Gender Differences in Office and Ambulatory Control of Hypertension

Background

Gender differences in hypertension control have not been explored fully.

Methods

We studied 15,212 white men and 13,936 white women with treated hypertension who were drawn from the Spanish Ambulatory Blood Pressure Registry. For each participant, we obtained office blood pressure (BP) (average of 2 readings) and 24-hour ambulatory BP (average of measurements performed every 20 minutes during day and night).

Results

Only 16.4% of women and 14.7% of men had both office (<140/90 mm Hg) and ambulatory (<130/80 mm Hg) BP controlled (P < .001). Women had a lower frequency of masked hypertension (office BP < 140/90 mm Hg and ambulatory BP ≥ 130/80 mm Hg) than men (5.9% vs 7.9%, P < .001). Women had a higher frequency of isolated office hypertension (office BP ≥ 140/90 mm Hg and ambulatory BP < 130/80 mm Hg) (32.5% vs 24.2%, P < .001). Although office BP control (office BP < 140/90 mm Hg, regardless of ambulatory values) was similar in women and men (22.3% vs 22.6%, P = .542), ambulatory BP control (ambulatory BP < 130/80 mm Hg, regardless of office values) was higher in women than in men (48.9% vs 38.9%, P < .001). After adjustment for age, number of antihypertensive drugs, hypertension duration, and risk factors, gender differences in BP control remained practically unchanged.

Conclusion

Ambulatory BP control was higher in women than in men. This may be due to the higher frequency of isolated office hypertension in women, and it is not explained by gender differences in other important clinical characteristics.     

Optimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials

Background

The optimal on-treatment blood pressure (BP) target has been a matter of debate. The recent SPRINT trial showed significant benefits of a BP target of <120 mm Hg, albeit with an increase in serious adverse effects related to low BP.

Melatonin reduces night blood pressure in patients with nocturnal hypertension

Purpose

Nocturnal hypertension is associated with a high risk of morbidity and mortality. A blunted nocturnal surge in melatonin excretion has been described in nondipping hypertensive patients. We therefore studied the potency of melatonin to reduce nighttime blood pressure (BP) in treated hypertensive patients with nocturnal hypertension.

Patients and Methods

Thirty-eight treated hypertensive patients (22 males, mean age 64 ± 11 years) with confirmed nocturnal hypertension (mean nighttime systolic BP >125 mm Hg), according to repeated 24-hour ambulatory blood pressure monitoring (ABPM), were randomized in a double-blind fashion to receive either controlled release (CR)-melatonin 2 mg or placebo 2 hours before bedtime for 4 weeks. A 24-hour ABPM was then performed.

Results

Melatonin treatment reduced nocturnal systolic BP significantly from 136 ± 9 to 130 ± 10 mm Hg (P = .011), and diastolic BP from 72 ± 11 to 69 ± 9 mm Hg (P = .002), whereas placebo had no effect on nocturnal BP. The reduction in nocturnal systolic BP was significantly greater with melatonin than with placebo (P = .01), and was most prominent between 2:00 am and 5:00 am (P = .002).

Conclusions

Evening CR-melatonin 2 mg treatment for 4 weeks significantly reduced nocturnal systolic BP in patients with nocturnal hypertension. Thus, an addition of melatonin 2 mg at night to stable antihypertensive treatment may improve nocturnal BP control in treated patients with nocturnal hypertension.     

Discrepancies between Office and Ambulatory Blood Pressure: Clinical Implications

Background

Recent trials have documented no benefit from small reductions in blood pressure measured in the clinical office. However, ambulatory blood pressure is a better predictor of cardiovascular events than office-based blood pressure. We assessed control of ambulatory blood pressure in treated hypertensive patients at high cardiovascular risk.

Methods

We selected 4729 patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Patients were aged ≥55 years and presented with at least one of the following co-morbidities: coronary heart disease, stroke, and diabetes with end-organ damage. An average of 2 measures of blood pressure in the office was used for analyses. Also, 24-hour ambulatory blood pressure was recorded at 20-minute intervals with a SpaceLabs 90207 device.

Results

Patients had a mean age of 69.6 (±8.2) years, and 60.8% of them were male. Average time from the diagnosis of hypertension to recruitment into the Registry was 10.9 (±8.4) years. Mean blood pressure in the office was 152.3/82.3 mm Hg, and mean 24-hour ambulatory blood pressure was 133.3/72.4 mm Hg. About 60% of patients with an office-pressure of 130-139/85-89 mm Hg, 42.4% with office-pressure of 140-159/90-99 mm Hg, and 23.3% with office-pressure ≥160/100 mm Hg were actually normotensive, according to 24-hour ambulatory blood pressure criteria (<130/80 mm Hg).

