ArticlePDF Available

Abstract and Figures

Hypertension is a major issue of public health because of its increasing prevalence and multiple complications caused by failing to achieve an efficient blood pressure control. Considering hypertension as a hemodynamic disorder allows to prescribe a tailored therapy guided by individual hemodynamic parameters, therefore leading to an increased rate of control. We present the case of a 59 years old diabetic, dyslipidemic and obese male who, although treated with 5 classes of antihypertensive drugs had uncontrolled hypertension that caused left ventricular failure. Using the HOTMAN system of hemodynamic monitoring using thoracic electrical bioimpedance allowed a quick identification of the cause and guided the therapy, achieving blood pressure control after 5 days of treatment. Treating hypertension by identifying the underlying hemodynamic imbalance allows prescribing a tailored therapy and shortens the initiation and stabilization phases of treatment.
Content may be subject to copyright.
Case Report
Clujul Medical
HEMODYNAMIC MONITORING USING THORACIC
BIOIMPEDANCE – AN OPTIMAL SOLUTION FOR THE
TREATMENT OF HYPERTENSION
ANCA DANIELA FARCAS, FLORIN PETRU ANTON, MIHAELA MOCAN,
LUMINITA ANIMARIE VIDA-SIMITI
Internal Medicine Department, Iuliu Hatieganu University of Medicine and
Pharmacy Cluj-Napoca, Romania
Internal Medicine Department, Emergency County Clinical Hospital Cluj-
Napoca, Romania
Abstract
Hypertension is a major issue of public health because of its increasing
prevalence and multiple complications caused by failing to achieve an efcient blood
pressure control. Considering hypertension as a hemodynamic disorder allows to
prescribe a tailored therapy guided by individual hemodynamic parameters, therefore
leading to an increased rate of control. We present the case of a 59 years old diabetic,
dyslipidemic and obese male who, although treated with 5 classes of antihypertensive
drugs had uncontrolled hypertension that caused left ventricular failure. Using the
HOTMAN system of hemodynamic monitoring using thoracic electrical bioimpedance
allowed a quick identication of the cause and guided the therapy, achieving blood
pressure control after 5 days of treatment. Treating hypertension by identifying the
underlying hemodynamic imbalance allows prescribing a tailored therapy and shortens
the initiation and stabilization phases of treatment.
Keywords: hypertension, hemodynamic, treatment, bio-impedance,
antihypertensive treatment
DOI: 10.15386/cjmed-1085
Manuscript received: 23.06.2018
Received in revised form: 06.07.2018
Accepted: 23.07.2018
Address for correspondence: orinantonfr@yahoo.com
Hypertension is a signicant and well-known risk
factor for cardiovascular diseases, associated with high
mortality. In Romania the prevalence of hypertension is
45.1% and on the rise in the last 7 years, possibly caused by
increased incidence of risk factors such as unhealthy diet,
obesity, diabetes or dyslipidemia [1].
Although 72.2% of patients receive treatment [2] and
although 51.9% of them receive 2 or 3 medications, only
30.8% reach blood pressure (BP) goals [1], thus making
hypertension in Romania an ”unsolved equation” [2].
In spite of major advances in treatment and efforts
to follow the guidelines, a signicant number of patients are
still poorly controlled even in other European countries [3].
This might be caused by the current paradigm
that views hypertension merely as a BP disorder and not
as a hemodynamic imbalance. Published data suggest
that prescribing antihypertensive therapy guided by
hemodynamic parameters gathered using thoracic electrical
bioimpedance would increase the BP control rate [4,5].
The HOTMAN system (HEMO SAPIENS,
INC). uses thoracic electrical bioimpedance to identify
hemodynamic imbalances in hypertensive patients, thus
allowing the physician to choose optimal therapy and
appropriate dosage for each patient [6].
