75 Send Orders for Reprints to [email protected] Current Hypertension Reviews, 2021, 17, 75-82 RESEARCH ARTICLE ISSN: 1573-4021 eISSN: 1875-6506 Ambulatory Blood Pressure Monitoring in the Diagnosis and Management of Arterial Hypertension in Current Medical Practice in Algeria BENTHAM SCIENCE Naima Hammoudi-Bendib1, Leila Manamani2, Souhila Ouabdesselam3, Dalila S. Ouamer3, Sofiane Ghemri1, Laurene Courouve4, Amine Cherif 5, Lamine Mahi6,* and Salim Benkhedda3 1EHS Dr Maouche (CNMS), Algiers, Algeria; 2CHU Ibn Sina, Annaba, Algeria; 3Cardiology Division, Mustapha Hospital Cardiology Oncology Collaborative Research Group (COCRG), Benyoucef Benkhedda University, Algiers, Algeria; 4CEMKA-EVAL, Bourg-la-Reine, France; 5MERINAL Laboratories, Algiers, Algeria; 6AXELYS SANTE DZ, Algiers, Algeria Abstract: Objective: There are limited data on the management of hypertension (HT) in Algeria. The aim of this study was to assess, in current medical practice, the use and benefits of ambulatory blood pressure monitoring (ABPM) for the diagnosis and management of HT. Methods: A prospective, observational, multicenter study was performed in 2017. Patients aged ≥ 18 years with suspected or treated HT were included. A 24-hour ABPM was performed at baseline A R T I C L E H I S T O R Y in all patients. Therapeutic decision was taken by the physician according to ABPM results and patients were then followed up to 6 weeks. Received: December 11, 2019 Results: The analysis included 1027 patients (mean age, 51.0 years; women, 61.6%) with treated Revised: February 26, 2020 Accepted: March 03, 2020 HT (37.3%) or suspected HT (62.7%). Major cardiovascular risk factors were diabetes (15.7%) and lipid disorders (7.2%). ABPM was pathological in 55.1% of patients on antihypertensive treatment DOI: and in 60.8% of patients with suspected HT. A therapeutic adjustment or a treatment switch was 10.2174/1573402116666200324144223 performed after pathological ABPM in 37.4% of patients already on antihypertensive treatment and an antihypertensive therapy was initiated in 54.9% of patients with initially suspected HT. Conclusion: This study is the first evaluation of the usefulness of ABPM for the management of HT in Algeria. Our results emphasize that ABPM is a highly valuable method for avoiding the white- coat effect and for detecting patients who are insufficiently treated with antihypertensive drugs. Keywords: Arterial hypertension, ambulatory blood pressure monitoring, office blood pressure, antihypertensive treatment, white coat effect, antihypertensive drugs. 1. INTRODUCTION remain insufficient: 29% in 1999-2000 and 37% in 2003- 2004 in the United States [8]; 37% in 2005-2011 in Italy [9]; The prevalence of arterial hypertension (HT) is 30-40% 38% in 2002 and 50% in 2007 and 2012 in France [10]. In in Algeria [1-3]. In the TAHINA study, the prevalence of HT Algeria, the PACT study performed in 2007 showed that was 23.5% and 34.2% in the age classes 55-59 years and 60- only 23.7% of hypertensive patients were controlled [11]. 64 years, respectively [3]. In Europe, comparable rates of prevalence (30-45%) were reported in 2013 [4]. High blood The definition of the control of BP varies in international pressure (BP) is the main risk factor for cardiovascular dis- guidelines. In the United Kingdom, the objective is treating ease and premature death worldwide [5]. The relationship hypertensive persons aged 60 years or older to a BP < between high BP and fatal coronary artery disease and fatal 150/90 mmHg and hypertensive persons 30-59 years of age stroke is now well established [6]. The increased cardiovas- to a BP < 140/90 mmHg [12]. The European guidelines for cular risk in patients with high BP can be reduced with early the management of HT recommend for diagnosis of HT a diagnosis and antihypertensive treatment [7]. unified BP target < 140/90 mmHg [7]. BP is usually con- trolled at the doctor’s office but self-monitoring is recom- Hypertension is a chronic condition which is clinically mended to assess the efficacy of antihypertensive treatment silent and the rates of well-controlled hypertensive patients and the achievement of the therapeutic target [13]. BP follows a circadian pattern during the daytime hours *Address correspondence to this author at the Axelys Santé DZ, 16 Rue des and is minimal after midnight. Moreover, the measurement Pins-16035 Hydra, Algiers, Algeria; E-mail: [email protected] of BP in the physician’s office may induce a transient rise in 1875-6506/21 $65.00+.00 © 2021 Bentham Science Publishers Current Hypertension Reviews 76 Current Hypertension Reviews, 2021, Vol. 17, No. 1 Hammoudi-Bendib et al. BP (“white coat effect”) [14]. Many studies have shown that tion of antihypertensive treatment, no treatment because HT the correlation of end-organ damages associated with hyper- not confirmed, treatment modification or other decision. tension (e.g., left ventricular hypertrophy, proteinuria, serum The secondary endpoints were