A Possible Relationship of Nocturnal Blood Pressure Variability with Coronary Artery Disease in Diabetic Nephropathy

Evidence suggests a relationship between short-term blood pressure (BP) variability and cardiovascular target-organ damage. Although a blunted nocturnal decrease in BP and reduced heart rate variability have been shown to be associated with cardiovascular morbidity in diabetic patients, little information is available on short-term BP variability. In this study, short-term BP variability was assessed in 36 subjects with type 2 diabetes and overt nephropathy who underwent ambulatory BP monitoring, and the factors that correlated with short-term BP variability were examined. The incidence of coronary artery disease (CAD) was significantly greater in the patients with increased 24-h systolic BP variability (67% versus 11%; p < 0.0005), while that of cerebrovascular disease was not significantly affected (61% versus 50%). Multiple stepwise regression analysis revealed that serum cholesterol (cholesterol) and plasma norepinephrine (p-NE) were significant and independent contributors to nighttime systolic BP variability (partial R² = 0.490, p < 0.001; partial R² = 0.470, p < 0.001) and demonstrated that body mass index and p-NE were primary determinants of nighttime diastolic BP variability (partial R² = 0.539, p < 0.0005; partial R² = 0.304, p < 0.05). Diabetic nephropathy patients with CAD had significantly increased daytime systolic (17.8 mmHg versus 13.1 mmHg, p < 0.0005), nighttime systolic (17.4 mmHg versus 10.5 mmHg, p < 0.0001), and nighttime diastolic (10.4 mmHg versus 7.2 mmHg, p < 0.05) BP variability. Furthermore, logistic regression analysis demonstrated that nighttime systolic BP variability was an independent risk factor for CAD (odds ratio 3.13 [95% CI 1.02–9.61]; p < 0.05). The increase in nighttime BP variability is associated with a proportional sympathetic activation in diabetic nephropathy. Elevated short-term BP variability combined with relative sympathetic prevalence during the night might represent an important risk factor for cardiovascular events in the diabetic population.     

Multifactorial intervention in individuals with type 2 diabetes and microalbuminuria: the Microalbuminuria Education and Medication Optimisation (MEMO) study

Aims

To determine whether tighter cardiovascular risk factor control with structured education in individuals with type 2 diabetes (T2DM) and microalbuminuria benefits cardiovascular risk factors.

Methods

Participants from a multiethnic population, recruited from primary care and specialist clinics were randomised to intensive intervention with structured patient (DESMOND model) education (n = 94) or usual care by own health professional (n = 95). Primary outcome: change in HbA1c at 18 months. Secondary outcomes: changes in blood pressure (BP), cholesterol, albuminuria, proportion reaching risk factor targets, modelled cardiovascular risk scores.

Results

Mean (SD) age and diabetes duration of participants were 61.5 (10.5) and 11.5 (9.3) years, respectively. At 18 months, intensive intervention showed significant improvements in HbA1c (7.1(1.0) vs. 7.8(1.4)%, p < 0.0001), systolic BP (129(16) vs. 139(17) mmHg, p < 0.0001), diastolic BP (70(11) vs. 76(12) mmHg, p < 0.001), total cholesterol (3.7(0.8) vs. 4.1(0.9) mmol/l, p = 0.001). Moderate and severe hypoglycaemia was 11.2 vs. 29.0%; p = 0.001 and 0 vs. 6.3%; p = 0.07, respectively. More intensive participants achieved ≥3 risk factor targets with greater reductions in cardiovascular risk scores.

Conclusions

Intensive intervention showed greater improvements in metabolic control and cardiovascular risk profile with lower rates of moderate and severe hypoglycaemia. Intensive glycaemic interventions should be underpinned by structured education promoting self-management in T2DM.     

Decreased circulating lipoprotein-associated phospholipase A2 levels are associated with coronary plaque regression in patients with acute coronary syndrome

Objective

Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a vascular-specific inflammatory enzyme, of which increases are associated with cardiovascular events. However, the relationship between circulating Lp-PLA2 levels and coronary plaque volume has not been clarified in patients with acute coronary syndrome (ACS).

Methods

We studied 40 patients with ACS (age, 61.4 ± 8.0 years; male, 87.5%; statin use, 45.0%) who had undergone successful percutaneous coronary intervention (PCI). Plaque volume (PV) in non-culprit sites of PCI lesions was precisely determined using grayscale intravascular ultrasound (IVUS) at onset and at six months later. We then analyzed associations among PV, lipid profiles and Lp-PLA2 levels.