Case report
A 59-year-old male with very high-risk stage 3
hypertension, type 2 diabetes with diabetic chronic kidney
disease (CKD) and neuropathy, dyslipidemia and obesity
is referred for edema, resting dyspnea and nocturnal
paroxysmal dyspnea in the last 2 weeks. The patient has
difcult BP control with repeated peaks reaching 180/100
mmHg. Clinical examination shows a patient with
abdominal obesity, edema, pulmonary rales, BP 160/100
mmHg, pulse 65 bpm and no heart murmurs. Current
medication includes valsartan 160 mg bid, lercanidipin
10mg od, moxonidine 0.4 mg od, indapamide 1.5mg od
and nebivolol 5mg od. Laboratory workup shows fasting
plasma glucose 124 mg/dl, HbA1c 7.1%, LDL-cholesterol
69mg/dl, HDL-cholesterol 55 mg/dl, triglycerides 178
mg/dl, creatinine 1.1 mg/dl, creatinine clearance 72.8 ml/
Case Report
Clujul Medical
min/1.73m², microalbuminuria - 189mg/dl and potassium
4.3 mEq/l. Echocardiogram shows mild concentric left
ventricular (LV) hypertrophy (LV posterior wall thickness
12 mm, interventricular septal thickness 12 mm), grade I
mitral regurgitation and grade I diastolic dysfunction. The
patient’s diagnosis is very high-risk grade 3 hypertension,
hypertensive and ischemic heart disease, grade I mitral
regurgitation and acute LV failure. In order to control LV
failure symptoms and prevent further complications, tight
BP control is required – BP needs to be brought below
130/80 mmHg.
For a patient with diabetic CKD and hypertension
under treatment with 5 types of antihypertensive drugs
(angiotensin receptor blocker, calcium antagonist,
indapamide, beta-blocker and a centrally acting agent)
what other medication could be added? The European
hypertension guidelines suggests adding an alpha-receptor
blocker.
Another answer to this question could be provided by
the HOTMAN F100 system (HEMO SAPIENS, INC). The
system uses the thoracic electrical bioimpedance to gather
hemodynamic data on volemia, vasoactivity, inotropy and
chronotropy that are specic to each hypertensive patient.
Using these parameters the device allows a virtual
modeling of therapy and provides information on the
impact of changes in therapy. For this patient, HOTMAN
monitoring shows a status with 86% hypervolemia and no
vasoconstriction (Figure 1).
“Virtual therapy” shows that adding a vasodilator
would achieve a 40% hyperdinamic/normotensive status
with 83% hypervolemia and 30% hyperchronotropy, as
shown in Figure 2.
Achieving the BP goal therefore requires the addition
of a diuretic, as shown in “virtual therapy” (Figure 3).
The patient’s treatment already includes indapamide
– a thiazide diuretic which has both vasodilator and diuretic
effects, therefore it is continued – thus a combination of
loop diuretic (Furosemide) and kalium-sparing diuretic
(Spironolactone) is added, in order to reduce the hypervolemia
by a combined diuretic effect and also to avoid hypokalemia.
After ve days of treatment with the new regimen
the patient is asymptomatic, BP is normal (110/70 mmHg)
and HOTMAN monitoring shows a normodynamic/
normotensive status with only 37% hypervolemia (Figure 4).
HOTMAN monitoring after 20 days of treatment
with Valsartan 160 mg bid, Lercanidipine 10 mg od,
Moxonidine 0.4 mg od, Indapamide 1.5 mg od, Nebivolol
5 mg od, Furosemide 40 mg od and Spironolactone 50 mg
od shows a normotensive/normodynamic status with 40%
hypervolemia (Figure 5).
Figure 1. Hemodynamic status at rst evaluation.
Case Report
Clujul Medical
Figure 2. Worsened hemodynamic status after adding a vasodilatator.
Figure 3. Improved hemodynamic status after adding a diuretic
Case Report
Clujul Medical
Figure 4. Hemodynamic status after 5 days of new treatment.
Figure 5. A normotensive/normodynamic status after 20 days of new treatment.
Case Report
Clujul Medical
Discussion
We present the case of a patient treated with 5
classes of antihypertensive drugs that failed to reach BP
goal and who had cardiac dysfunction due to organ damage
a widespread scenario found in daily practice. Using a
trial-and-error approach to therapy would not bring any
benets and would actually prolong or even worsen the
current status of the patient, whereas using the HOTMAN
monitoring allowed a quick and accurate identication of
the optimal type of medication needed and achieving better
BP control. Besides, using noninvasive hemodynamic
monitoring in BP control was proven to be extremely
useful [7,8], both in newly diagnosed patients and long-
time but uncontrolled hypertension [9,10], and ultimately
improved the outcome for hypertensive patients [11].
A meta-analysis of 7 studies enrolling 1087 patients has
shown that prescribing medication using hemodynamic
monitoring protocols leads to an average control rate of
72.6% [7]. The study of Sramek et al. achieved BP control
in 75% of patients already treated with 2 or more drugs,
after only 3 weeks of treatment [12].
