may be helpful.”

Improvements in early detection of diabetes, guideline dissemination, and education should also be considered, the authors noted.

The ADA has released several versions of dietary and physical activity guidelines, with the latest guidelines published last year (Diabetes Care 2006;29:2140-57).

Compared with the 2002 guidelines, the new guidelines for persons with diabetes call for more sodium restriction (less than 2,000 mg/day), lower dietary cholesterol (less than 200 mg/day), and less saturated fats (less than 7% of energy intake), Dr. Cheng noted.

CHICAGO — Few adults with diabetes and prediabetes are adhering to American Diabetes Association nutrition and activity recommendations, and even fewer with undiagnosed diabetes are doing so.

After adjustment for age, gender, and race, a logistic regression analysis of 6,446 U.S. adults revealed that only a small proportion of those with diabetes (40.2%), undiagnosed diabetes (31.5%), prediabetes (40.7%), and normal glucose (41.4%) were meeting at least three out of five American Diabetes Association (ADA) dietary recommendations.

Similarly, the proportion of adults reporting physical activity of 150 minutes or more per week was low at 19.6%, 24.6%, 21.4%, and 26.3%, respectively, Dr. Yiling J. Cheng of the division of diabetes translation at the Centers for Disease Control and Prevention, and colleagues reported in a poster at the annual scientific sessions of the ADA.

The investigators analyzed self-reported dietary and physical activity information from adults aged 20–79 years in the National Health and Nutrition Examination Survey (NHANES) 1999–2004 database. The cohort included 1,333 adults with self-reported diagnosed diabetes, 180 with undiagnosed diabetes defined by a fasting glucose of 126 mg/dL or more, 1,459 adults with prediabetes defined by a fasting glucose between 110 and 125 mg/dL, and 3,474 adults with a normal fasting glucose of less than 100 mg/dL.

The median age was 43 years; 62% were women, 72% were non-Hispanic white, 11% black, and 13% Hispanic.

The 2002 ADA guidelines used in the study recommend the following:

▸ Carbohydrate and monosaturated fat together provide 60%–70% of total energy intake.

▸ Saturated fats contribute less than 10% of energy intake.

▸ Dietary cholesterol is less than 300 mg/day.

▸ Total fat intake is less than 30% of daily energy.

▸ Daily sodium intake is no more than 2,400 mg.

▸ Thirty minutes or more of physical activity 5 or more days per week.

The best adherence was observed for cholesterol, with 64.4% of those with diabetes, 53.4% with undiagnosed diabetes, 61.9% with prediabetes, and 65.2% with normal glucose levels meeting the daily target. Conversely, adherence to the total daily fat intake was poor at 31%, 24.5%, 30%, and 33.2%, respectively.

The study did not evaluate obstacles to adherence, but lack of knowledge, reluctance to change, and socioeconomic status are known barriers. How the guidelines are translated to the general public also may play a role, Dr. Cheng said. For example, it's hard for patients to know what 2,000 mg of sodium looks like without further knowledge.

“These recommendations seem to be quantified, but hard to be practiced or followed by the general population,” Dr. Cheng said in an interview. “A layman's recommendation may be helpful.”

Improvements in early detection of diabetes, guideline dissemination, and education should also be considered, the authors noted.

The ADA has released several versions of dietary and physical activity guidelines, with the latest guidelines published last year (Diabetes Care 2006;29:2140-57).

Compared with the 2002 guidelines, the new guidelines for persons with diabetes call for more sodium restriction (less than 2,000 mg/day), lower dietary cholesterol (less than 200 mg/day), and less saturated fats (less than 7% of energy intake), Dr. Cheng noted.

CHICAGO — Few adults with diabetes and prediabetes are adhering to American Diabetes Association nutrition and activity recommendations, and even fewer with undiagnosed diabetes are doing so.

After adjustment for age, gender, and race, a logistic regression analysis of 6,446 U.S. adults revealed that only a small proportion of those with diabetes (40.2%), undiagnosed diabetes (31.5%), prediabetes (40.7%), and normal glucose (41.4%) were meeting at least three out of five American Diabetes Association (ADA) dietary recommendations.

