Changing relationship between home and office blood pressure with increasing age in children: the Arsakeion School study

BACKGROUND: Home blood pressure (HBP) monitoring is being used in children. However, there is no information on the relationship between HBP and office measurements (Office BP (OBP)) in this population. METHODS: This school-based study investigated the effect of age on the difference between HBP and OBP in 765 healthy subjects aged 6-18 years (mean age 12 +/- 3 (SD years)). HBP (3 days, 12 readings) and OBP (2 visits, 6 readings) were measured using electronic devices validated in children (Omron 705IT). RESULTS: Average OBP was slightly lower than HBP by 0.6+/- 7.0 mm Hg (95% confidence intervals (CI) 0.1, 1.1, P=0.01) systolic and 1+/- 6 mm Hg (95% CI 0.7, 1.6, P<0.0001) diastolic, whereas pulse rate was higher in the office by 7+/- 10 beats/min (95% CI 6.2, 7.6, P<0.0001). Age was significantly correlated with the OBP-HBP difference (r = 0.13/0.24 for systolic/diastolic, P< 0.001). In the younger children (6-12 years), both diastolic and systolic HBP were higher than OBP, whereas pulse rate was higher in the office. In older children and adolescents, the BP difference was eliminated whereas the pulse rate difference was reduced but remained significant. These changes with age were similar in boys and girls. CONCLUSIONS: In the pediatric population OBP appears to be higher than HBP. This difference is reduced with advancing age and eliminated after the age of 12 years. These data should be taken into account in the assessment of HBP in children and adolescents.     

Relative utility of home, ambulatory, and office blood pressures in the prediction of end-organ damage

BACKGROUND: Home blood pressure (HBP) monitoring plays an increasingly important role in the diagnosis and treatment of hypertension. We evaluated the independent value of HBP compared with ambulatory blood pressure (ABP) and office blood pressure (OBP) in the prediction of cardiovascular end-organ damage in normotensive subjects and untreated patients with mild hypertension. METHODS: One hundred sixty-three subjects underwent measurements of OBP, HBP, ABP, and echocardiography. A physician using a mercury-column sphygmomanometer performed three OBP measurements. The ABP was recorded using a noninvasive ambulatory monitor (mean, 35.4 awake readings per subject). Participants took HBP readings with an automatic, oscillometric device over a 10-week period (mean, 277.9 readings per subject). The left-ventricular mass index (LVMI) was calculated from measurements obtained from two-dimensionally guided M-mode or linear tracings on echocardiography. RESULTS: For systolic and diastolic blood pressures (SBP/DBP), the correlation coefficients of the LVMI with OBP, awake ABP, and HBP were 0.29/0.27, 0.41/0.26, and 0.47/0.35, respectively (all P < .01). In a multivariate regression analysis in which age, sex, body mass index, OBP, awake ABP, and HBP were included, only age, sex, and HBP were significant predictors of LVMI. When only the first 12 home readings were used, the superiority of HBP was no longer evident. CONCLUSIONS: In contrast to OBP and ABP, HBP measurements, when averaged over a 10-week period, are independently related to LVMI. The HBP adds prognostic information over and above OBP and ABP in the prediction of cardiovascular end-organ damage, but this relationship appears to depend on the number of readings taken.     

Association between hypertensive urgencies and subsequent cardiovascular events in patients with hypertension

OBJECTIVE: To determine whether patients with hypertensive urgency have a higher risk for subsequent cardiovascular events compared with hypertensive patients without this event. METHODS: Overall, 384 patients with hypertensive urgency and 295 control patients were followed up for at least 2 years. Hypertensive urgency was defined as a systolic blood pressure above 220 mmHg and/or a diastolic blood pressure above 120 mmHg without any evidence of acute end-organ damage. The control group consisted of patients admitted to the emergency department with a systolic blood pressure between 135 to 180 mmHg and a diastolic blood pressure between 85-110 mmHg. The number of cardiovascular events defined as acute coronary syndrome, acute stroke, atrial fibrillation, acute left ventricular failure and aortic aneurysm were consecutively analyzed during follow-up. The median follow-up time was 4.2 years (interquartile range 2.9-5.7 years). Twenty-six patients of the urgency group and 23 patients of the control group were lost for follow-up. RESULTS: Overall, 117 (17%) patients had nonfatal clinical cardiovascular events and 13 had (2%) fatal cardiovascular events. The frequency of cardiovascular events was significantly higher in patients with hypertensive urgencies (88 vs. 42; P = 0.005). The Cox regression analysis identified age (P < 0.001) and hypertensive urgencies (P = 0.035) as independent predictors for subsequent cardiovascular events. CONCLUSIONS: Hypertensive urgencies are associated with an increased risk for subsequent cardiovascular events in patients with arterial hypertension.     