Conclusion
Hemodynamic monitoring in hypertension with
thoracic electrical bioimpedance using the HOTMANTM
F100 system (HEMO SAPIENS, INC.) provides valuable
data for hypertension treatment. Following the system’s
recommendations leads to an expedited stabilization of
the patients’ status, therefore shortening the initiation and
stabilization phases of the treatment, which can often be a
frustrating period, both for the physician and for the patient.
References
1. Dorobantu M, Tautu OF, Dimulescu D, Sinescu C, Gusbeth-
Tatomir P, Arsenescu-Georgescu C, et al. Perspectives on
hypertension’s prevalence, treatment and control in a high
cardiovascular risk East European country: data from the
SEPHAR III survey. J Hypertens. 2018;36(3):690-700.
2. Dorobanţu M, Darabont R, Ghiorghe S, Arsenescu-Georgescu
C, Macarie C, Mitu F, et al. Hypertension prevalence and control
in Romania at a seven-year interval. Comparison of SEPHARI
and II surveys. J Hypertens. 2014;32(1):39-47.
3. Banegas JR, López-García E, Dallongeville J, Guallar E, Halcox
JP, Borghi C, et al. Achievement of treatment goals for primary
prevention of cardiovascular disease in clinical practice across
Europe: the EURIKA study. Eur Heart J. 2011;32(17):2143-2152.
4. Chacón-Lozsán F. Non-Invasive Hemodynamic Analyses to
Guide Pharmacotherapy of High Blood Pressure: Mini-Review.
Journal of Cardiology & Cardiovascular Therapy 2017;3(3):1-3.
5. Krzesiński P, Gielerak G, Stańczyk A, Piotrowicz K, Skrobowski
A. Who benets more from hemodynamically guided hypotensive
therapy? The experience from two randomized, prospective and
controlled trials. Ther Adv Cardiovasc Dis. 2016;10(1):21-29.
6. Farcas AD, Stoia MA, Anton FP, Goidescu CM, Vida-Simiti
L. Improving blood pressure control beyond the guidelines.
European heart journal. 2016;37:212-213.
7. Chacón-Lozsán F, Rodriques-Torres M, Rojas R. Hemodynamic
Management of High Blood Pressure. Therapeutic Advances in
Cardiology. 2017;1(3):73-79.
8. Viigimaa M, Talvik A, Wojciechowska W, Kawecka-Jaszcz
K, Toft I, Stergiou GS, et al. Identication of the hemodynamic
modulators and hemodynamic status in uncontrolled hypertensive
patients. Blood Press. 2013;22(6):362-370.
9. Hernández-Hernández R, Domenech M, Coca A. 481
Hemodynamic evaluation and selection of hypertension treatment.
Journal of Hypertension. 2012;30:e142-e143.
10. Krzesiński P, Gielerak GG, Kowal JJ. A “patient-tailored”
treatment of hypertension with use of impedance cardiography:
a randomized, prospective and controlled trial. Med Sci Monit.
2013;19:242-250.
11. Sramek B.Bo, Badila E, Bartos D, Târziu C, Ghiorge S.
Treating hypertension as a hemodynamic disorder results in three-
fold improvement in outcomes. American Society of Hypertension
- 23rd Annual Scientic Meeting and Exposition, 2008. Abstract
Number: 350091. Available from:
http://www.hemodynamicsociety.org/ash2008.html
12. Shramek B.Bo, Tinky JA, Hojerova M, Cervenka V.
Normohemodynamic goal-oriented antihypertensive therapy
improves the outcome. The American Society of Hypertension,
11th Scientic Meeting, New York. 1996. Available from: http://
www.hemodynamicsociety.org/abstract.html
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Background: Hypertension is an important risk factor for cardiovascular events, stroke and kidney disease, optimal hypertension control still a controversial subject in medical literature, several studies proposed the hypertension control calculating hemodynamic parameters. Materials and Methods: In the present study we recruited 84 patients’ males (34%) and females (49%) between 32 and 95 years of age with non-controlled hypertension taken 2 or more medications and measured heart rate (HR), systolic (SBP), diastolic (DBP) and mean (MAP) blood pressure, pulse pressure (PP), cardiac index (CI) using Liljestrand & Zander modified formula to calculate stroke volume (CI = [HR*(PP/MAP)]/Body surface area), central venous pressure (CVP) using inferior vena cava diameter (IVCD), systemic vascular resistance index (SVRi = MAP/CI*80) and divided in six hemodynamic groups Hyperdynamics (Hd) were those with CI > 3,5L/min/m2, High Resistance (Hr) group when SVRi > 2500 dynas, Fluid overload (FO) when CVP > 8 cm H2O or IVCD > 2 cm and mixed types, Hd + Hr, Hd + FO and Hr + FO, a basal values was measured after 1 week washout with captopril, after washout treatment was selected according hemodynamic groups with a 6 months follow up. Results: We found a statistical significant reduction of all parameters at the first month after treatment and hypertension control according European of Society Cardiology guidelines in 100% of patients at 3rd month of treatment with hemodynamic normalization, only Hd + FO at 6th month, with no symptomatic hypotension. Conclusion: Hemodynamic guided treatment to control high blood pressure had good results in this study; however, bigger trials are needed to prove his efficacy.