Conclusion

We suggest that the lack of benefit of antihypertensive therapy in some trials may partly be due to some patients having normal pressure at trial baseline. Ambulatory monitoring of blood pressure may allow for a better assessment of trial eligibility.     

2014 Eighth Joint National Committee Panel Recommendation for Blood Pressure Targets Revisited : Results From the INVEST Study

Background

The 2014 Eighth Joint National Committee panel recommendations for management of high blood pressure (BP) recommend a systolic BP threshold for initiation of drug therapy and a therapeutic target of <150 mm Hg in those ≥60 years of age, a departure from prior recommendations of <140 mm Hg. However, it is not known whether this is an optimal choice, especially for the large population with coronary artery disease (CAD).

Objectives

This study sought to evaluate optimal BP in patients ≥60 years of age.

Methods

Patients 60 years of age or older with CAD and baseline systolic BP >150 mm Hg randomized to a treatment strategy on the basis of either atenolol/hydrochlorothiazide or verapamil-SR (sustained release)/trandolapril in INVEST (INternational VErapamil SR Trandolapril STudy) were categorized into 3 groups on the basis of achieved on-treatment systolic BP: group 1, <140 mm Hg; group 2, 140 to <150 mm Hg; and group 3, ≥150 mm Hg. Primary outcome was first occurrence of all-cause death, nonfatal myocardial infarction (MI), or nonfatal stroke. Secondary outcomes were all-cause mortality, cardiovascular mortality, total MI, nonfatal MI, total stroke, nonfatal stroke, heart failure, or revascularization, tabulated separately. Outcomes for each group were compared in unadjusted and multiple propensity score–adjusted models.

Results

Among 8,354 patients included in this analysis with an accumulated 22,308 patient-years of follow-up, 4,787 (57%) achieved systolic BP of <140 mm Hg (group 1), 1,747 (21%) achieved systolic BP of 140 to <150 mm Hg (group 2), and 1,820 (22%) achieved systolic BP of ≥150 mm Hg (group 3). In unadjusted models, group 1 had the lowest rates of the primary outcome (9.36% vs. 12.71% vs. 21.32%; p < 0.0001), all-cause mortality (7.92% vs. 10.07% vs. 16.81%; p < 0.0001), cardiovascular mortality (3.26% vs. 4.58% vs. 7.80%; p < 0.0001), MI (1.07% vs. 1.03% vs. 2.91%; p < 0.0001), total stroke (1.19% vs. 2.63% vs. 3.85%; p <0.0001), and nonfatal stroke (0.86% vs 1.89% vs 2.86%; p<0.0001) compared with groups 2 and 3, respectively. In multiple propensity score–adjusted models, compared with the reference group of <140 mm Hg (group 1), the risk of cardiovascular mortality (adjusted hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 1.01 to 1.77; p = 0.04), total stroke (adjusted HR: 1.89; 95% CI: 1.26 to 2.82; p = 0.002) and nonfatal stroke (adjusted HR: 1.70; 95% CI: 1.06 to 2.72; p = 0.03) was increased in the group with BP of 140 to <150 mm Hg, whereas the risk of primary outcome, all-cause mortality, cardiovascular mortality, total MI, nonfatal MI, total stroke, and nonfatal stroke was increased in the group with BP ≥150 mm Hg.

Conclusions

In hypertensive patients with CAD who are ≥60 years of age, achieving a BP target of 140 to <150 mm Hg as recommended by the JNC-8 panel was associated with less benefit than the previously recommended target of <140 mm Hg.     

