高血压患者的中心动脉压、肱动脉压与脉压

目的比较高血压患者中心动脉压、肱动脉压、脉压,了解脉压随年龄变化趋势。方法随机选取728名高血压患者,其中男性410例,女性318例,年龄24～88岁,测量患者的中心动脉压、肱动脉压,根据年龄进行分组,分析脉压与年龄之间变化趋势。结果患者中心动脉收缩压、脉压低于肱动脉收缩压、脉压,差异有显著统计学意义(P均0.01);中心动脉舒张压高于肱动脉舒张压,两者之间差异也有显著统计学意义(P0.01)。男性肱动脉及中心动脉脉压随着年龄增长呈先下降后上升的趋势,女性两者均呈逐渐上升趋势。结论中心动脉压和肱动脉压有显著差异性,中心动脉与肱动脉脉压随年龄变化的趋势一致。     

Independent prognostic information provided by sphygmomanometrically determined pulse pressure and mean arterial pressure in patients with left ventricular dysfunction

OBJECTIVES: The purpose of this study was to evaluate the relationship of baseline pulse pressure and mean arterial pressure to mortality in patients with left ventricular dysfunction. BACKGROUND: Increased conduit vessel stiffness increases pulse pressure and pulsatile load, potentially contributing to adverse outcomes in patients with left ventricular dysfunction. METHODS: Pulse and mean arterial pressure were analyzed for their effect on mortality, adjusting for other modifiers of risk, using Cox proportional hazards regression analysis of data collected from 6,781 patients randomized into the Studies of Left Ventricular Dysfunction trials. RESULTS: Pulse and mean arterial pressure were related positively to each other, age, ejection fraction and prevalence of diabetes and hypertension and inversely to prior myocardial infarction and beta-adrenergic blocking agent use. Higher pulse pressure was associated with increased prevalence of female gender, greater calcium channel blocking agent, digoxin and diuretic use, lower heart rate and a higher rate of reported smoking history. Higher mean arterial pressure was associated with higher heart rate, lower calcium channel blocker and digoxin use and lower New York Heart Association functional class. Over a 61-month follow-up 1,582 deaths (1,397 cardiovascular) occurred. In a multivariate analysis adjusting for the above covariates and treatment assignment, higher pulse pressure remained an independent predictor of total and cardiovascular mortality (total mortality relative risk, 1.05 per 10 mm Hg increment; 95% confidence interval, 1.01 to 1.10; p = 0.02). Mean arterial pressure was inversely related to total and cardiovascular mortality (total mortality relative risk, 0.89; 95% confidence interval, 0.85 to 0.94; p <0.0001). CONCLUSIONS: One noninvasive blood pressure measurement provides two independent prognostic factors for survival. Increased conduit vessel stiffness, as assessed by pulse pressure, may contribute to increased mortality in patients with left ventricular dysfunction, independent of mean arterial pressure.     

High pulse pressure and low mean arterial pressure: two predictors of death after a myocardial infarction

OBJECTIVES: Although the negative prognostic implication of a clinical history of arterial hypertension in myocardial infarction (MI) survivors is well known, the predictive role of the blood pressure (BP) regimen after MI is not well defined. The aim of this study was to investigate the prognostic significance of different BP indices in post-MI. METHODS AND RESULTS: We evaluated the relationship between baseline systolic, diastolic, pulse and mean arterial pressure (MAP), measured by sphygmomanometry at discharge from hospital or within 3 months of an MI, and total and cardiovascular mortality in 11 116 patients enrolled in the GISSI-Prevenzione trial. Over 3.5 years of follow-up, 999 patients died, 657 of them from cardiovascular causes. Low mean and high pulse pressure were significantly associated with total and cardiovascular mortality after controlling for potential confounders in the multivariate analysis. As compared with patients with less extreme BP values, patients with MAP of 80 mmHg or less (n = 1241; 11.2%) had a 48% higher risk of cardiovascular death [95% confidenceinterval (CI) 1.16-1.87; P = 0.001] and those with pulse pressure greater than 60 mmHg (n = 958; 8.6%) had a 35% higher risk (95% CI 1.09-1.69; P = 0.007); only four subjects (0.04%) had both a high pulse pressure and a low MAP (relative risk of cardiovascular death 3.48; 95% CI 0.48-25.88; P = 0.218). CONCLUSIONS: Our results show for the first time an additional prognostic importance of two easily measurable components of BP, definitely high pulse pressure (> 60 mmHg) and low MAP (< or = 80 mmHg), in a large sample of non-selected patients surviving MI who entered a modern programme of cardiovascular prevention.     

Systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure as predictors of cardiovascular disease risk in Men

We compared systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) in predicting the risk of cardiovascular disease (CVD), stratifying results at age 60 years, when DBP decreases while SBP continues to increase. We prospectively followed 11 150 male physicians with no history of CVD or antihypertensive treatment through the 2-year questionnaire, after which follow-up began. Reported blood pressure was averaged from both the baseline and 2-year questionnaires. During a median follow-up of 10.8 years, there were 905 cases of incident CVD. For men aged <60 years (n=8743), those in the highest versus lowest quartiles of average SBP (>/=130 versus <116 mm Hg), DBP (>/=81 versus <73 mm Hg), and MAP (>/=97 versus <88 mm Hg) had relative risks (RRs) of CVD of 2.16, 2.23, and 2.52, respectively. Models with average MAP and PP did not add information compared with models with MAP alone (P>0.05). For men aged >/=60 years (n=2407), those in the highest versus lowest quartiles of average SBP (>/=135 versus <120 mm Hg), PP (>/=55 versus <44 mm Hg), and MAP (>/=99 versus <91 mm Hg) had RRs of CVD of 1.69, 1.83, and 1.43, respectively. The addition of other blood pressure measures did not add information compared with average SBP or PP alone (all P>0.05). These data suggest that average SBP, DBP, and MAP strongly predict CVD among younger men, whereas either average SBP or PP predicts CVD among older men. More research should distinguish whether MAP, highly correlated with SBP and DBP, better predicts CVD.     

Atrial natriuretic factor and right atrial pressure in patients undergoing chronic haemodialysis

To quantitate the mutual relationship between central venous pressure (CVP) and circulating atrial natriuretic factor (ANF) during haemodialysis, nine end-stage renal failure patients on chronic haemodialysis underwent ultrafiltration (UF) and biochemical correction (3 h) separated by 1 h (no dialysis, ND). During UF CVP and circulating ANF decreased significantly in all patients from basal levels (0.5±1.0 vs 5.4±2.0 mmHg and 58±16 vs 95±19 pmol/l respectively,P<0.01 for both), while microhaematocrit increased significantly (29.5±1 vs 26.0±1%,P<0.01). During ND, CVP and ANF rose significantly (P<0.05 for both) in seven of the nine patients, while microhaematocrit returned towards basal values. In two patients CVP did not change during ND and circulating ANF remained unchanged. A significant correlation between CVP and circulating ANF was found (end-basal to end-UF,r=0.72,P<0.05; end-UF to end-ND,r=0.77,P=0.025;n=7). As expected, during biochemical correction plasma creatinine and K⁺ decreased significantly and consistently in all the patients (from 875±74 to 400±56 mol/l and from 4.7±0.07 to 4.0±0.04 mEq/l, respectively;n=9,P<0.01 for both) as did body weight during UF (65.6±7 vs 67±5 kg;n=9,P<0.05). No significant changes were seen for systolic and diastolic blood pressure, heart rate and plasma renin activity at any time. Our data provide further evidence that the regulation of circulating ANF is synchronized with changes in CVP. They also quantitate the mutual relationship between CVP and ANF in end-stage renal failure.     

Pulmonary arterial pulse pressure and mortality in pulmonary arterial hypertension

In the Framingham studies, systemic arterial pulse pressure correlated linearly with morbidity and mortality. Right ventricular (RV) systolic dysfunction and pulmonary circulation stiffening result in abnormalities of pulmonary arterial (PA) pulse pressure in PA hypertension (PAH). We investigated the prognostic potential of PA pulse pressure in 67 patients with PAH diagnosed between January 1996 and March 2004 (33 idiopathic PAH, 34 PAH-connective tissue disease). The population was arbitrarily divided into tertiles of PA pulse pressure (= systolic-diastolic PA pressure) and 5-year mortality was assessed using the Kaplan-Meier method. The extent of RV systolic dysfunction and pulmonary circulation stiffening within each tertile was assessed by comparing the mean cardiac index and alpha (a recently described measure of pulmonary circulation distensibility) in each. Independent predictors of mortality were identified by Cox regression. Five-year mortality rates in patients with low, intermediate and high pulse pressures were 40%, 91% and 54%, respectively. Pulse pressure did not independently predict mortality, but cardiac index, 6-min walk test distance and mixed venous oxygen saturation did. Pulse pressure correlated with circulation stiffening (alpha) but did not correlate with cardiac index which tended to be lower in patients with intermediate pulse pressure and high mortality. PA pulse pressure correlated with pulmonary circulation stiffening but did not predict mortality in this study. RV dysfunction provided better prognostic information and probably explains the higher mortality seen in patients with intermediate pulse pressure.     