Results

Circulating Lp-PLA2 levels and PV significantly decreased between baseline and six months of follow-up (458.6 ± 166.7 IU/L vs. 378.4 ± 158.5 IU/L, p < 0.001 and 82.2 ± 34.8 mm³ vs. 77.3 ± 33.1 mm³, p < 0.001, respectively). The % change in PV positively and significantly correlated with % change in LDL-C and in the LDL-C/HDL-C ratio (r = 0.444, p = 0.004 and r = 0.462, p = 0.003, respectively). Furthermore, % changes in Lp-PLA2 and in PV correlated even more closely (r = 0.496, p = 0.001). The absolute change in PV also significantly correlated with the change in Lp-PLA2 levels (r = 0.404, p = 0.009).

Conclusions

Circulating Lp-PLA2 levels are associated with changes in coronary plaque determined by IVUS in patients with ACS.     

Nondiabetic older adults with untreated hypertension in Taiwan: Treatment implication in elderly hypertension

Background

Hypertension is common and often left undiagnosed in the elderly. The main purpose of this study was to evaluate the clinical characteristics of nondiabetic hypertensive older adults.

Methods

Community-living older adults in Taipei City participating in annual health examinations were invited for study. Subjects with diabetes mellitus, whether treated or newly diagnosed, were excluded for further analysis. All participants were classified into three groups: normotension, untreated hypertension (UH), and treated hypertension (TH).

Results

In total, 3244 subjects (mean age: 73.4 ± 5.4 years, 56.2% males) were enrolled. The prevalence of hypertension, chronic kidney disease (CKD), and left ventricular hypertrophy (LVH) was 52.9% (36.1% TH and 16.8% UH), 20.9%, and 6.2%, respectively. Compared with the normotension group, UH subjects were older (73.8 ± 5.5 years vs. 72.9 ± 5.6 years, p = 0.003); having higher body mass index (24.2 ± 3.4 kg/m²vs. 23.6 ± 3.4 kg/m², p = 0.001), fasting glucose (101.7 ± 9.1 mg/dL vs. 100.5 ± 9.0 mg/dL, p = 0.007), total cholesterol (TC) (205.0 ± 37.8 mg/dL vs. 196.5 ± 36.4 mg/dL, p < 0.001), triglyceride (TG) (134.5 ± 84.9 mg/dL vs. 119.4 ± 77.0 mg/dL, p < 0.001); and higher prevalence of overt proteinuria (19.3% vs. 13.5%, p = 0.001), CKD (21.1% vs. 16.6%, p = 0.025), and LVH (8.1% vs. 3.8%, p < 0.001). However, the prevalence of overt proteinuria (19.3% vs. 21.1%, p = 0.378) and LVH (8.1% vs. 8.5%, p = 0.79) between UH and TH groups was similar. Adjusted for age, TC, TG, fasting plasma glucose, and the incidence of LVH, both UH [odds ratio (OR) = 1.30, 95% confidence interval (CI) = 1.01–1.66, p = 0.040] and TH (OR = 1.69, 95% CI = 1.39–2.05, p < 0.001) were significant risk factor for CKD. In addition, independent risk factors for CKD included age (OR = 1.07, 95% CI = 1.05–1.09, p < 0.001), body mass index (OR = 1.07, 95% CI = 1.04–1.10, p < 0.001), TC (OR = 1.003, 95% CI = 1.001–1.005, p = 0.021), TG (OR = 1.002, 95% CI = 1.001–1.003, p < 0.001), and hypertension (TH or UH) (OR = 1.44, 95% CI = 1.20–1.72, p < 0.001).

Conclusion

In conclusion, risk of CKD existing along with blood pressure rises among nondiabetic older hypertensive adults, and hypertension (TH or UH) carries a significant risk of CKD after adjustment of other cardiovascular risk factors. Renal protection should be highlighted in the antihypertensive treatment strategy in older hypertensive patients.     