The predictive value of cardiorespiratory fitness for cardiovascular events in men with various risk profiles: a prospective population-based cohort study.

AIMS: Few data exist to show if the prognostic value of peak exercise oxygen consumption (VO2peak) for fatal and non-fatal coronary events is different among men with low and high pre-test probability for cardiovascular disease (CVD). Our objective was to determine whether VO2peak could predict fatal and non-fatal cardiac events in 2361 men aged 42-60 years with and without conventional risk predictors of CVD or with documented CVD during a 13-year follow-up. METHODS AND RESULTS: Maximal oxygen consumption (ml/kg/min) was measured directly by using respiratory gas exchange in a cycle ergometer exercise test. Of 204 CVD deaths, 153 were due to coronary disease and 51 were due to other CVDs. A total of 323 non-fatal coronary events occurred during the follow-up. One metabolic equivalent (MET) increment in VO2peak was related to a decreased risk of coronary death in both healthy (RR=0.82, 95% CI 0.66-0.99) and unhealthy (RR=0.72, 95% CI 0.63-0.82) men. VO2peak was predictive of non-fatal and fatal cardiac events among men with or without known risk factors. In subjects with or without common risk factors, one MET increment amounted to an average decrease of 17-29% in non-fatal and 28-51% in fatal cardiac events, after adjustment for age. VO2peak and smoking represented two strongest independent and consistent risk predictors. CONCLUSIONS: VO2peak can be used as a very powerful predictor of future fatal cardiac events beyond that predicted by many conventional risk factors. On the prognostic consideration, unfit men with unfavourable risk profiles or underlying chronic disease are the risk groups that will benefit most from preventive measures.     

Spatial QRS-T angle predicts cardiac death in a general population.

AIMS: The aim of this study was to assess the prognostic importance of the spatial QRS-T angle for fatal and non-fatal cardiac events. METHODS AND RESULTS: Electrocardiograms (ECGs) were recorded in 6134 men and women aged 55 years and over from the prospective population-based Rotterdam Study. Spatial QRS-T angles were categorized as normal, borderline or abnormal. Using Cox's proportional hazards model, abnormal angles showed increased hazard ratios of cardiac death (age-and sex-adjusted hazard ratio 5.2 (95% CI 4.0-6.8)), non-fatal cardiac events (2.2 (1.5-3.1)), sudden death (5.6 (3.7-8.5)) and total mortality (2.3 (2.0-2.7)). None of the classical cardiovascular and ECG predictors provided larger hazard ratios. After adjustment for these predictors, the association of abnormal spatial QRS-T angles with all fatal study endpoints remained strong, but the association with non-fatal cardiac events disappeared. Computation of Akaike's information criterion showed that the angle contributed significantly to the prediction of all fatal endpoints by classical cardiovascular and ECG predictors. CONCLUSION: The spatial QRS-T angle is a strong and independent predictor of cardiac mortality in the elderly. It is stronger than any of the classical cardiovascular risk factors and ECG risk indicators and provides additional value to them in predicting fatal cardiac events.     