脉压及平均动脉压对中老年人脑卒中预测价值的队列研究

目的探讨中老年人脉压及平均动脉压水平对脑卒中发病的预测价值。方法对10 867例中老年人群进行基线调查,其中中年组7 635例,老年组3 232例,随访8年,应用Cox回归分析脉压、平均动脉压对脑卒中的预测价值。结果脉压、平均动脉压均为中老年人脑卒中发病的危险因子。校正其他因素及舒张压后,中年人脉压、平均动脉压每增加10 mm Hg(1 mm Hg=0.133 kPa),脑卒中的发病危险分别增加32.4%和100.8%,且平均动脉压与脑卒中发病危险独立于收缩压;老年人脉压每增加10 mm Hg,脑卒中的危险增加9.1%,但不独立于收缩压。结论平均动脉压对中年人脑卒中的预测作用大于脉压,且独立于收缩压。脉压能在平均动脉压、舒张压水平上提供额外的危险分层信息,但不独立于收缩压。     

Systolic and diastolic blood pressure, mean arterial pressure and pulse pressure for prediction of cardiovascular events and mortality in a Middle Eastern population

We compared systolic (SBP) and diastolic blood pressure (DBP), mean arterial pressure (MAP) and pulse pressure (PP) as independent predictors of cardiovascular disease (CVD), total and CVD mortality among an Iranian population. The study conducted among 5991 subjects aged ≥ 30 years without baseline CVD and antihypertensive medication. The mean of two measurements of SBP and DBP, in sitting position, was considered the subject's blood pressure. During a median follow-up of 8.7 years, 346 CVD and 157 deaths, 63 attributed to CVD, occurred. Hazard ratios (HRs) of each outcome were calculated for a one standard deviation (SD) increase in each blood pressure (BP) measures. In multivariate models, all BP measures were associated with increased risk of CVD regardless of age. In those aged < 60 years, SBP, DBP, PP and MAP were associated with total mortality (p < 0.05), but in subjects aged ≥ 60 years, only SBP and PP increased risk of total mortality significantly. In multivariate analyses, a 1SD increase in SBP, PP and MAP were associated with 35%, 31% and 28% increased risk of CVD mortality (p < 0.05). In terms of fitness and discrimination of models, DBP, PP and MAP were not superior to SBP. In conclusion, our findings provided further evidence from a Middle Eastern population, in support of SBP predictability for CVD events and CVD and all-cause mortality compared with other BP measures.     

First-trimester mean arterial pressure and risk of preeclampsia

BACKGROUND: Maternal second-trimester mean arterial pressure (MAP) is associated with a risk of preeclampsia in some but not all published studies. We examined average first-trimester MAP in relation to preeclampsia risk among 1655 women. METHODS: Using blood-pressure measurements recorded during prenatal care, we calculated MAP, and averaged the values within the first trimester. We defined preeclampsia according to national criteria, using information abstracted from medical records. We classified participants by MAP quartiles: <79, 79-83, 84-88, and >or=89 mm Hg. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) adjusted for prepregnancy body mass index, age, race/ethnicity, and parity. RESULTS: High-quartile MAP was associated with an increased risk of preeclampsia when using current diagnostic criteria (adjusted RR versus low-quartile, 3.0; 95% CI, 1.2-7.4) but not when using older criteria (RR, 1.2; 95% CI, 0.6-2.2). First-trimester MAP did not strongly predict future preeclampsia (area under the receiver operating curve, 0.71). A MAP >/=88 mm Hg predicted preeclampsia with a sensitivity of 0.78 and a specificity of 0.63. CONCLUSIONS: Although first-trimester MAP is strongly associated with risk of preeclampsia, it poorly discriminates between women who will and will not develop the disease.     