sociodemographic charac- creatinine, vascular damages) was higher using ambulatory teristics of patients, indications for ABPM (diagnostic aim or blood pressure monitoring (ABPM) compared to office BP therapeutic aim), comorbidities and cardiovascular risk fac- measurement [14]. Therefore, the use of ABPM is recom- tors, ABPM outcomes (daytime and nocturnal), antihyper- mended for HT diagnosis and more particularly in the fol- tensive treatments, treatment modifications after ABPM and lowing situations: suspected “white coat” HT, excessive BP after 6 weeks of follow-up, rates of BP self-monitoring and variability during the same visit or at different visits, suspi- treatment observance (as defined by the Compliance Evalua- cion of hypotensive episodes or suspicion of resistance to tion Test of Girerd et al. [22]). antihypertensive drug treatment [15-21]. It was calculated that the description of the primary end- The objective of this study was to evaluate, in current points with sufficient precision (3%) required sample size of medical practice, the use and benefit of ABPM in the man- at least 966 patients. With a percentage of incomplete or agement of HT in Algeria, both in public and private cardi- unusable data around 10%, a sample size of 1062 patients ology settings. was necessary. It was planned to select 100 centers which included a maximum of 20 patients. 2. MATERIALS AND METHODS Categorical variables were compared by Chi-square test 2.1. Study Design and Patients or Fisher’s exact test and continuous variables by Student’s This was a prospective, observational, national and mul- t-test or Wilcoxon test. Tests were two-sided and a p-value ticentric study performed in public and private settings in lower than 0.05 was considered to be statistically significant. Algeria from February to August 2017. 3. RESULTS Centers were selected with a concern for representativity from a database of cardiologists who practiced in private 3.1. Patient Characteristics offices or in university hospitals. The 69 centers which recruited patients were distributed Patients aged ≥ 18 years who were either hypertensive on the national territory and were representative of the Alge- (defined as office SBP ≥ 140 mmHg or DBP ≥ 90 mmHg) or rian facilities that offer health care services in cardiology. referred for suspected hypertension were included. Patients Thus, among the 48 wilayas (provinces) that divide Algeria, were not included if they had a contraindication to ABPM, 32 of them had at least one study center (Ain Defla, Ain psychiatric disorders or unable to follow the protocol. In Témouchent, Alger, Annaba, Bordj Bou-Arreridj, Béjaïa, order to avoid biases, patients were included consecutively in Blida, Batna, Bouira, Boumerdes, Chlef, Constantine, Djelfa, each center. El Tarf, Guelma, Ghardaïa, Jijel, Mascara, Médéa, Mosta- A 24-hour ABPM was performed at inclusion (visit V1 at ganem, M’Sila, Naama, Oran, Oum El Bouaghi, Sétif, Sidi Bel Abbes, Skikda, Tiaret, Tipaza, Tissemsilt, Tizi Ouzou, Day 0) in all patients. According to the recommendations of Tlemcen). the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH), the diagnostic threshold for The population analysis included 1027 patients with a hypertension is ≥ 130/80 mmHg over 24 h, ≥ 135/85 mmHg majority of women (61.6%) (Table 1). For 383 (37.3%) pa- for the daytime average and ≥ 120/70 mmHg for the night- tients, ABPM was performed with therapeutic aim (treated time average [7]. Patients were considered as “dippers” if HT patients) and for 644 (62.7%) with diagnostic aim (sus- their nocturnal BP falls by >10% of the daytime average BP pected HT). In treated HT patients, the mean (SD) duration value. from diagnosis was 6.6 (6.9) years. Patients with suspected Therapeutic decision was taken by the physician accord- HT were significantly younger than patients with treated HT ing to ABPM results (visit V2 on Day 1). Treated patients (47.7 vs. 56.6 years; p < 0.001). The main comorbidities were then followed up to 6 weeks (visit V3). were diabetes (15.7%) and lipid disorders (7.2%). Mean (SD) office systolic blood pressure (SBP) was 2.2. Study Objectives 145.8 (21.7) and 146.4 (18.1) mmHg in treated and sus- The primary objective was to evaluate, in current medical pected HT patients (p >0.1) and mean (SD) office diastolic practice, the use and benefits of ABPM in the diagnosis and blood pressure (DBP) was 86.2 (11.5) and 87.8 (11.2) management of HT in Algeria. The secondary objectives mmHg (p = 0.042), respectively (Table 1). Office BP pres- were to describe conditions for using ABPM, socio- sure was elevated (SBP ≥ 140 and DBP ≥ 90 mmHg) at in- demographic characteristics of patients, therapeutic strate- clusion visit in 68.7% of patients with treated HT and in gies and hypertensive drug prescribed and BP values with 78.5% of patients with suspected HT. ABPM. At inclusion visit, patients with treated HT received mainly monotherapy (44.5%) and dual therapy (34.6%).