Prognostic role of flow-mediated dilatation of the brachial artery in hypertensive patients

BACKGROUND: The prognostic role of endothelial dysfunction, as evaluated by flow-mediated vasodilatation of the brachial artery, has been demonstrated in patients at very high risk. We aimed to investigate whether flow-mediated vasodilatation predicts cardiovascular events in uncomplicated hypertensive patients. METHODS AND RESULTS: A total of 172 prospectively identified uncomplicated hypertensive patients (age 56 +/- 8 years, 41% women, 48 with diabetes mellitus type 2) were studied. At baseline all patients were untreated and underwent baseline standard laboratory examination. A standard echocardiogram was performed for the evaluation of left ventricular anatomy and function and patients with systolic dysfunction or left ventricular wall motion abnormalities were excluded. Endothelial function was measured as flow-mediated vasodilatation of the brachial artery using high-resolution ultrasound. Patients were followed for 95 +/- 37 months (range 2-136 months). A first nonfatal or fatal cardiovascular event occurred in 32 patients. The incidence of cardiovascular events was 1.4 and 3.1 per 100 patient-years in patients with a flow-mediated vasodilatation below and above the median value (4.7%), respectively (P < 0.005 by the log-rank test). In Cox analysis, controlling for age, sex, glycemia, cholesterol, smoking, BMI, systolic and diastolic blood pressure at baseline and left ventricular mass index, a low flow-mediated vasodilatation conferred an increased risk of cardiovascular events (odds ratio 2.67, 95% confidence interval 1.17 to 6.1, P = 0.02). CONCLUSION: The presence of endothelial dysfunction, as evaluated by flow-mediated vasodilatation of the brachial artery, identifies hypertensive patients at increased risk of nonfatal and fatal cardiovascular events.     

Pulse pressure and systolic night-day ratio interact in prediction of macrovascular disease in patients with type 2 diabetes mellitus

Patients with type 2 diabetes mellitus are at increased risk of cardiovascular disease (CVD). We examined the predictive ability of 24-hour ambulatory pulse pressure (24-h PP), ambulatory arterial stiffness index (AASI) and diurnal blood pressure (BP) parameters for fatal and non-fatal CVD in patients with type 2 diabetes mellitus. A total of 108 patients with type 2 diabetes mellitus (mean duration 6.6 years) were followed for 9.5 (0.5-14.5) years. At baseline, all patients underwent ambulatory BP monitoring. During follow-up, 45 patients had cardiovascular (CV) events (35 non-fatal and 10 fatal). In bivariate analysis, events during follow-up were predicted by 24-h PP (P<0.01), AASI, 24-h systolic BP and systolic and diastolic night-day BP ratio (P<0.05 for all). In Cox regression analysis adjusted for established risk markers, only 24-h PP and systolic night-day BP ratio predicted CV events, P<0.05 for both. A significant interaction between the two parameters was found, P<0.05; thus, the higher the systolic night-day ratio, the greater the increase in hazard ratio (HR) per mmHg increase in 24-h PP and vice versa. A combined 10?mmHg increase in 24-h PP and 10%-point increase in systolic night-day ratio from the 25th percentile increased the adjusted HR (95% confidence interval) for CV events with 1.29 (0.53; 3.12), whereas a similar increase from the 75th percentile increased the HR with 4.2 (1.54; 11,51). Our study showed that 24-h PP and systolic night-day ratio interact as predictors of CV events in type 2 diabetes patients, and should be considered in conjunction when evaluating the risk of CVD.     

Pulsatile blood pressure component as predictor of mortality in hypertension: a meta-analysis of clinical trial control groups.

OBJECTIVE: Although current guidelines rest exclusively on the measurement of systolic and diastolic blood pressures, the arterial pressure wave is more precisely described as consisting of a pulsatile (pulse pressure) and a steady (mean pressure) component. This study explored the independent roles of pulse pressure and mean pressure as predictors of mortality in a wide range of patients with hypertension. DESIGN AND METHODS: This meta-analysis, based on individual patient data, has combined results from the control groups of seven randomized clinical trials conducted in patients with systolo-diastolic or isolated systolic hypertension. The relative hazard rates associated with pulse pressure and mean pressure were calculated using Cox's proportional hazard regression models with stratification for the seven trials and with adjustment for sex, age, smoking and the other pressure. RESULTS: A 10 mmHg wider pulse pressure at baseline, which corresponds to approximately one-half of its standard deviation, was independently associated with an increase in risk by 6% for total mortality (P = 0.001), 7% for cardiovascular mortality (P = 0.01), and 7% for fatal coronary accidents (P = 0.03).The corresponding increase in risk of fatal stroke was similar (+6%, P = 0.27) but there were too few strokes to reach statistical significance. In similar analyses, mean pressure was not identified as an independent predictor of these outcomes. Significant interactions of pulse pressure or mean pressure with age suggested that the prognostic power of pulse pressure for fatal stroke was more important at higher age (P = 0.04), whereas the prognostic power of mean pressure for coronary mortality was greatest in the young (P = 0.01). CONCLUSIONS: In hypertensive patients pulse pressure, not mean pressure, is associated with an increased risk of fatal events. This appears to be true in a broad range of patients with hypertension.     