Article
Full-text available
Background: Hypertension is an important risk factor for cardiovascular events, stroke and kidney disease, optimal hypertension control still a controversial subject in medical literature, several studies proposed the hypertension control calculating hemodynamic parameters. Materials and Methods: In the present study we recruited 84 patients’ males (34%) and females (49%) between 32 and 95 years of age with non-controlled hypertension taken 2 or more medications and measured heart rate (HR), systolic (SBP), diastolic (DBP) and mean (MAP) blood pressure, pulse pressure (PP), cardiac index (CI) using Liljestrand & Zander modified formula to calculate stroke volume (CI = [HR*(PP/MAP)]/Body surface area), central venous pressure (CVP) using inferior vena cava diameter (IVCD), systemic vascular resistance index (SVRi = MAP/CI*80) and divided in six hemodynamic groups Hyperdynamics (Hd) were those with CI > 3,5L/min/m2, High Resistance (Hr) group when SVRi > 2500 dynas, Fluid overload (FO) when CVP > 8 cm H2O or IVCD > 2 cm and mixed types, Hd + Hr, Hd + FO and Hr + FO, a basal values was measured after 1 week washout with captopril, after washout treatment was selected according hemodynamic groups with a 6 months follow up. Results: We found a statistical significant reduction of all parameters at the first month after treatment and hypertension control according European of Society Cardiology guidelines in 100% of patients at 3th month of treatment with hemodynamic normalization, only Hd + FO at 6th month, with no symptomatic hypotension. Conclusion: Hemodynamic guided treatment to control high blood pressure had good results in this study; however, bigger trials are needed to prove his efficacy.
Article
Full-text available
Hypertension is the biggest risk factor to cardiovascular events, stroke and kidney disease, despite a numerous antihypertensive drugs, control rates still suboptimal. In the present mini-review, we will analyze an emergent method to control high blood pressure using hemodynamic parameters. We found seven trials since 1996 to 2106, a total of 1087 patients were studied comparing the standard method with the hemodynamic method with a success rate mean of 72, 6% in control blood pressure values using hemodynamic method. Hemodynamic guided pharmacotherapy has demonstrated be superior to standard recommendations con control high blood pressure, the assessment of more hemodynamic variables aloud to the physician to analyses more detailed the accurate parameter to guide antihypertensive therapy, however, more controlled trials are needed to increase evidence of this emergent method
Article
Full-text available
Objectives: Arterial hypertension (AH) may be related to fluid retention, increased vascular resistance or hyperdynamic heart function. Impedance cardiography (ICG) is shown to be useful in the individualization of antihypertensive therapy but little is known about who most benefits from this therapeutic approach. The aim of this analysis was to estimate the effectiveness of ICG-guided antihypertensive therapy with respect to baseline blood pressure (BP) from the perspective of 12 weeks' observation in randomized, prospective and controlled trials. Methods: This analysis involved 272 patients (average age: 44.1 ± 10.8 years) with AH. After baseline evaluation, including: office BP measurement (systolic, SBP; diastolic, DBP; mean, MBP) and ambulatory BP monitoring (mean 24-h SBP, mean 24-h DBP) the subjects were randomly assigned to groups of empiric [GE] and ICG-guided antihypertensive therapy [HD]. The results were evaluated separately in subgroups derived from median of MBP (110 mmHg): with slightly increased ('SI_BP') and more increased BP ('MI_BP'). The comparative analysis included absolute change in BP (d_OSBP, d_ODBP, d_24-h SBP, d_24-h DBP) and the percentage of patients with reduction of BP ⩾ 10 mmHg (d10_OSBP, d10_ODBP, d10_24-h SBP, d10_24-h DBP). Results: ICG-guided therapy was shown to be superior to the empiric approach, especially in MI_BP. In this subgroup, the BP reduction in HD was higher than in GE: d_OSBP (23.3 ± 10.8 versus 18.5 ± 13.9 mmHg; p = 0.035), d_ODBP (16.0 ± 6.3 versus 11.6 ± 9.6 mmHg; p = 0.003), d_24-h SBP (17.7 ± 10.8 versus 13.1 ± 13.1 mmHg; p = 0.035). This benefit was also confirmed by a higher percentage of patients with significant BP reduction: d10_OSBP (87.7% versus 69.1%; p = 0.012), d10_ODBP (69.2% versus 47.3%; p = 0.012) and d10_24-h SBP (72.3% versus 52.7%; p = 0.012). The comparison in the SI_BP subgroup did not reveal such significant differences. Conclusions: The hemodynamically guided pharmacotherapy results in greater BP reduction. This effect is more pronounced in patients with higher baseline BP, while in those with slightly increased BP the empiric approach seems comparable to ICG.