Similarly, the proportion of adults reporting physical activity of 150 minutes or more per week was low at 19.6%, 24.6%, 21.4%, and 26.3%, respectively, Dr. Yiling J. Cheng of the division of diabetes translation at the Centers for Disease Control and Prevention, and colleagues reported in a poster at the annual scientific sessions of the ADA.

The investigators analyzed self-reported dietary and physical activity information from adults aged 20–79 years in the National Health and Nutrition Examination Survey (NHANES) 1999–2004 database. The cohort included 1,333 adults with self-reported diagnosed diabetes, 180 with undiagnosed diabetes defined by a fasting glucose of 126 mg/dL or more, 1,459 adults with prediabetes defined by a fasting glucose between 110 and 125 mg/dL, and 3,474 adults with a normal fasting glucose of less than 100 mg/dL.

The median age was 43 years; 62% were women, 72% were non-Hispanic white, 11% black, and 13% Hispanic.

The 2002 ADA guidelines used in the study recommend the following:

▸ Carbohydrate and monosaturated fat together provide 60%–70% of total energy intake.

▸ Saturated fats contribute less than 10% of energy intake.

▸ Dietary cholesterol is less than 300 mg/day.

▸ Total fat intake is less than 30% of daily energy.

▸ Daily sodium intake is no more than 2,400 mg.

▸ Thirty minutes or more of physical activity 5 or more days per week.

The best adherence was observed for cholesterol, with 64.4% of those with diabetes, 53.4% with undiagnosed diabetes, 61.9% with prediabetes, and 65.2% with normal glucose levels meeting the daily target. Conversely, adherence to the total daily fat intake was poor at 31%, 24.5%, 30%, and 33.2%, respectively.

The study did not evaluate obstacles to adherence, but lack of knowledge, reluctance to change, and socioeconomic status are known barriers. How the guidelines are translated to the general public also may play a role, Dr. Cheng said. For example, it's hard for patients to know what 2,000 mg of sodium looks like without further knowledge.

“These recommendations seem to be quantified, but hard to be practiced or followed by the general population,” Dr. Cheng said in an interview. “A layman's recommendation may be helpful.”

Improvements in early detection of diabetes, guideline dissemination, and education should also be considered, the authors noted.

The ADA has released several versions of dietary and physical activity guidelines, with the latest guidelines published last year (Diabetes Care 2006;29:2140-57).

Compared with the 2002 guidelines, the new guidelines for persons with diabetes call for more sodium restriction (less than 2,000 mg/day), lower dietary cholesterol (less than 200 mg/day), and less saturated fats (less than 7% of energy intake), Dr. Cheng noted.

CHICAGO — Bedtime dosing of valsartan is more efficient than morning dosing in controlling blood pressure and improving renal function in hypertensive patients with or without diabetes, Ramon Hermida, Ph.D., said at the annual meeting of the American Society of Hypertension.

He suggested this effect may be class related for angiotensin II receptor blockers (ARBs) and should be taken into account when treating patients with hypertension.

Dr. Hermida and his colleagues randomized 204 untreated hypertensive patients to receive valsartan 160 mg/day either upon awakening or at bedtime. Blood pressure was measured at 20-minute intervals from 7:00 a.m. to 11:00 p.m., and at 30-minute intervals at night for 48 hours before and after 12 weeks of therapy. Patients collected urine samples during the first 24 hours of monitoring. Their mean age was 52 years; 97 had type 2 diabetes mellitus.

Bedtime dosing with valsartan was significantly more efficient than morning dosing in reducing nocturnal BP in those with or without diabetes, said Dr. Hermida, of the University of Vigo (Spain). The diurnal/nocturnal BP ratio was unchanged after taking valsartan on awakening, but significantly increased by 5.3% when taken before bedtime. Urinary albumin excretion was significantly reduced by 23% from baseline in patients without diabetes and by 31% in those with diabetes only after bedtime administration, said Dr. Hermidat.

CHICAGO — Bedtime dosing of valsartan is more efficient than morning dosing in controlling blood pressure and improving renal function in hypertensive patients with or without diabetes, Ramon Hermida, Ph.D., said at the annual meeting of the American Society of Hypertension.