MRI-derived left ventricular function parameters and mass in healthy young adults: Relation with gender and body size

Purpose: To obtain normal values of left ventricular (LV) end-diastolic volume (EDV), stroke volume (SV), cardiac output (CO) and LV mass, in relation to gender, weight (W), length (L) and body surface area (BSA). Methods: Sixty-one healthy volunteers (32 male, 22.4 ± 2.2years) were examined, weight was 70.9 ± 12.2kg, length was 1.78 ± 0.09m, BSA was 1.88 ± 0.19 m². Segmented k-space breathhold cine MRI was used to obtain a stack of parallel short-axis images, from which LV volumes and end-diastolic mass were derived by slice summation. Four different body size indices were studied: W, L, L² and BSA. Results: After indexing for L, L² and BSA, the gender differences in all LV parameters are still persisting. After indexing for W, gender differences persist for EDV and EDM, but are no longer observed for SV and CO. Separate regression analyses for males and females were performed. EDV, SV, CO and EDM correlated significantly with each body size index, both in males and in females. L or BSA were in general better predictors for LV parameters than W. Linear regression equations of EDV (ml) vs. L(m) were for males: EDV = 275 × L – 359 and for females: EDV = 190 × L – 215. Equations of SV(ml) vs. L were for males: SV = 186 × L – 237 and for females: SV = 118 × L – 121. Equations of LV mass(g) vs. L were for males: Mass = 175 × L – 179 and for females: Mass = 65.8 × L – 10.9. Conclusion: Most gender differences in LV parameters remain even after correction for body size indices. Normal reference values for LV parameters are given in relation to body size indices, by calculating regression coefficients separately for males and females. These normal values serve to obtain more accurate reference values for a patient with given gender, weight and length, and thus to improve the differentiation between normal and abnormal LV parameters.     

A Comparative Study of the First Dose Hypotensive Effects of Captopril and Perindopril in Patients with Heart Failure

Angiotensin converting enzyme (ACE) inhibitors reduce morbidity and mortality in patients with heart failure and are a first-line therapy for chronic heart failure. However, the first-dose may be associated with asymptomatic or symptomatic hypotension. In previous small series with different ACE inhibitors, different blood pressure responses have been reported. We defined hypotension as a fall in mean blood pressure 20 mm Hg and an absolute value of systolic blood pressure 90 mm Hg and diastolic blood pressure 60 mm Hg. We studied the evolution of mean, systolic and diastolic blood pressure after initiation of perindopril and captopril treatments in a multicentre, double-blind, randomised, comparative, prospective study. One hundred seventy-six patients, mean age 64.9 ± 12.1 years, 116 men, with symptomatic heart failure, NYHA class II–IV, and a left ventricular ejection fraction <40%, were randomised to receive a single dose of captopril 6.25 mg (n = 85) or perindopril 2 mg, (n = 91). Systolic and diastolic blood pressure were recorded with Dinamap every 15 minutes during a baseline period of 2 hours, every 30 minutes from 2 to 7 hours and at 8 hours after the drug administration. Baseline characteristics of both groups were similar (demography, heart failure aetiology, NYHA class and blood pressure). Throughout the study there were 23 asymptomatic episodes of hypotension in the captopril group and 6 in the perindopril group (p = 0.039). One patient in the captopril group had symptomatic episodes.Mean blood pressure falls were significantly higher in the captopril versus perindopril group at 60 minutes (–4.6 mm Hg vs +0.7 mm Hg; p = 0.004), 75 minutes (–4.4 mm Hg vs –1.1 mm Hg; p = 0.042), and 180 minutes (–3.4 mm Hg vs +0.0 mm Hg; p = 0.042).When elderly patients (70 years) were considered the same pattern of response was found. In summary, first-dose hypotension is not negligible on initiation of therapy with ACE inhibitors in heart failure patients with low ejection fraction. Perindopril results in significantly less reduction in blood pressure and a lower incidence of symptomatic or asymptomatic hypotensive episodes and allows a safer start of therapy than captopril in heart failure patients.     

Improved survival in patients with diabetic nephropathy

Summary The effect of early antihypertensive treatment on survival of patients with diabetic nephropathy was evaluated by studying two cohorts of Type 1 (insulin-dependent) diabetic patients developing persistent proteinuria in I: 1957–1973 (late treatment group n=49) and II: 1979–1983 (early treatment groupn=71). At onset of nephropathy, the two cohorts were comparable with regard to age (29(8) vs 30(8) years, mean (SD)), duration of diabetes (16(6) vs 18(7) years), blood pressure (132(16)/85(11) vs 134(16)/86(8) mm Hg), proteinuria (0.8 (0.5–1.2) vs 0.8 (0.6–1.2) g × 24 h^–1, median (quartiles)) and serum creatinine (87(14) vs 85(16) mol×1^–1). The patients were followed frequently at the outpatients clinic until death or for a median duration of 8 years. In the first cohort antihypertensive treatment was seldom used, whereas, in the second cohort antihypertensive treatment was started when blood pressure reached 144(18)/93(7) mm Hg. The probability of survival with a functioning kidney for more than 8 years was 48% in the first cohort and 87% in the second cohort, p<0.001. The improvement of survival was due mainly to a decreased mortality from uraemia. Early antihypertensive treatment is the most likely explanation for this improvement.     