Interaction between vascular dysfunction and cardiac mass increases the risk of cardiovascular outcomes in essential hypertension.

AIMS: To investigate the additive prognostic impact of both forearm endothelial dysfunction and left ventricular mass (LVM) for future cardiovascular events. METHODS AND RESULTS: We enrolled 324 Caucasian, never treated, hypertensive outpatients. Endothelial function, by intra-arterial infusion of acetylcholine (ACh), and echocardiographic LVM were investigated. Patients were divided into tertiles on the basis of their increase in ACh-stimulated forearm blood flow (FBF) and LVM indexed by body surface area (LVMI). Cardiovascular events assessed were: fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, transient cerebral ischaemic attack, unstable angina, coronary revascularization procedures, and symptomatic aorto-iliac occlusive disease. During a mean follow-up of 45.2+/-23.6 months, there were 47 new cardiovascular events (3.8 events/100 patient-years). The event rate was 6.8, 2.8, and 1.6% in the tertiles of ACh-stimulated FBF (log-rank test, P=0.0009), and 1.4, 3.4, and 6.6% in the tertiles of LVMI (log-rank test, P=0.0002), respectively. Besides, a significant interaction was documented between FBF and LVMI. In fact, the cardiovascular risk increases up to 11.4% in patients with low FBF and high LVMI. CONCLUSION: For the first time, we demonstrate that the co-existence of LVH and endothelial dysfunction in hypertensive patients increases significantly the risk of subsequent cardiovascular events.     

The Study on COgnition and Prognosis in the Elderly (SCOPE); outcomes in patients not receiving add-on therapy after randomization

OBJECTIVE: To assess clinical outcomes in the Study on COgnition and Prognosis in the Elderly (SCOPE) in patients who did not receive add-on antihypertensive therapy after randomization, i.e. in patients that best reflect the original intention of a placebo-controlled trial. DESIGN: Post-hoc analysis of a prospective, randomized, controlled trial. SETTINGS AND PARTICIPANTS: Five hundred and twenty-seven centres in 15 countries participated in SCOPE. Patients aged 70-89 years, with systolic blood pressure 160-179 mmHg and/or diastolic blood pressure 90-99 mmHg, and preserved cognitive function were eligible. Out of 4937 patients in SCOPE, 2098 did not receive add-on therapy. INTERVENTION: The number of patients who received candesartan 8-16 mg once daily was 1253, and 845 received placebo. Mean follow-up was 3.7 and 3.5 years, respectively. MAIN OUTCOME MEASURES: Primary: major cardiovascular events (cardiovascular mortality, non-fatal stroke or non-fatal myocardial infarction). Secondary: total mortality, cardiovascular mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, cognitive function, and dementia. RESULTS: The treatment groups were generally well balanced for baseline characteristics. Blood pressure fell by 21.8/11.0 mmHg in the candesartan group and by 17.2/8.4 mmHg in the placebo group. There were significant relative risk reductions with candesartan in major cardiovascular events (32%, P = 0.013), cardiovascular mortality (29%, P = 0.049), and total mortality (27%, P = 0.018). There were no significant differences between the treatment groups in cognitive outcomes. Both treatments were generally well tolerated. CONCLUSIONS: Treatment of elderly patients with mild hypertension is beneficial and supports current recommendations. Candesartan appears an appropriate therapy in such patients, in view of its favourable tolerability profile and ability to reduce major cardiovascular events.     