Ambulatory pulse pressure, decreased nocturnal blood pressure reduction and progression of nephropathy in type 2 diabetic patients

Aims/hypothesis  We followed type 2 diabetic patients over a long period to evaluate the predictive value of ambulatory pulse pressure (PP) and decreased nocturnal BP reduction (non-dipping) for nephropathy progression. Methods  Type 2 diabetic patients (n = 112) were followed for an average of 9.5 (range 0.5–14.5) years. At baseline, all patients underwent 24 h ambulatory BP measurement. Urinary albumin excretion rate was evaluated by three urinary albumin:creatinine ratio measurements at baseline and follow-up. Results  At baseline, patients who subsequently progressed to a more advanced nephropathy stage (n = 35) had reduced diastolic night/day BP variation and higher 24 h systolic BP and PP values; they also had more advanced nephropathy and were more likely to smoke than those with no progression of nephropathy (n = 77). In a Cox regression analysis, independent predictors of nephropathy progression were 24 h PP (p < 0.01), diastolic night:day BP ratio (p = 0.02) and smoking (p = 0.02). The adjusted hazards ratio (95% CI) for each mmHg increment in 24 h PP was 1.04 (1.01–1.07), whereas the adjusted hazards ratio (95% CI) for each 1% increase in diastolic night:day BP ratio was 1.06 (1.01–1.11). Only one of 33 patients (3.0%) with both a diastolic night:day BP ratio and a 24 h PP below the median progressed, whereas 17 of 32 patients (53.1%) with both a diastolic night:day BP ratio and a 24 h PP equal to or above the median progressed to a more advanced nephropathy stage (p < 0.001). Conclusions/interpretation  Ambulatory PP, impaired nocturnal BP decline and smoking are strong, independent predictors of nephropathy progression in type 2 diabetic patients.     

Chronobiological analysis by ambulatory blood pressure monitoring of the hyperbaric and hypobaric indexes for evaluation of the antihypertensive effect of long-acting nifedipine.

BACKGROUND: It has been suggested that chronobiology can provide new insights into the evaluation and treatment of cardiovascular disease. In the present study the hyperbaric index (hyperBI) and hypobaric index (hypoBI) were compared with the mean blood pressure (BP) over 24 h to evaluate the antihypertensive effect of long-acting nifedipine on essential hypertension. METHODS AND RESULTS: Fourteen patients were treated with nifedipine CR (20-40 mg/day) for 6 months. Ambulatory BP monitoring was performed before and after treatment. The hyperBI (mmHg . h/day) was calculated as the integrated BP area above the conventional upper limit (140/90 mmHg for the daytime and 120/80 mmHg at night), and the hypoBI was calculated as the integrated BP area below the conventional lower limit (110/60 mmHg for the daytime and 100/50 mmHg at night). At baseline, both the systolic and diastolic 24-h hyperBI values closely correlated with the 24-h mean BP (r=0.994 and 0.935, p<0.0001). Treatment with nifedipine significantly lowered both the 24-h mean systolic and diastolic BP (143+/-14/89 +/-12 to 124+/-16/80+/-8 mmHg, p<0.001/p=0.001), as well as the casual BP (167+/-11/101 +/-8 to 140+/-13/86+/-10 mmHg, p<0.001/p<0.01). Reduction of both the systolic and diastolic hyperBI values was statistically significant over the 24-h period (274+/-266 to 90+/-155, p=0.009; 145+/-187 to 41+/-63, p=0.024), as well as during the daytime (200+/-181 to 66+/-116, p=0.014; 105+/-120 to 24+/-38, p=0.017) and at night (systolic, 74+/-106 to 24+/-52, p=0.021). The 24-h mean BP was normalized, but a small excess BP load persisted despite treatment. There was no significant increase of systolic hypoBI during the 24-h period (1+/-2 to 25+/-30, p=0.065), the daytime (0+/-0 to 14+/-38, p=0.20), or at night (1+/-3 to 11+/-19, p=0,052). Similar findings were obtained for diastolic hypoBI. CONCLUSIONS: Nifedipine CR improved the 24-h hyperBI and mean BP without causing excessive hypotension. These 2 parameters have a close relationship when assessment is done by 24-h BP monitoring. The hyperBI and hypoBI may assist in providing adequate antihypertensive therapy for individual patients by detecting an excessive BP load or hypotension, respectively.     