He suggested this effect may be class related for angiotensin II receptor blockers (ARBs) and should be taken into account when treating patients with hypertension.

Dr. Hermida and his colleagues randomized 204 untreated hypertensive patients to receive valsartan 160 mg/day either upon awakening or at bedtime. Blood pressure was measured at 20-minute intervals from 7:00 a.m. to 11:00 p.m., and at 30-minute intervals at night for 48 hours before and after 12 weeks of therapy. Patients collected urine samples during the first 24 hours of monitoring. Their mean age was 52 years; 97 had type 2 diabetes mellitus.

Bedtime dosing with valsartan was significantly more efficient than morning dosing in reducing nocturnal BP in those with or without diabetes, said Dr. Hermida, of the University of Vigo (Spain). The diurnal/nocturnal BP ratio was unchanged after taking valsartan on awakening, but significantly increased by 5.3% when taken before bedtime. Urinary albumin excretion was significantly reduced by 23% from baseline in patients without diabetes and by 31% in those with diabetes only after bedtime administration, said Dr. Hermidat.

CHICAGO — Bedtime dosing of valsartan is more efficient than morning dosing in controlling blood pressure and improving renal function in hypertensive patients with or without diabetes, Ramon Hermida, Ph.D., said at the annual meeting of the American Society of Hypertension.

He suggested this effect may be class related for angiotensin II receptor blockers (ARBs) and should be taken into account when treating patients with hypertension.

Dr. Hermida and his colleagues randomized 204 untreated hypertensive patients to receive valsartan 160 mg/day either upon awakening or at bedtime. Blood pressure was measured at 20-minute intervals from 7:00 a.m. to 11:00 p.m., and at 30-minute intervals at night for 48 hours before and after 12 weeks of therapy. Patients collected urine samples during the first 24 hours of monitoring. Their mean age was 52 years; 97 had type 2 diabetes mellitus.

Bedtime dosing with valsartan was significantly more efficient than morning dosing in reducing nocturnal BP in those with or without diabetes, said Dr. Hermida, of the University of Vigo (Spain). The diurnal/nocturnal BP ratio was unchanged after taking valsartan on awakening, but significantly increased by 5.3% when taken before bedtime. Urinary albumin excretion was significantly reduced by 23% from baseline in patients without diabetes and by 31% in those with diabetes only after bedtime administration, said Dr. Hermidat.

CHICAGO — Statin therapy does not significantly influence central aortic pressures or hemodynamics in patients with treated hypertension, Dr. Bryan Williams reported at the annual meeting of the American Society of Hypertension.

He presented data from the lipid-lowering arm of the Conduit Artery Function Evaluation (CAFE-LLA) study, a substudy of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT).

Overall, 891 patients were recruited from the statin arm of the ASCOT trial in which patients were treated with atorvastatin 10 mg/day or placebo. ASCOT was stopped early when it became clear that atorvastatin had benefits over placebo in reducing major cardiovascular events and stroke.

The CAFE-LLA investigators hypothesized that this benefit could arise from a favorable effect of statins on large-artery function. They used radial artery pulse-wave analysis to derive central aortic pressures and hemodynamic indexes on repeated visits over a 2.5-year follow-up with the same treatment regimen.

The patients' mean age was 63 years; 86% were men, and 85% were white. At baseline, average total cholesterol level was 210 mg/dL, LDL cholesterol 130 mg/dL, and HDL cholesterol 50 mg/dL.

Atorvastatin lowered the LDL cholesterol level by 32.5 mg/dL, compared with placebo. Time-averaged brachial BP was similar in people receiving atorvastatin or placebo (brachial systolic BP changed by 0.1 mm Hg and brachial pulse pressure changed by 0.02 mm Hg).

The drug had no influence on central aortic BP, compared with placebo (the change in aortic systolic BP was −0.5 mm Hg and the change in aortic pulse pressure was −0.4 mm Hg).

It also did not alter augmentation index or heart rate, compared with placebo, said Dr. Williams, professor of medicine, department of cardiovascular sciences, University of Leicester (England).

The atorvastatin given to 147 patients previously treated with placebo did not subsequently influence brachial or central systolic pressure after 1.4 years of follow-up.