Article
Full-text available
Background Arterial hypertension might be caused by hemodynamic disturbances such as fluid retention, increased vascular resistance, and hyperdynamic function of the heart. The aim of this study was to estimate the effectiveness of antihypertensive therapy based on hemodynamic assessment by impedance cardiography in a randomized, prospective, controlled trial. Material/Methods This study involved 128 patients (average age: 42.9±11.1 years) with arterial hypertension, randomized into groups: (1) empiric, and (2) hemodynamic, in which treatment choice considered impedance cardiography results. Evaluation of treatment effects was performed after 12 weeks and included office blood pressure measurement and ambulatory blood pressure monitoring. Results All final blood pressure values were lower in the hemodynamic group, significantly for office systolic blood pressure (empiric vs. hemodynamic: 136.1 vs. 131.6 mmHg; p=0.036) and diastolic blood pressure (87.0 vs. 83.7 mmHg; p=0.013), as well as night-time systolic blood pressure (121.3 vs. 117.2 mmHg; p=0.023) and diastolic blood pressure (71.9 vs. 68.4 mmHg; p=0.007). Therapy based on impedance cardiography significantly increased the reduction in office systolic blood pressure (11.0 vs. 17.3 mmHg; p=0.008) and diastolic blood pressure (7.7 vs. 12.2 mmHg; p=0.0008); as well as 24-h mean systolic blood pressure (9.8 vs. 14.2 mmHg; p=0.026), daytime systolic blood pressure (10.5 vs. 14.8 mmHg; p=0.040), and night-time systolic blood pressure (7.7 vs. 12.2 mmHg; p=0.032). Conclusions Antihypertensive treatment based on impedance cardiography can significantly increase blood pressure reduction in hypertensive patients.
Article
Objectives: To estimate the trend in arterial hypertension's prevalence, awareness, treatment, and control in Romania, starting from the latest national survey Study for the Evaluation of Prevalence of Hypertension and Cardiovascular Risk in Romania III that has a crucial importance for the development of prevention strategies at national level. Methods: A representative sample of 1970 Romanian adults (mean age 48.38 years, age range 18-80 years, 52.5% women, 72.58% response rate), was enrolled. During the two study visits, three blood pressure (BP) measurements were performed at 1-min interval. Hypertension was defined as study SBP at least 140 mmHg and/or study DBP at least 90 mmHg at both study visits or previously diagnosed hypertension, regardless of BP values. BP control was defined as SBP less than 140 mmHg and DBP less than 90 mmHg in hypertensive patients. Results: General hypertension prevalence is 45.1% (19.1% newly diagnosed hypertension, 80.9% awareness of hypertension), increasing with age, regardless of sex and area of residence. Although the majority (72.2%) of hypertensive patients were treated (51.9% with two or more drugs), only 30.8% of them had controlled BP values. Following the evolution from the last 11 years, it is expected that in 2020 the prevalence of hypertension to be up to 44%, the awareness up to 96.2%, treatment of hypertension up to 83.7%, and BP control up to 36.6%. Conclusion: Hypertension's prevalence in Romania is on the rise despite the increase in awareness, treatment, and control. Possible explanations of this trend might be the increasing incidence of unhealthy lifestyle and diet, including high salt intake, and a general increase in the prevalence of obesity, diabetes mellitus, and dyslipidemia.