Ambulatory Blood Pressure Variability Is Increased in Diabetic Hypertensives

The purpose of this study was to examine the possible difference in the 24-hr BP profile—including short-term BP variability, assessed as the standard deviation—between diabetic and non-diabetic hypertensives. We measured 24-hr ambulatory BP in 11 diabetic hypertensives (diabetic HT) and 10 non-diabetic hypertensives (non-diabetic HT) who were hospitalized for the educational program in our hospital and were under stable salt intake. Renal function and sleep apnea were also estimated. There were no significant differences in 24-hr systolic BP (141 mmHg vs. 135 mmHg, ns), daytime systolic BP (143 mmHg vs. 138 mmHg, ns), and nighttime systolic BP (135 mmHg vs. 130 mmHg, ns) between diabetic HT and non-diabetic HT. The values of 24‐hr HR (69.7 beats/min vs. 65.2 beats/min, ns) and 24-hr HR variability (9.9 beats/min vs. 10.1 beats/min, ns) were also similar between the groups. Interestingly, diabetic HT had a significantly greater 24-hr systolic and diastolic BP variability than non-diabetic HT (18.2 mmHg vs. 14.5 mmHg, p < 0.05; 11.5 mmHg vs. 9.6 mmHg, p < 0.05, respectively). The values for creatinine clearance, urinary protein excretion, and apnea-hypopnea index were similar between the groups. Bivariate linear regression analysis demonstrated that fasting blood glucose was the primary determinant of 24-hr diastolic BP variability (r = 0.661, p < 0.01). Multiple stepwise regression analysis revealed that fasting blood glucose was a significant and independent contributor to 24-hr systolic BP variability (r = 0.501, p < 0.05). Taken together, these results demonstrate that BP variability is increased in diabetic hypertensives. Furthermore, it is possible that an elevation of fasting blood glucose may contribute to the enhanced BP variability in hypertensives.     

The Effects of Natural Antioxidants from Tomato Extract in Treated but Uncontrolled Hypertensive Patients

Purpose  To evaluate the effect of adding tomato extract to the treatment regime of moderate hypertensives with uncontrolled blood pressure (BP) levels. Methods  Fifty four subjects with moderate HT treated with one or two antihypertensive drugs were recruited and 50 entered two double blind cross-over treatment periods of 6 weeks each, with standardized tomato extract or identical placebo. Plasma concentrations of lycopene, nitrite and nitrate were measured and correlated with BP changes. Results  There was a significant reduction of systolic BP after 6 weeks of tomato extract supplementation, from 145.8 ± 8.7 to 132.2 ± 8.6 mmHg (p < 0.001) and 140.4 ± 13.3 to 128.7 ± 10.4 mmHg (p < 0.001) in the two groups accordingly. Similarly, there was a decline in diastolic BP from 82.1 ± 7.2 to 77.9 ± 6.8 mmHg (p = 0.001) and from 80.1 ± 7.9 to 74.2 ± 8.5 mmHg (p = 0.001). There was no significant change in systolic and diastolic BP during the placebo period. Serum lycopene level increased from 0.11 ± 0.09 at baseline, to 0.30 ± 01.3 μmol/L after tomato extract therapy (p < 0.001). There was a significant correlation between systolic BP and lycopene levels (r = −0.49, p < 0.001). Conclusions  Tomato extract when added to patients treated with low doses of ACE inhibition, calcium channel blockers or their combination with low dose diuretics, had a clinically significant effect—reduction of BP by more than 10 mmHg systolic and more than 5 mmHg diastolic pressure. No side-effects to treatment were recorded and the compliance with treatment was high. The significant correlation between systolic blood pressure values and level of lycopene suggest the possibility of cause–effect relationships.     

Decreased left atrial myocardial strain in patients with suboptimal blood pressure control

Background: Suboptimal blood pressure (BP) control is commonly observed in patients receiving antihypertensive agents, but the relationship between uncontrolled BP and left atrial (LA) impairment remains unknown. Methods: This study enrolled 279 hypertensive patients who had been medicated, as well as 85 matched normal controls. The BP of systolic <140 mmHg and diastolic<90 mmHg was defined as optimal (HT1 group, n=146), otherwise as suboptimal BP control (HT2 group, n = 133). LA myocardial function was assessed by the systolic (S_Sa), early diastolic (S_Ea), and late diastolic (S_Aa) LA strains. Results: Both the HT1 group and HT2 group had higher BP reading, thicker interventricular septum, larger LA volume index, and enhanced active atrial emptying fraction than the control group (all <0.05). When compared with normal subjects, hypertensive patients displayed obvious reduction in the S_Sa (50.0 ± 10.9 vs. 35.9 ± 8.0%), S_Ea (30.1 ± 7.7 vs. 18.5 ± 7.1%) and S_Aa (19.9 ± 6.4 vs. 17.8 ± 4.2%) (all p < 0.001). In addition to a further impaired S_Ea found in the HT2 group than in the HT1 group (17.2 ± 5.3 vs. 19.8 ± 8.3%, p = 0.002), the treated BP of >140/90 mmHg appeared an independent risk factor associated with the abnormal S_Ea (odds ratio, 2.957; interval of confidence, 1.614-5.415; p = 0.001). Conclusions: Suboptimal BP control status in hypertensive patients is related to a further reduction of LA myocardial function assessed by the novel 2DSTI free strain, and suboptimal BP might be regarded as a composite risk factor and therefore a simplified treatment target. However, the prognostic value of LA free strain in patients with inability to achieve the BP target needs to be evaluated in future prospective studies.     