Mild renal insufficiency as a cardiovascular risk factor in non-proteinuric type II diabetes

OBJECTIVES: To evaluate cardiovascular risk according to baseline renal function in a group of non-proteinuric type II diabetic patients. MATERIAL AND METHODS: Prospective study with a follow-up of 423 non-proteinuric type II diabetic patients with creatinine <150 micromol/l for an average of 4.7 years (S.D. 1.55). Creatinine clearance (CC) was estimated using the Cockcroft-Gault formula and expressed in millilitre per minute. The hazard ratio (HR) associated with each millilitre per minute decrease in baseline CC on fatal or non-fatal cardiovascular events and total mortality was evaluated using the Cox regression model. RESULTS: Baseline creatinine was 89 micromol/l (S.D. 15.9) and CC was 69.5 ml/min (S.D. 20). There were 63 cardiovascular events (15 unstable angina, 10 non-fatal myocardial infarctions, 25 non-fatal strokes, two amputations, nine fatal myocardial infarctions and two fatal strokes) and 39 total deaths (11 for cardiovascular causes). The cardiovascular event rate was 31.7/1000 patient-years and the total mortality rate was 19.6/1000 patient-years. The independent predictors of cardiovascular events were: CC (HR=1.035; confidence interval (CI) 95% 1.02-1.05; P<0.0001), total cholesterol/HDL cholesterol ratio (HR=1.25; CI 95% 1.1-1.4; P=0.0008), baseline coronary heart disease (HR=2.05; CI 95% 1.07-3.9; P=0.04) and baseline microalbuminuria (HR=2.3; CI 95% 1.3-3.8; P=0.003). The independent total mortality predictors were: CC (HR=1.04; CI 95% 1.02-1.08; P<0.0001), male (HR=2.1; CI 95% 1.1-4; P=0.027) and baseline microalbuminuria (HR=2.1; CI 95% 1.1-4;P=0.03). CONCLUSIONS: Mild renal insufficiency increases cardiovascular risk in non-proteinuric patients with type II diabetes.     

Prognostic importance of the right ventricular function assessed by Doppler tissue imaging.

AIMS: We sought to assess whether the peak systolic and diastolic tricuspid annular velocities as indicators of the right ventricular systolic and diastolic function are of prognostic importance in patients with symptomatic heart failure. METHODS AND RESULTS: The study included 139 consecutive patients with symptomatic heart failure. Their mean left ventricular ejection fraction was 24% (range, 10-39%); 107 patients (77%) were in functional class III according to the New York Heart Association. All patients underwent clinical and laboratory examination, standard echocardiography completed by the Doppler tissue imaging of the tricuspid annular motion, and the right-sided heart catheterization. They were followed up for cardiac-related death and non-fatal cardiac events including the need for implantation of a cardioverter-defibrillator and hospitalization for heart failure. The median follow-up was 11 months (range, 1-48 months). There were 17 cardiac-related deaths and 23 non-fatal cardiac events. The multivariate stepwise Cox regression modelling revealed three effective predictors for both survival and event-free survival: aetiology of heart failure, left ventricular end-diastolic diameter, and the peak systolic tricuspid annular velocity (Sa). Patients with Sa<10.8cms(-1) exhibited worse survival (P=0.048) and event-free survival (P<0.001) compared with those having Sa>/=10.8cms(-1). Risk values of Sa (<10.8cms(-1)) and the left ventricular end-diastolic diameter (>70mm) were found to be of additive simultaneous influence leading to a very poor prognosis, mainly if aetiology of heart failure was idiopathic dilated cardiomyopathy (P<0.001). CONCLUSION: The Sa represents a significant independent predictor of survival and event-free survival in patients with symptomatic heart failure. Its combination with the left ventricular end-diastolic diameter provides a very powerful tool for patient risk stratification.     

Automated office blood pressure measurements in primary care are misleading in more than one third of treated hypertensives: The VALENTINE-Greece Home Blood Pressure Monitoring study