“The benefits of atorvastatin in the ASCOT trial, in significantly reducing coronary heart disease and stroke in hypertensive patients, are not dependent on changes in central aortic pressures or pressure-grade reflections,” he said. The results suggest that “statin effects cannot be reproduced by blood pressure-lowering agents, thereby supporting the use of these two strategies to reduce risk in high-risk hypertensives.”

Dr. Williams has received research support from Pfizer and Merck.

CHICAGO — Statin therapy does not significantly influence central aortic pressures or hemodynamics in patients with treated hypertension, Dr. Bryan Williams reported at the annual meeting of the American Society of Hypertension.

He presented data from the lipid-lowering arm of the Conduit Artery Function Evaluation (CAFE-LLA) study, a substudy of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT).

Overall, 891 patients were recruited from the statin arm of the ASCOT trial in which patients were treated with atorvastatin 10 mg/day or placebo. ASCOT was stopped early when it became clear that atorvastatin had benefits over placebo in reducing major cardiovascular events and stroke.

The CAFE-LLA investigators hypothesized that this benefit could arise from a favorable effect of statins on large-artery function. They used radial artery pulse-wave analysis to derive central aortic pressures and hemodynamic indexes on repeated visits over a 2.5-year follow-up with the same treatment regimen.

The patients' mean age was 63 years; 86% were men, and 85% were white. At baseline, average total cholesterol level was 210 mg/dL, LDL cholesterol 130 mg/dL, and HDL cholesterol 50 mg/dL.

Atorvastatin lowered the LDL cholesterol level by 32.5 mg/dL, compared with placebo. Time-averaged brachial BP was similar in people receiving atorvastatin or placebo (brachial systolic BP changed by 0.1 mm Hg and brachial pulse pressure changed by 0.02 mm Hg).

The drug had no influence on central aortic BP, compared with placebo (the change in aortic systolic BP was −0.5 mm Hg and the change in aortic pulse pressure was −0.4 mm Hg).

It also did not alter augmentation index or heart rate, compared with placebo, said Dr. Williams, professor of medicine, department of cardiovascular sciences, University of Leicester (England).

The atorvastatin given to 147 patients previously treated with placebo did not subsequently influence brachial or central systolic pressure after 1.4 years of follow-up.

“The benefits of atorvastatin in the ASCOT trial, in significantly reducing coronary heart disease and stroke in hypertensive patients, are not dependent on changes in central aortic pressures or pressure-grade reflections,” he said. The results suggest that “statin effects cannot be reproduced by blood pressure-lowering agents, thereby supporting the use of these two strategies to reduce risk in high-risk hypertensives.”

Dr. Williams has received research support from Pfizer and Merck.

CHICAGO — Statin therapy does not significantly influence central aortic pressures or hemodynamics in patients with treated hypertension, Dr. Bryan Williams reported at the annual meeting of the American Society of Hypertension.

He presented data from the lipid-lowering arm of the Conduit Artery Function Evaluation (CAFE-LLA) study, a substudy of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT).

Overall, 891 patients were recruited from the statin arm of the ASCOT trial in which patients were treated with atorvastatin 10 mg/day or placebo. ASCOT was stopped early when it became clear that atorvastatin had benefits over placebo in reducing major cardiovascular events and stroke.

The CAFE-LLA investigators hypothesized that this benefit could arise from a favorable effect of statins on large-artery function. They used radial artery pulse-wave analysis to derive central aortic pressures and hemodynamic indexes on repeated visits over a 2.5-year follow-up with the same treatment regimen.

The patients' mean age was 63 years; 86% were men, and 85% were white. At baseline, average total cholesterol level was 210 mg/dL, LDL cholesterol 130 mg/dL, and HDL cholesterol 50 mg/dL.

Atorvastatin lowered the LDL cholesterol level by 32.5 mg/dL, compared with placebo. Time-averaged brachial BP was similar in people receiving atorvastatin or placebo (brachial systolic BP changed by 0.1 mm Hg and brachial pulse pressure changed by 0.02 mm Hg).

The drug had no influence on central aortic BP, compared with placebo (the change in aortic systolic BP was −0.5 mm Hg and the change in aortic pulse pressure was −0.4 mm Hg).