Nocturnal hypotension in patients after ischemic stroke: does it really matter?

Background

We aimed to evaluate the presence of nocturnal hypotension (NHP) in ischemic stroke (IS) survivors using ambulatory blood pressure (BP) monitoring (ABPM).

Methods

We included fifty consecutive patients presenting at our outpatient clinic for review and who had been discharged for IS in the previous six months. 24-h ABPM was performed with Spacelab 90207 monitor. NHP episodes were considered those values on which the mean arterial pressure (MAP) < 70 mm Hg. Patients were divided into two groups according to the presence or absence of NHP.

Results

We studied 31 men and 19 women, mean age 68 ± 11 years. Episodes of NHP were observed in 21 patients (42%). There were no significant differences with regard to clinical characteristics between groups. With regard to BP, patients with NHP had significantly lower mean 24-hour BPs, mean daytime BPs and mean nighttime BPs. Dipper pattern occurred more often in patients with NHP, although differences were only statistically significant in the diastolic BP values. Mean office readings were 142 ± 26/77 ± 13 mm Hg (149 ± 26 versus 133 ± 20; P = 0.06; 82 ± 12 versus 71 ± 12; P = 0.008). None of the patients showed office SBP < 90 mmHg and only four had office DBP < 60 mmHg.

Conclusions

Episodes of NHP in patients with recent IS are common and difficult to detect with clinical cuff measurements. It is necessary to redefine the target BP levels in secondary stroke prevention, possibly because we are subjecting our patients to increased risk of NHP and cerebral hypoperfusion.     

Dysautonomia and its underlying mechanisms in the hypermobility type of Ehlers–Danlos syndrome

Objectives

Many non-musculoskeletal complaints in EDS-HT may be related to dysautonomia. This study therefore aims to investigate whether dysautonomia is present and to explore the underlying mechanisms.

Methods

A total of 39 females with EDS-HT and 35 age-matched controls underwent autonomic function testing. Resting autonomic tone was assessed using heart rate variability (frequency domain) and baroreflex sensitivity analysis (cross correlation). Autonomic reactivity was assessed using the Autonomic Reflex Screen test battery. Factors suspected to contribute to dysautonomia, e.g., neuropathy, medication use, decreased physical activity, depression, pain-induced sympathetic arousal, and connective tissue laxity, were quantified using validated questionnaires, the Beighton score, and measurement of skin extensibility.

Results

The EDS-HT group showed autonomic deregulation with increased sympathetic activity at rest and reduced sympathetic reactivity to stimuli. Increased resting activity was indicated by a higher LF/HF ratio compared to controls (1.7 ± 1.23 vs 0.9 ± 0.75, p = 0.002); decreased reactivity by a greater BP fall during valsalva (−19 ± 12 vs −8 ± 10, p < 0.001), and a smaller initial diastolic BP increase during tilt (7% vs 14%, p = 0.032). Orthostatic intolerance was significantly more prevalent in EDS-HT than controls (74% vs 34%) and was most frequently expressed as postural orthostatic tachycardia. Lowered QSART responses suggest that sympathetic neurogenic dysfunction is common in patients (p < 0.013), which may explain the dysautonomia in EDS-HT. Further, connective tissue laxity and vasoactive medication use were identified as important factors in aggravating dysautonomia (p < 0.035).

Conclusion

Dysautonomia consisting of cardiovascular and sudomotor dysfunction is present in EDS-HT. Neuropathy, connective tissue laxity, and vasoactive medication probably play a role in its development.     

Five-year follow-up of left ventricular diastolic function in systemic sclerosis patients: Determinants of mortality and disease progression

Objectives

In systemic sclerosis (SSc), left ventricular diastolic dysfunction reflects primary myocardial involvement of the disease. We aimed to assess the abnormalities of the diastolic function, analyze the characteristics of the disease progression, and investigate the prognostic value of diastolic dysfunction in SSc patients.