动态血压均值及脉压在评估原发性高血压早期肾损害中的临床研究

目的探讨动态血压均值及动态脉压与微量蛋白尿的关系,以期为动态血压监测(ABPM)应用于早期诊断和评价高血压性肾损害提供科学依据。方法将原发性高血压患者125例按动态脉压(24 h PP)≤40 mm Hg(1mm Hg=0.133 kPa)、41～55 mm Hg、56～70 mm Hg、>70 mm Hg分为Ⅰ、Ⅱ、Ⅲ、Ⅳ组,测量24 h 平均收缩压(24h SBP)、24 h 平均舒张压(24 h DBP)、24 h PP、尿微量白蛋白(mA1b)及尿 N-乙酰-β-D-氨基葡萄糖苷酶(NAG),比较各组的尿 mA1b、NAG 检测值及其阳性率,进行24 h SBP、24 h DBP、24 h PP 与尿 mA1b、NAG 的相关回归分析。结果 (1)Ⅰ组与Ⅱ组之间,尿 mA1b、NAG 及微量蛋白尿阳性率差异无统计学意义(P>0.05),Ⅱ组、Ⅲ组与Ⅳ组随24 h PP 的增高,尿 mA1b、NAG 及微量蛋白尿阳性率均依次明显增高,各组间差异有统计学意义(P<0.05);(2)24 h PP、24 h SBP 与尿 mA1b、NAG 呈正相关(r=0.79、0.78、0.78、0.76,P<0.05),24 h DBP 与mA1b、NAG 呈负相关(r=0.64、-0.65,P<0.05);建立多元回归方程得出高血压早期肾损害时对应的24 hSBP、24 h DBP 及24 h PP 值分别为150 mm Hg、91 mm Hg、58 mm Hg。结论动态血压均值及动态脉压可为原发性高血压患者早期肾损害的检测评价指标,24 h SBP 高于150 mm Hg、24 h PP 高于58 mm Hg,24 h DBP 过度下降的患者为高血压性肾损害高危患者。     

动态血压均值及动态脉压对高血压早期肾损害的预测

目的:探讨动态血压均值及动态脉压对原发性高血压患者早期肾损害的预测价值。方法:原发性高血压患者125例按24小时动态脉压(24hPP)分为四组:Ⅰ组:≤40mmHg、Ⅱ组:41～55mmHg、Ⅲ组:56～70mmHg、Ⅳ组:>70mmHg。测量24h平均收缩压(24hSBP)、24h平均舒张压(24hDBP)、24hPP及尿微量白蛋白(MAN)。比较各组的MAN检测值及其阳性率。行24hSBP、24hDBP。24hPP与MAN的关回归分析。结果:24hSBP、24hPP与MAN呈正相关(r=0.78、0.79,P<0.05),24hDBP与MAN呈负相关(r=-0.64,P<0.05)。进一步建立一元线性回归方程,得出与早期肾损害对应的24hSBP、24hDBP及24hPP值分别为150mmHg、91mmHg、58mmHg。结论:动态血压均值及动态脉压可作为高血压患者早期肾损害的预测指标。     

Correlation of plasma homocysteine level with arterial stiffness and pulse pressure in hemodialysis patients

Elevated plasma homocysteine, arterial stiffness, and increased pulse pressure (PP) are independently associated with higher cardiovascular risk in patients with end-stage renal disease. The aim of this study is to investigate the influence of plasma homocysteine on arterial stiffness and PP in hemodialysis (HD) patients. One hundred and nine HD patients were stratified into three groups by plasma homocysteine levels: low (11.2-20.8 micromol/L), middle (21.2-25.1 micromol/L), and high tertiles of plasma homocysteine (Hcy) group (25.2-43.9 micromol/L). Using a computerized oscillometry, we measured the arterial stiffness index (ASI) and blood pressure (BP) hemodynamic parameters in the brachial artery. The high Hcy group exhibited a higher ASI (110.4+/-129.5 versus 46.2+/-17.5, mean+/-S.E., P<0.01), PP (59.7+/-23.1 versus 43.3+/-16.3 mmHg, P<0.01), and age (57.8+/-14.1 versus 49.9+/-12.7 years, P<0.05) compared with the low Hcy group. Plasma homocysteine was significantly correlated with ASI (r=0.25, P<0.001), PP (r=0.33, P<0.001), systolic BP (r=0.31, P<0.001), and age (r=0.24, P<0.05). Serum ferritin was significantly correlated with ASI (r=0.24, P<0.05) and PP (r=0.23, P<0.05). ASI was also correlated with PP (r=0.64, P<0.001). Multiple regression analyses showed that both plasma homocysteine and serum ferritin had significant associations with ASI (beta=4.246, P=0.007 and beta=0.024, P=0.006, respectively), and with PP (beta=1.089, P=0.002 and beta=0.005, P=0.005, respectively) independent of other classic risk factors for atherosclerosis. In conclusion, plasma homocysteine, along with serum ferritin, may act as an important predictor for arterial stiffness and PP in HD patients.     