BackgroundThis study assessed the diagnostic reliability of automated office blood pressure (OBP) measurements in treated hypertensive patients in primary care by evaluating the prevalence of white coat hypertension (WCH) and masked uncontrolled hypertension (MUCH) phenomena.MethodsPrimary care physicians, nationwide in Greece, assessed consecutive hypertensive patients on stable treatment using OBP (1 visit, triplicate measurements) and home blood pressure (HBP) measurements (7 days, duplicate morning and evening measurements). All measurements were performed using validated automated devices with bluetooth capacity (Omron M7 Intelli-IT). Uncontrolled OBP was defined as ≥140/90 mmHg, and uncontrolled HBP was defined as ≥135/85 mmHg.ResultsA total of 790 patients recruited by 135 doctors were analyzed (age: 64.5 ± 14.4 years, diabetics: 21.4%, smokers: 20.6%, and average number of antihypertensive drugs: 1.6 ± 0.8). OBP (137.5 ± 9.4/84.3 ± 7.7 mmHg, systolic/diastolic) was higher than HBP (130.6 ± 11.2/79.9 ± 8 mmHg; difference 6.9 ± 11.6/4.4 ± 7.6 mmHg, p < 0.001). WCH phenomenon (high OBP with low HBP) was observed in 22.7% of the patients, MUCH (low OBP with high HBP) in 15.8%, uncontrolled hypertension (high OBP with high HBP) in 29.9%, and controlled hypertension (low OBP with low HBP) in 31.6%. In multivariate logistic regression analysis, WCH was determined by stage-1 systolic hypertension (odds ratio [OR] 8.6, 95% confidence intervals [CI] 5.7, 13.1) and female gender (OR 1.6, 95% CI 1.1, 2.4), whereas MUCH was determined by high-normal systolic OBP (OR 6.2, 95% CI 3.8, 10.1) and male gender (OR 2.0, 95% CI 1.2, 3.1).ConclusionsIn primary care, automated OBP measurements are misleading in approximately 40% of treated hypertensive patients. HBP monitoring is mandatory to avoid overtreatment of subjects with WCH phenomenon and prevent undertreatment and subsequent excess cardiovascular disease in MUCH.     

Out-of-office blood pressure in children and adolescents: disparate findings by using home or ambulatory monitoring

BACKGROUND: The validity of home blood pressure (HBP) measurements in children has not been evaluated, although in clinical practice such measurements are being used. This study compares HBP, with clinic (CBP) and daytime ambulatory blood pressure (ABP) in children and adolescents. METHODS: Fifty-five children and adolescents aged 6 to 18 years were evaluated with CBP (three visits), HBP (6 days), and daytime ABP. Mean age was 12.3 +/- 2.9 (SD) years, 33 boys. According to the Task Force CBP criteria, 26 were hypertensives, 6 had high-normal BP (hypertensive group), and 23 were normotensives (normotensive group). RESULTS: In the hypertensive group, CBP was 130.8 +/- 7.6/72.5 +/- 8.1 mm Hg (systolic/diastolic), HBP 118.9 +/- 6.3/73.7 +/- 6.7, and ABP 130.8 +/- 8.1/75.5 +/- 8.3. In the normotensive group, CBP was 112.8 +/- 8/63.1 +/- 6.3, HBP 106.7 +/- 8.4/67.2 +/- 5.2, and ABP 123.9 +/- 7.2/72 +/- 4.3. Strong correlations (P < .001) were observed between CBP-HBP (r = 0.73/0.57, systolic/diastolic), CBP-ABP (r = 0.59/0.49), and HBP-ABP (r = 0.72/0.66). In normotensive subjects, ABP was higher than both CBP and HBP for systolic and diastolic BP (P < .001). Furthermore, systolic HBP was lower than CBP (P < .01), whereas the opposite was true for diastolic BP (P < .05). In hypertensive subjects systolic HBP was lower than both CBP and ABP (P < .001), whereas CBP did not differ from ABP. For diastolic BP no differences were found among measurement methods. CONCLUSIONS: These data suggest that, in contrast to adults in whom HBP is close to the levels of daytime ABP, in children and adolescents HBP appears to be significantly lower than daytime ABP. Until more data become available, caution is needed in the interpretation of HBP in children and adolescents.     