Patients and methods

A total of 34 SSc patients (57 ± 12 years, 31 female) were involved in the study. The following traditional or tissue Doppler parameters of left ventricular diastolic function were obtained: E/A, lateral E?, E/E?, left ventricular mass index (LVM index), and maximal left atrial (LA) volume index. Measurements were repeated after 5.5 years.

Results

At baseline, diastolic dysfunction was found in 62% of the SSc patients. Follow-up time was 5.4 ± 1.2 years. A total of 6 patients died of heart failure. In univariate Cox regression analysis, age (HR = 1.08, p < 0.05), LVM index (HR = 1.07, p < 0.01), lateral E? (HR = 1.57, p = 0.05), and LA volume index (HR = 1.11, p < 0.01) were predictors of survival. During the follow-up, significant increase in LA volume index (27.5 ± 9.7 vs. 35.4 ± 10.6 cm³/m², p < 0.001) and E/E? was found (7.6 ± 2.5 vs. 8.7 ± 3.8, p < 0.05) while E? did not change (9.6 ± 2.6 vs. 9.2 ± 1.9 cm/s, NS). The increase in LA volume index showed positive correlation (r = 0.46, p < 0.05) while the decrease in E? values showed negative correlation (r = −0.54, p < 0.01) with the duration of the SSc.

Conclusion

In SSc patients, left ventricular diastolic dysfunction is highly prevalent and is associated with increased risk of mortality. Our data suggest that in the advanced phase of the disease, the myocardial fibrotic processes burns out while the increase of the filling pressure progresses continuously.     

Circadian variation of blood pressure in patients with diabetic nephropathy

Summary The association between diurnal blood pressure variation and diabetic nephropathy was assessed in four groups of Type 1 (insulin-dependent) diabetic patients who underwent 24-h ambulatory blood pressure monitoring using an oscillometrie technique. Patients with nephropathy, who had never been treated for hypertension (group D₃,n = 13), were individually matched for age, sex and diabetes duration to a group of microalbuminuric patients (D₂,n = 26), to normoalbuminuric patients (D₁,n = 26) and to healthy control subjects (C,n = 26). Group D3 was also compared to patients with advanced nephropathy receiving treatment for hypertension, mainly a combination of angiotensin converting enzyme inhibitors, metoprolol and diuretics (D₄,n = 11). In group D₃ 24-h diastolic blood pressure (85 ± 8 mm Hg) was comparable to the results obtained in D₄ (85 ± 8 mm Hg) but significantly higher than in D₂ (78 ± 7 mm Hg), D₁ (73 ± 7 mm Hg) and C (73 ± 7 mm Hg,p < 0.05, Tukey's test). The night/day ratio of diastolic blood pressure was higher in D₃ (86 ± 5 %) and D₂ (85 ± 7%) than in C (80 ± 7 %,p < 0.02). This ratio was also elevated in group D₄ (94 ± 8%) compared to D₃ (p < 0.05) corresponding to a marked smoothing of the diurnal blood pressure curve. The 24-h heart rate (beats per min) was significantly elevated in D₃ (84 ± 8) and D₂ (80 ± 10) compared with C (73 ± 11,p < 0.05 Tukey's test), suggesting the presence of parasympathetic neuropathy In conclusion the normal circadian variation of blood pressure was moderately disturbed in a group of microalbuminuric patients and patients with less advanced overt nephropathy. Patients with advanced diabetic nephropathy receiving antihypertensive therapy showed a marked reduction of nocturnal blood pressure fall, which can only be identified by the application of ambulatory blood pressure measurements to verify the 24-h effectiveness of blood pressure control.     

Urinary angiotensinogen level is correlated with blood pressure level and proteinuria in patients with masked hypertension