La pose d’un cathéter intraveineux associée à une période de repos est utile pour le dosage du cortisol mais ne l’est pas pour le dosage de la prolactine

Objective

The use of an intravenous catheter with a rest period has been recommended to avoid false-positive results for hyperprolactinaemia and false-negative results for hypocortisolaemia. We tested the relevance of this recommendation.

Design

Plasma cortisol and prolactin levels were determined before (T-15) and after a 15-min rest period (T0) in 119 patients, 38 males (M) and 81 females (F). 52 of the 119 patients were known (K; 30 females and 22 males) and 67 unknown (UK; 49 females and 18 males) to the unit.

Results

Prolactin was lower after rest in women (12.3 ± 22.7 ng/l vs 11.7 ± 22.5 ng/ml, P = 0.03), but not in men (6.2 ± 4.5 ng/ml at T-15 vs 5.8 ± 3.2 ng/ml at T0, P = 0.09), in the UK subgroup (10.6 ± 20.7 ng/ml at T-15 vs 10.1 ± 20.9 ng/ml at T0, P = 0.06) and in the K subgroup (10.1 ± 16.7 ng/ml at T-15 vs 9.7 ± 15.8 ng/ml at T0, P = 0.08). None of the patients with prolactin levels higher than 20 ng/ml at T-15 diminished its prolactin value below this cut-off value. Plasma cortisol levels were lower after rest in women (17.9 ± 5.9 μg/dl at T-15 vs 16.5 ± 6.1 μg/dl at T0, P < 0.0001), in the UK subgroup (18 ± 6.1 μg/dl at T-15 vs 16.6 ± 6.4 μg/dl at T0, P = 0.0003) but not in men (18 ± 4.4 μg/dl at T-15 vs 17.5 ± 5.8 μg/dl at T0, P = 0.47) and in the K subgroup (17.8 ± 4.6 μg/dl at T-15 vs 17 ± 5.4 μg/dl at T0, P = 0.13). At T0, 3.3% and 15% of patients presented values below the cut-off value of 10 μg/dl (276 nmol/l) and 17 μg/dl (470 nmol/l), respectively.

Conclusion

These results don’t justify intravenous catheterisation with a rest period for plasma prolactin determination in contrast with plasma cortisol determination.     

Differential Effects of Morning or Evening Dosing of Amlodipine on Circadian Blood Pressure and Heart Rate

Objectives: To compare the effects of morning and evening dosing of amlodipine on both circadian blood pressure (BP) and heart rate (HR) in mild-to-moderate essential hypertension. Design: A perspective, double-blind, randomized, crossover design with dose titration. Patients and methods: Sixty-two patients recruited in the study were aged 21–77 years and had mild-to-moderate essential hypertension. At the end of a 2-week single-blind, placebo run-in period, eligible patients were randomly assigned to morning (7 AM) and evening (9 PM) amlodipine treatment. The initial dose was 5 mg. After 2 weeks of double-blind therapy, patients with a seated diastolic blood pressure 90 mm Hg had their doses titrated upward to 10 mg, while the other patients remained on their original 5 mg doses for another 4 weeks period, than crossover to the alternate dosing regimen for 6 additional weeks. The 24-h ambulatory monitoring was performed at baseline and at 6 and 12 weeks after randomization. Results: 24-h diastolic BP load (11.0 ± 17.5% vs. 6.5 ± 9.1%, P < 0.05) and night-time BP load (28.5 ± 31.4%/17.7 ± 28.2% vs. 20.0 ± 27.9%/9.2 ± 17.8%, P < 0.05/0.05) were significantly greater with evening dosing compared with morning dosing. Nocturnal fall of BP was greater with morning dosing than with evening dosing (9.8 ± 6.7/7.4 ± 5.3 vs. 6.7 ± 6.6/5.4 ± 5.4 mm Hg, P < 0.01/0.05). Percentage of nocturnal BP fall was greater with morning dosing versus with evening dosing (7.9 ± 5.3%/9.6 ± 6.8% vs. 5.4 ± 7.0%/7.0 ± 6.9%, P < 0.01/0.05). Conclusions: Morning administered amlodipine had a better effect on the circadian BP compared with evening administrated amlodipine in mild-to-moderate essential hypertension.     