血压、脉压水平及高血压病程对高血压患者动脉僵硬度的影响

目的探讨血压、脉压水平及高血压病程对高血压患者动脉僵硬度的影响。方法从上海市宝山区6家社区卫生中心及本院入选1026例高血压患者,收集相关病史信息,检测其颈-股动脉(C-F)、颈-桡动脉(C-R)、颈-足背动脉(C-D)脉搏波传导速度(PWV),672例患者在随访1年后复测PWV。从血压、脉压、高血压病程3者的不同水平进行分组比较及随访前后对照分析。结果 (1)1、2、3级高血压患者的C-FPWV随血压水平的增高而增快,分别为(12.61±2.76)m/s,(14.35±3.41)m/s,(15.50±2.93)m/s(均为P<0.01)。1级高血压组较2级、3级高血压组C-FPWV差异有统计学意义(均为P<0.01)。(2)随访前后C-FPWV在1级和2级高血压组分别为(12.73±2.91)m/s和(13.39±3.25)m/s,(13.96±3.07)m/s和(14.75±4.10)m/s,差异有统计学意义,而在3级高血压组差异无统计学意义。(3)脉压<40 mm Hg,40～60 mm Hg,≥60 mm Hg 3组C-FPWV随脉压的增大而增快,分别为(11.95±2.60)m/s,(12.94±2.85)m/s,(14.89±3.22)m/s(均为P<0.01)。随访1年后3组的C-FPWV分别较前增快0.70 m/s,0.65 m/s,0.85 m/s,差异均有统计学意义。(4)高血压病程<5年、5～10年、≥10年3组C-FPWV分别为(12.77±2.75)m/s,(12.85±3.07)m/s,(13.76±3.05)m/s,3组比较差异有统计学意义(均为P<0.01),病程越长,C-FPWV越快。结论(1)C-FPWV较C-RPWV、C-DPWV更能反映动脉僵硬度的变化。(2)C-FPWV随血压、脉压水平的增高及高血压病程的延长而增快,3者均为动脉僵硬度的重要影响因素。     

Sodium thiopental and mean arterial pressure during cardiopulmonary bypass

Sodium thiopental is known to have a number of cardiovascular effects, but injection into the cardiopulmonary bypass reservoir has not been studied. The effect of sodium thiopental on mean arterial blood pressure during cardiopulmonary bypass was assessed in 150 patients undergoing elective coronary artery bypass grafting. Sodium thiopental 3 mg · kg(-1) was administered via the cardiopulmonary bypass reservoir. Mean arterial pressure was recorded just before drug administration and at 15-sec intervals up to 120 sec afterwards. Compared to the baseline value, mean arterial pressure was significantly higher at 30, 45, 60, and 75 sec after drug administration, and it was significantly lower at 90, 105, and 120 sec. Sodium thiopental, in addition to its effects on myocardial tissue, acts initially as a potent vasopressor, and shortly after, as a potent vasodilator.     

Fluctuations of haemoglobinaemia in chronic haemodialysis patients

In March 2008 and June 2009, an ad hoc working group of nephrologists discussed the status of anaemia therapy with erythropoiesis-stimulating agents [ESA] in patients on chronic haemodialysis, the phenomenon of fluctuations of haemoglobinaemia, and the need for individualisation of ESA treatment. The working group put together the following statements: (1) ESAs increase the haemoglobin concentration and adaptations of the ESA dose adjust the response according to a negative-feedback loop. The long lag time between an ESA dose change and its effect on erythropoiesis is cumbersome. The optimal haemoglobin target concentration is different for every haemodialysis patient; the lowest haemoglobin concentration upon which one could consistently demonstrate a positive subjective and objective clinical benefit in chronic dialysis is 11 g/dL, in contrast to the lowest haemoglobin concentration of 10 g/dL recommended in the current EMEA label for ESAs. (2) Intra-individual fluctuation of haemoglobinaemia over time is unavoidable, not only due to the ESA dose/haemoglobin response interaction, but also, and more importantly, due to the occurrence of acute illnesses and exacerbations of co-morbid conditions. Many different methodologies to characterise haemoglobin variability have been described but there is currently no universally applied definition of the phenomenon. (3) An impact of the haemoglobin level and the amplitude of the haemoglobin fluctuations on patient outcome has been observed. Without disclosing any causal relationship, worse outcomes were associated with haemoglobin fluctuations around the lower target level, but later on, more simply linked to the relative time spent below the haemoglobin concentration of 11 g/dL and to the administration of inappropriately high ESA doses in order to achieve the recommended haemoglobin target range. A plausible mechanism might be that acute illnesses blunt the patients' basal ESA sensitivity; this leads to subnormal and/or varying haemoglobin levels, currently initiating an ESA dose increase. The longer it takes the patient to recover from the acute illness, the more the prolongation of the clinically poor condition is to some extent maintained by the persistence of low haemoglobinaemia and/or by the administration of high ESA doses, and, as such, on their turn possibly contributing to an ultimate poor outcome. In the absence of clinical trials, recommendations should be offered how to proceed with the administration of ESAs as optimal as possible in periods of clinical instability.