Urinary <AQ: Please check whether all the edits made in this paper convey your intended meaning, and correct if necessary.>angiotensinogen (UAGT) level is an index of the intrarenal-renin angiotensin system status and is significantly correlated with blood pressure (BP) and proteinuria in patients with hypertension (HT). We aimed to investigate the possible relationship between UAGT levels and albuminuria in masked hypertensives. A total of 96 nondiabetic treated hypertensive patients were included in this study. The patients were divided into two groups: masked hypertensives (office BP <140/90 mmHg and ambulatory BP ≥130/80 mmHg) and controlled hypertensives (office BP <140/90 mmHg and ambulatory BP <130/80). The mean UAGT/UCre level and urinary albumin–creatinine ratio (UACR) of masked hypertensives were higher than those of controlled hypertensives (7.76 μg/g vs 4.02 μg/g, p < 0.001 and 174.21 mg/g vs 77.74 mg/g, p < 0.001, respectively). A significant positive correlation was found between UAGT/UCre levels and ambulatory systolic BP and diastolic BP levels in patients with masked HT, but this was not found with office SBP or DBP levels. Importantly, UAGT/UCre levels showed a significant positive correlation with UACR in both groups, but correlation of the UAGT levels with UACR was more pronounced in masked hypertensives (r = 0.854, p < 0.001 vsr = 0.512, p < 0.01). As a result, UAGT level was increased in patients with masked HT, which was associated with an elevation in albuminuria. Overproduction of the UAGT may play a pivotal role in development of proteinuria.     

Periprocedural myocardial infarction in patients undergoing complex versus noncomplex percutaneous coronary intervention

Background

Limited data are available on the risk of periprocedural myocardial infarction (MI) in patients undergoing complex versus noncomplex percutaneous coronary intervention (PCI).

Methods

We assessed the risk of periprocedural MI according to the fourth Universal definition of myocardial infarction (UDMI) and several other criteria among patients undergoing elective PCI in a prospective, single-center registry. Complex PCI included at least one of the following: 3 coronary vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, treatment of chronic total occlusion, and use of rotational atherectomy.

Results

Between 2017 and 2021, we included 1010 patients with chronic coronary syndrome, of whom 226 underwent complex PCI (22.4%). The rate of periprocedural MI according to the fourth UDMI was significantly higher in complex compared to noncomplex PCI patients (26.5% vs. 14.5%, p < 0.001). Additionally, periprocedural MI was higher in the complex PCI group using SCAI (4% vs. 1.1%, p = 0.009), ARC-2 (13.7% vs. 8.0%, p = 0.013), ISCHEMIA (5.8% vs. 1.7%, p = 0.002), and EXCEL criteria (4.9% vs. 2.0%, p = 0.032). SYNTAX periprocedural MI occurred at low rates in both groups (0.9% vs. 0.6%, p = 0.657). Complex PCI was an independent predictor of the fourth UDMI periprocedural MI (odds ratio [OR] 1.54, 95% confidence interval [CI]: 1.04–2.27, p = 0.031).

Conclusions

In patients with chronic coronary syndrome undergoing elective PCI, complex PCI is associated with a significantly higher risk of periprocedural MI using multiple definitions. These findings highlight the importance of considering upfront this risk in the planning of complex PCI procedures.     

Vulnerable plaque features on coronary CT angiography as markers of inducible regional myocardial hypoperfusion from severe coronary artery stenoses

Objective

We explored whether the presence of 3 known features of plaque vulnerability on coronary CT angiography (CCTA) – low attenuation plaque content (LAP), positive remodeling (PR), and spotty calcification (SC) – identifies plaques associated with greater inducible myocardial hypoperfusion measured by myocardial perfusion imaging (MPI).

Methods

We analyzed 49 patients free of cardiac disease who underwent CCTA and MPI within a 6-month period and were found on CCTA to have focal 70–99% stenosis from predominantly non-calcified plaque in the proximal or mid segment of 1 major coronary artery. Presence of LAP (≤30 Hounsfield Units), PR (outer wall diameter exceeds proximal reference by ≥5%), and SC (≤3 mm long and occupies ≤90° of cross-sectional artery circumference) was determined. On MPI, reversible hypoperfusion in the myocardial territory corresponding to the diseased artery was quantified both as percentage of total myocardium (RevTPD_ART) by an automatic algorithm and as summed difference score (SDS_ART) by two experienced readers. RevTPD_ART ≥ 3% and SDS_ART ≥ 3 defined significant inducible hypoperfusion in the territory of the diseased artery.