Article
Objective: To assess the hemodynamic evaluation of hypertensive patients and give drug treatment according hemodynamic parameters. Design and Methods: A group of 31 hypertensive patients (19 men, 12 women; weight: 80.2 +/- 12.6 Kg; height: 170.1 +/- 9.1 cm), six patients were new diagnosis and 25 were treated but not controlled patients. An ambulatory blood pressure monitoring was carried out previous to initial treatment or make changes in the treatment received by them. Afterwards, a Bioimpedance Integrate Hemodynamic Management System (Hemo Sapiens, Bucharest, Romania) for evaluation of Stroke Index (SI), Mean Arterial Pressure (MAP) to classify individual subjects on hypodynamic, normodynamic or hyperdynamic as well as normotensive hypo or hypertensive. Selection of antihypertensive drugs was carried out in one single step. Patients were revaluated 4 to 6 six later and an ABPM and hemodynamic evaluation were carried out again. Results: ABPM pre-treatment or adjustment was, in average, for 24 hours: 144.4/89.1 mmHg; awake period: 149.4/92.7 mmHg; sleep period: 131.9/78.5 mmHg, post adjustment treatment: 126.3/80.2 mmHg; 128.7/84.1 mmHg and 113.6/71.8 mmHg respectively (p < 0.001). 79.3 % of patients were on control. When SI was consider, subjects were classified as hypodynamic in 12.9%, normodynamic in 70.97% and hyperdynamic in 16.12% after the initial or adjustment in the treatment. Conclusion: This preliminary report show the usage of the hemodynamic evaluation in the individual patient seems to improve the selection of antihypertensive drug treatment since 80% of hypertensive patients gone on control values in the short time.
Article
To present the current epidemiologic situation regarding hypertension's prevalence and control in Romania's adult population (revealed by SEPHAR II survey results) and to evaluate their tendency during the last 7 years (by comparing with the SEPHAR I survey results). The two SEPHAR cross-sectional national surveys were conducted on a representative sample for the Romanian adult population (SEPHAR I: 2017 individuals aged 18-85 years, 45% response rate, SEPHAR II: 1975 individuals aged 18-80 years, 69% response rate), by means of questionnaire interview, blood pressure (BP) and anthropometric measurements during two study visits. Hypertension was defined as SBP at least 140 mmHg and/or DBP at least 90 mmHg at both study visits or previously diagnosed hypertension under current treatment. Controlled BP was defined as SBP less than 140 mmHg and DBP less than 90 mmHg in currently treated hypertensive individuals. Prevalence of hypertension in Romanian is 40.41%, awareness of hypertension is 69.55%, with 59.15% hypertensive individuals under current treatment with a control rate of 25%. In the last 7 years, there has been a 10.7% decrease in hypertension's prevalence together with an increase by 57% in awareness of hypertension and an increase by 52% in treatment of hypertension, leading to almost doubling of the hypertension's control rate in all hypertensive individuals. Although in the last 7 years, the tendency of hypertension's prevalence seems to be a descending one with an increasing trend in awareness, treatment and control of this condition, hypertension in Romania at this time still remains an 'unsolved equation'.
Article
Only 20-30% out of the treated hypertensive patients in Europe are achieving blood pressure (BP) control. Among other recognized factors, these poor results could be attributable to the fact that for many doctors it is very difficult to detect which is the predominant hemodynamic cause of the hypertension (hypervolemia, hyperinotropy or vasoconstriction). The aim of the study was to use non-invasive thoracic electrical bioimpedance (TEB) to evaluate hemodynamic modulators and subsequent hemodynamic status in uncontrolled hypertensive patients, receiving at least two antihypertensive drugs. A number of 134 uncontrolled hypertensive patients with essential hypertension were evaluated in nine European Hypertension Excellence centers by means of TEB (the HOTMAN(®) System). Baseline office systolic and diastolic BP averaged 156/92 mmHg. Hemodynamic measurements show that almost all patients (98.5%) presented at least one altered hemodynamic modulator: intravascular hypervolemia (96.4%) and/or hypoinotropy (42.5%) and/or vasoconstriction (49.3%). Eleven combinations of hemodynamic modulators were present in the study population, the most common being concomitant hypervolemia, hypoinotropy and vasoconstriction in 51(38%) patients. Six different hemodynamic states (pairs of mean arterial pressure and stroke index) were found. Data suggest that there is a strong relation between hypertension and abnormal hemodynamic modulators. This method might be helpful for treatment individualization of hypertensive patients.