Patients with type 2 diabetes have exaggerated brachial and central exercise blood pressure: relation to left ventricular relative wall thickness

BACKGROUND: A hypertensive response to exercise has prognostic significance. Patients with type 2 diabetes have vascular abnormalities which may predispose to exaggerated brachial and central blood pressure (BP) during exercise. This study aimed to test this hypothesis and to determine the clinical significance of high exercise BP by examining its relation to left ventricular (LV) mass. METHODS: Brachial and central BP were recorded at rest and in response to maximal exercise in 73 diabetic patients (aged 54 +/- 10 years) and 73 controls (aged 53 +/- 12 years). Brachial BP was recorded using mercury sphygmomanometry and LV mass using 2D-echocardiography. Central BP was estimated by radial tonometry using an exercise-validated generalized transfer function. RESULTS: At rest there were no significant (P > 0.05) differences between groups in brachial or central BP. The diabetic patients had significantly increased exercise brachial systolic BP (SBP: 199 +/- 25 mm Hg vs. 185 +/- 21 mm Hg; P = 0.002) and central SBP (158 +/- 17 mm Hg vs. 149 +/- 15 mm Hg; P = 0.002). There was a significantly higher prevalence of an exaggerated exercise BP response (> or =210/105 mm Hg; men and > or =190/105 mm Hg; women) in the diabetic patients (51% vs. 22%; P < 0.01). Compared with those with normal exercise BP, LV relative wall thickness (RWT) was significantly higher (0.41 +/- 0.09 vs. 0.36 +/- 0.08; P < 0.05) and LV hypertrophy was more prevalent (35% vs. 16%; P < 0.05) in those with a hypertensive response. After accounting for other confounding variables, exercise central SBP remained independently associated with LV RWT (beta = 0.22; P = 0.006). CONCLUSION: Diabetic patients are more likely to exhibit exaggerated exercise BP. Regardless of disease status, high exercise central SBP may contribute to cardiovascular risk via adverse cardiac remodeling.     

Ambulatory blood pressure monitoring: Is it mandatory for blood pressure control in treated hypertensive patients?: Prospective observational study

Objective

Twenty-four hour ambulatory blood pressure (ABP) is superior to office blood pressure (BP) in predicting cardiovascular events. However, its use to optimise BP control in treated hypertensive patients is less well examined.

Design and method

In this observational study conducted in 899 general practitioners' offices, 4078 hypertensive patients with uncontrolled office BP were included. Antihypertensive therapy was intensified and after 1 year office BP and 24-hour ABP were measured to categorise patients according to the ESC/ESH 2007 guidelines.

Results

In this cohort (mean office BP 156/90 mm Hg, mean ABP 146/85 mm Hg), 2059 out of 4078 patients (50.5%) had controlled office BP (< 140/90 mm Hg) at 1 year examination. Of these apparently controlled patients (N = 2059), 1339 (65.8%) had 24-hour ABP ≥ 130/80 mm Hg, indicating masked hypertension (32.9% of all treated patients). In the prespecified subgroups the prevalence of masked hypertension was the following: diabetes 28.2%, CVD 29.1%, and CKD 32.1%. White coat hypertension (24 h-ABP < 130/80 mm Hg and office BP ≥ 140/90 mm Hg) was found in 12.4% (N = 233) of patients with elevated office BP (6.1% of all treated patients), and in 5.7% of the diabetic subgroup, 5.6% CVD and 7.1% CKD. Discrepancies in BP categorisation between office BP and 24-hour ABP were high; all subjects 52.8%, diabetes 50.0%, CVD 49.0% and CKD 50.4%.

Conclusion

In hypertensive patients on therapy, 2 out of 3 with apparently controlled office BP had masked hypertension, suggesting a more aggressive therapy, and 1 out of 8 with elevated office BP had white coat hypertension potentially falsely forcing physicians to intensify therapy.The 3A Registry is listed under clinicaltrials.gov, NCT01454583.     

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.     

Association between subjective sleep duration on workdays or non-workdays and uncontrolled blood pressure in Southern China

Objectives

To examine the association between sleep duration on workdays or non-workdays and unsatisfactory blood pressure (BP) control in Southern China.