Results

Plaques in patients with RevTPD_ART ≥ 3% more frequently exhibited LAP (70% vs. 14%, p < 0.001) and PR (70% vs. 24%, p = 0.001) but not SC (55% vs. 34%, p = 0.154). RevTPD_ART increased from 1.3 ± 1.2% in arteries with LAP−/PR− plaques to 3.2 ± 4.3% with LAP+/PR− or LAP−/PR+ plaques to 8.3 ± 2.4% with LAP+/PR+ plaques (p < 0.001); SDS_ART showed a similar increase: 0.3 ± 0.7 to 2.3 ± 2.8 to 6.0 ± 3.8 (p < 0.001). Using the same LAP/PR categorization, there was a marked increase in the frequency of significant hypoperfusion as determined by both RevTPD_ART ≥ 3% (1/19 to 10/21 to 9/9, p < 0.001) and SDS_ART ≥ 3 (1/19 to 8/21 to 8/9, p < 0.001). LAP and PR, but not SC, were strong predictors of RevTPD_ART and SDS_ART in regression models adjusting for potential confounders.

Conclusions

Presence of low attenuation plaque and positive remodeling in severely stenotic plaques on CCTA is strongly predictive of myocardial hypoperfusion and may be useful in assessing the hemodynamic significance of such lesions.     

Assessment of cardiac involvement of hepatitis C virus; tissue Doppler imaging and NTproBNP study

Introduction

Hepatitis C disease burden is substantially increasing in Egyptian community, it is estimated that prevalence of Hepatitis C virus (HCV) in Egyptian community reach 22% of total population. Recently there is a global alert of HCV cardiovascular complications.

Objective

To evaluate LV diastolic functions of HCV patients using tissue Doppler Imaging and NTPBNP.

Methods

30 HCV patients of 30 years, sex & BMI matched controls were evaluated by PCR, ECG, Echocardiography “conventional Doppler, pulsed wave tissue Doppler (PW-TD), strain rate imaging” & NTPBNP to assess LV diastolic functions. Mean age was 32.8 years ± 5.1 in HCV group, 29.8 years ± 6.6 in control group. Cardiovascular anomalies and predisposing factors were excluded.

Results

HCV group has shown significant increase in QTc interval, significant statistical increase in A wave, deceleration time; (p < 0.05), highly significant decrease in tissue Doppler E_a (p < 0.001), highly significant decrease in A_a (p < 0.001), highly significant increased E/E_a ratio (p value < 0.001), significant decrease in E_a/A_a ratio and significant increase in SR_a (p < 0.05).NTPBNP levels showed highly significant increase with mean value 222 pg/ml ± 283 in HCV group and 32.7 pg/ml ± 21.2 in control group (p value < 0.001). The best cut-off value of NTPBNP to detect diastolic dysfunction in HCV group was 213 pg/ml.No statistical differences in SR_e/SR_a and E/SR_e ratios were observed, however they had significant correlation with NTPBNP level and tissue Doppler parameters. The best cut-off value of E/SR_e ratio to detect diastolic dysfunction in HCV group was 0.91, with 75% sensitivity and 100% specificity.

Conclusion and recommendation

This data show the first direct evidence that HCV infection causes diastolic dysfunction without any other predisposing factors, probably due to chronic inflammatory reaction with mild fibrosis in the heart. Previous studies did not follow strict inclusion and exclusion criteria that confirm the independent role of HCV to cause diastolic dysfunction. Tissue Doppler was more sensitive to diagnose diastolic dysfunction than conventional Doppler.     

Sex-related differences in Japanese patients with peripheral arterial disease

Objective

The goal of the study was to examine possible sex-related differences in the clinical characteristics and risk factors in Japanese patients with peripheral arterial disease (PAD).

Methods

Sex-related differences in clinical profiles, risk factors and treatments were examined in 730 consecutive patients with PAD (148 women (20.3%) and 582 men (79.7%)).

Results

The mean age of the women was higher than that of the men (73.6 ± 11.2 vs. 70.9 ± 9.1 years old, p = 0.002) and the proportion of subjects aged ≥75 years old was also higher in women (P = 0.005). Women more frequently had critical limb ischemia (P < 0.001) and diabetes mellitus (P = 0.026), but less frequent smoking and alcohol intake, compared to men (P < 0.001). Total cholesterol (P < 0.001) and LDL cholesterol (P = 0.014) were higher in women. Fontaine stages were correlated with age, diabetes, cerebral infarction and women (p < 0.001). The prevalence of iliac artery lesions was higher in men (p < 0.001), whereas that for below the knee lesions was higher in women (p < 0.001). The number of affected below the knee arteries was also higher in women than in men (p < 0.001). The prevalence of medical treatment was higher in women (P = 0.009) and major amputation tended to be higher in women (p = 0.056).

Conclusions

Women had more severe symptomatic states and uncontrolled risk factors. The prevalence of iliac artery lesions was lower, but below the knee lesions were more severe in women.