Left atrial size may predict exercise capacity and cardiovascular events in patients with heart failure

Our aim was to investigate, in patients with heart failure, the relationship between left atrial size and exercise capacity and cardiovascular events. Seventy-five patients (67 men and 8 women; mean age, 53.4 +/- 8.8 yr) with left ventricular ejection fractions of < or =0.45 (New York Heart Association functional classes I-III) were matched by age and sex with 20 healthy control subjects. Echocardiographic examinations were performed, as was exercise testing by the modified Bruce protocol. Patients were monitored for a period of 330 to 480 days for cardiac death or for heart failure that required hospitalization. The indexed left atrial diastolic size (beta level = -0.534, P <0.001) and left ventricular late diastolic filling velocity (beta level = 0.247, P <0.017) were the most important values in predicting low exercise capacity. The only independent predictor of low exercise capacity (<5 METS) was the indexed left atrial diastolic size (odds ratio, 1.428; 95% confidence interval, 1.09-1.702; P <0.001). Every 1 mm/m2 increase in indexed left atrial diastolic dimension caused a 42.8% increase in the risk of severe heart failure (exercise capacity, <5 METS). Independent predictors for cardiovascular events were indexed as left atrial systolic size (odds ratio, 1.383; 95% confidence interval, 1.145-1.671; P <0.001) and left ventricular early diastolic/late diastolic filling velocity (odds ratio, 1.096; 95% confidence interval, 1.010-1.189; P <0.027). Indexed left atrial diastolic and left atrial systolic size predict exercise capacity and cardiovascular events, respectively, in New York Heart Association functional class I through III heart failure patients.     

Self-measured versus ambulatory blood pressure in the diagnosis of hypertension

OBJECTIVE: We examined to what extent self-measurement of blood pressure at home (HBP) can be an alternative to ambulatory monitoring (ABP) to diagnose white-coat hypertension. METHODS: In 247 untreated patients, we compared the white-coat effects obtained by HBP and ABP. The thresholds to diagnose hypertension were > or = 140/> or = 90 mmHg for conventional blood pressure (CBP) and > or = 135/> or = 85 mmHg for daytime ABP and HBP. RESULTS: Mean systolic/diastolic CBP, HBP and ABP were 155.4/100.0, 143.1/91.5 and 148.1/95.0 mmHg, respectively. The white-coat effect was 5.0/3.5 mmHg larger on HBP compared with ABP (12.3/8.6 versus 7.2/5.0 mmHg; P < 0.001). The correlation coefficients between the white-coat effects based on HBP and ABP were 0.74 systolic and 0.60 diastolic (P < 0.001). With ABP as a reference, the specificity of HBP to detect white-coat hypertension was 88.6%, and the sensitivity was 68.4%. CONCLUSION: Our findings are in line with the recommendations of the ASH Ad Hoc Panel that recommends HBP for screening while ABP has a better prognostic accuracy.     

Prognostic relevance of metabolic syndrome in hypertensive patients at low-to-medium risk

BACKGROUND: The prognostic impact of metabolic syndrome (MetS) in the hypertensive population at low-medium risk is unknown. In this study, we evaluated the prognostic relevance of MetS in hypertensive patients at low-medium risk. METHODS: The occurrence of nonfatal and fatal cardiac and cerebrovascular events was evaluated in 802 patients with mild to moderate essential hypertension at low-medium risk according to the 2003 World Health Organization/International Society of Hypertension statement on the management of hypertension. Among these patients, 218 (27.2%) had MetS according to a modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) definition (body mass index in place of waist circumference). RESULTS: During follow-up (6.9 +/- 3.1 years; range, 0.5 to 13.1 years, mean +/- SD), 58 first cardiovascular events occurred. The event rates per 100 patient-years in patients without and with MetS were 0.87 and 1.51, respectively. Event-free survival was significantly different between groups (P = .03). After adjustment for several covariates, Cox regression analysis showed that cardiovascular risk was significantly higher in patients with than in patients without MetS (relative risk, 2.64; 95% confidence interval, 1.52 to 4.58; P = .001). Other independent predictors of outcome were age, smoking habit, 24-h systolic BP, and LDL cholesterol. CONCLUSIONS: Hypertensive patients at low-medium risk with MetS are at higher cardiovascular risk than those without MetS. Metabolic syndrome may be a useful tool for clinicians to identify subjects who are at increased risk when traditional assessment may indicate low-medium risk.     