It also did not alter augmentation index or heart rate, compared with placebo, said Dr. Williams, professor of medicine, department of cardiovascular sciences, University of Leicester (England).

The atorvastatin given to 147 patients previously treated with placebo did not subsequently influence brachial or central systolic pressure after 1.4 years of follow-up.

“The benefits of atorvastatin in the ASCOT trial, in significantly reducing coronary heart disease and stroke in hypertensive patients, are not dependent on changes in central aortic pressures or pressure-grade reflections,” he said. The results suggest that “statin effects cannot be reproduced by blood pressure-lowering agents, thereby supporting the use of these two strategies to reduce risk in high-risk hypertensives.”

Dr. Williams has received research support from Pfizer and Merck.

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep. The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic BP dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients with a dipper BP pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern. Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than were dippers (4.4%) or extreme dippers (4%). However, nondippers were significantly less likely to be smokers (17%) than were dippers (25%) or extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in dipper, nondipper, and extreme-dipper patients, respectively. Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that adjusted for various covariates, including 24-hour BP and drug therapy, showed that cardiovascular risk was significantly higher in nondipper patients (relative risk 1.7) and in extreme-dipper patients (RR 2.2), compared with dipper patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, in a statement, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep. The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic BP dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients with a dipper BP pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern. Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than were dippers (4.4%) or extreme dippers (4%). However, nondippers were significantly less likely to be smokers (17%) than were dippers (25%) or extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in dipper, nondipper, and extreme-dipper patients, respectively. Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that adjusted for various covariates, including 24-hour BP and drug therapy, showed that cardiovascular risk was significantly higher in nondipper patients (relative risk 1.7) and in extreme-dipper patients (RR 2.2), compared with dipper patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, in a statement, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m

CHICAGO — Treated hypertensive patients who have either extreme or very slight dips in nighttime blood pressure are at greater cardiovascular risk than are those with moderate dips, according to a study in 1,472 patients.

Prior research has shown that people whose blood pressure fails to dip at night (“nondippers”) are at much higher risk for cardiovascular events than are patients whose BP follows the normal diurnal pattern and falls by 10%–20% during sleep. The new data extend these findings to include “extreme dippers,” or those whose nighttime systolic and/or diastolic BP dips by at least 20%.

“Circadian blood pressure pattern influences cardiovascular outcome in treated hypertension and its evaluation allows a better prognostic stratification and may suggest a more appropriate pharmacological management,” lead investigator Dr. Sante D. Pierdomenico and associates reported in a poster at the annual meeting of the American Society of Hypertension.

The investigators studied 388 patients with a dipper BP pattern (systolic and diastolic nighttime BP reduction of at least 10% and less than 20%), 745 with a nondipper BP pattern (systolic and/or diastolic reduction of less than 10%), and 339 with an extreme-dipper BP pattern. Blood pressure measurements were taken with a 24-hour ambulatory blood pressure monitoring system.

Nondippers (mean age 61 years) were significantly older than dippers (58 years) or extreme dippers (55 years), and were more likely to have diabetes (8%) than were dippers (4.4%) or extreme dippers (4%). However, nondippers were significantly less likely to be smokers (17%) than were dippers (25%) or extreme dippers (22%).

During an average of 5 years of follow-up, there were 116 cardiovascular events. The event rate per 100 patient-years was 0.91, 1.93, and 1.73 in dipper, nondipper, and extreme-dipper patients, respectively. Event-free survival was significantly different among the groups, reported Dr. Pierdomenico, professor of medicine and aging science at G. d'Annunzio University in Chieti, Italy.

A Cox regression analysis that adjusted for various covariates, including 24-hour BP and drug therapy, showed that cardiovascular risk was significantly higher in nondipper patients (relative risk 1.7) and in extreme-dipper patients (RR 2.2), compared with dipper patients.

“This and many other studies would argue for 24-hour blood pressure monitoring at least in the subgroup of people at very high risk of being nondippers,” said Dr. George Bakris, director of the hypertension center at the University of Chicago, in a statement, “for example, those with kidney disease [glomerular filtration rate less than 60 mL/min per 1.73 m