Combined right ventricular systolic and diastolic dysfunction represents a strong determinant of poor prognosis in patients with symptomatic heart failure

BACKGROUND: The presence of right ventricular systolic dysfunction is known to significantly worsen prognosis of patients with heart failure. However, the prognostic impact of right ventricular diastolic dysfunction and of its combination with right ventricular systolic dysfunction and with other prognostic markers has not yet been systematically studied. The aim of this study was to assess the prognostic impact of combined right ventricular systolic and diastolic dysfunction in patients with symptomatic heart failure due to ischemic or idiopathic dilated cardiomyopathy. METHODS: The study included 177 consecutive patients with symptomatic heart failure (mean left ventricular ejection fraction of 23%). All patients underwent clinical and laboratory examination, standard echocardiography completed by Doppler tissue imaging of the tricuspid annular motion, and right-sided heart catheterization. They were followed up for a mean period of 16 months (range, 1-48 months). RESULTS: During the follow-up, there were 28 cardiac-related deaths and 35 non-fatal cardiac events (31 hospitalizations for heart failure decompensation and 4 hospitalizations for malignant arrhythmias requiring the implantation of a cardioverter-defibrillator). The multivariate stepwise Cox regression modeling revealed the right ventricular systolic (represented by the peak systolic tricuspid annular velocity-Sa) and diastolic (represented by the peak early diastolic tricuspid annular velocity-Ea) function to be the independent predictors of event-free survival or survival (p<0.01). The Sa separated better between patients with and without the risk of cardiac events (p<0.05), while the Ea appeared to further distinguish patients with increased risk (those at risk of late event from those at risk of early non-fatal event and early death). The strongest predictive information was obtained by the combination of Sa and Ea creating the Sa/Ea categories. The Sa/Ea I category of patients (Sa>or=10.8 cm s(-1) and Ea>or=8.9 cm s(-1)) had excellent prognosis. On the other hand, the Sa/Ea IV category (Sa<10.8 cm s(-1) and Ea<8.9 cm s(-1)) was found to be at a very high risk of cardiac events (p<0.001 vs. Sa/Ea I). Imbalanced categories of patients (Sa/Ea II and III) with only one component (Sa or Ea) pathologically decreased were at medium risk when assessing event-free survival. However, a significantly better survival (p<0.05) was found in patients with Ea>or=8.9 cm s(-1) (Sa/Ea I and III categories) as compared with those having Ea<8.9 cm s(-1) (Sa/Ea II and IV categories). Thus, in contrast to event-free survival, the survival pattern was determined mainly by the Ea value with only little additional contribution of Sa. CONCLUSIONS: The assessment of right ventricular systolic and diastolic function provides complementary information with a very high power to stratify prognosis of patients with heart failure. The combination of right ventricular systolic and diastolic dysfunction identifies those with a very poor prognosis.     

Comparison of Office, Ambulatory, and Home Blood Pressure Antihypertensive Response to Atenolol and Hydrochlorthiazide

J Clin Hypertens (Greenwich). 2010;12:14–21. ^© 2009 Wiley Periodicals, Inc.
Office, home, and ambulatory blood pressure (BP) demonstrate variable associations with outcomes. The authors sought to compare office BP (OBP), home BP (HBP), and ambulatory BP (ABP) for measuring responses to hydrochlorothiazide (HCTZ), atenolol, and their combination. After completing washout, eligible patients were randomized to atenolol 50 mg or HCTZ 12.5 mg daily. Doses were doubled after 3 weeks and the alternate drug was added after 6 weeks if BP was >120/70 mm Hg (chosen to allow maximum opportunity to assess genetic associations with dual BP therapy in the parent study). OBP (in triplicate), HBP (twice daily for 5 days), and 24-hour ABP were measured at baseline, after monotherapy, and after combination therapy. BP responses were compared between OBP, HBP, and ABP for each monotherapy and combination therapy. In 418 patients, OBP overestimated BP response compared with HBP, with an average 4.6 mm Hg greater reduction in systolic BP ( P <.0001) and 2.1 mm Hg greater reduction in diastolic BP ( P <.0001) across all therapies. Results were similar for atenolol and HCTZ monotherapy. ABP response was more highly correlated with HBP response ( r =0.58) than with OBP response ( r =0.47; P =.04). In the context of a randomized clinical trial, the authors have identified significant differences in HBP, OBP, and ABP methods of measuring BP response to atenolol and HCTZ monotherapy.