Masked Hypertension in Elderly Managerial Employees and Retirees

Masked hypertension is reported to have the same level of hazard risk of cardiovascular mortality and stroke morbidity as sustained hypertension. The number of managerial employees suffering from cardiovascular disease and stroke is known to be greater than other employee. The aim of this study was to compare the 24-h blood pressure (BP) recordings between elderly male managerial employees and retirees and to propose a strategy for identifying masked hypertension. A total of 38 males (16 managerial employees aged 50–69 years and 22 retirees aged 60–65 years) who were not taking any antihypertensive medications participated in this study. Their 24-h BP was measured by an ambulatory BP monitoring device. Daytime (9:00–17:00 h) BPs of the employees (mean, 139/92 mm Hg) were significantly higher than in the retirees (mean 124/80 mm Hg), while there was no difference in BP before and during sleep. In all, 5 of 16 employees (31%) who were diagnosed as normotensive (<140/90 mm Hg) at a periodic health check had hypertension (>135/85 mm Hg) in the morning measured by ambulatory BP monitoring, while 6 (38%) had a similar level of hypertension during the daytime (9:00–17:00h). These individuals were diagnosed as having masked hypertension. Multiple regression analyses showed that the job was the only factor that contributed to the difference in BP in the subjects during the daytime. This finding suggested that job stress seemed to be one of the main causes of masked hypertension. We argue that more frequent measurements of BP at the work place are necessary to identify subjects with masked hypertension.     

Hypotensive Effect of Heated Water-Based Exercise Persists After 12-Week Cessation of Training in Patients With Resistant Hypertension

Background

Heated water-based exercise (HEx) promotes a marked reduction of blood pressure (BP), but it is not entirely clear whether its effects on BP persist after cessation of HEx.

The Risk Factors for Bleeding of Fundal Varices in Patients with Liver Cirrhosis

Background/Aims

The relationship between portal hemodynamics and fundal varices has not been well documented. The purpose of this study was to understand the pathophysiology of fundal varices and to investigate bleeding risk factors related to the presence of spontaneous portosystemic shunts, and to examine the hepatic venous pressure gradient (HVPG) between fundal varices and other varices.

Methods

In total, 85 patients with cirrhosis who underwent HVPG and gastroscopic examination between July 2009 and March 2011 were included in this study. The interrelationship between HVPG and the types of varices or the presence of spontaneous portosystemic shunts was studied.

Results

There was no significant difference in the HVPG between fundal varices (n=12) and esophageal varices and gastroesophageal varices type 1 (GOV1) groups (n=73) (17.1±7.7 mm Hg vs 19.7±5.3 mm Hg). Additionally, there was no significant difference in the HVPG between varices with spontaneous portosystemic shunts (n=28) and varices without these shunts (n=57) (18.3±5.8 mm Hg vs 17.0±8.1 mm Hg). Spontaneous portosystemic shunts increased in fundal varices compared with esophageal varices and GOV1 (8/12 patients [66.7%] vs 20/73 patients [27.4%]; p=0.016).

Conclusions

Fundal varices had a high prevalence of spontaneous portosystemic shunts compared with other varices. However, the portal pressure in fundal varices was not different from the pressure in esophageal varices and GOV1.     

Correlation of lower esophageal mucosal ring and lower esophageal sphincter pressure

We assessed the relationship of lower esophageal sphincter pressure (LESP) to presence and absence of lower esophageal mucosal ring (LEMR) in 66 patients to determine if the LEMR was more likely related to prolonged sphincter hypotension. This potential relationship is of interest because LEMR may be due to reflux esophagitis. Each patient had radiographic and manometric studies, and both examinations were done within one week of each other. The mean LESP in patients with LEMR was 23.8 mm Hg (range 4.2–64 mm Hg) compared to 28.7 mm Hg (range 8–59 mm Hg) in patients without LEMR; the difference was not statistically significant. Patients with LEMR were also divided into three subgroups according to the diameter of the rings (13 mm, 14–19 mm, 20 mm). There was no significant relationship between the caliber of LEMR and LESP (P>0.05). Presence of LEMR did not affect the amplitude or duration of primary esophageal peristalsis. These results do not support a relationship between LEMR and prolonged LESP hypotension or abnormal esophageal motility. However, other pathogenetic mechanisms involved in producing reflux esophagitis not related to prolonged sphincter hypotension were not studied.     

Nocturnal blood pressure fluctuation and associated influential factors in severe obstructive sleep apnea patients with hypertension

Purpose

Obstructive sleep apnea syndrome (OSAS) can induce dramatic blood pressure (BP) fluctuations during sleep and it can be associated with hypertension. We investigated the properties and associated influential factors of BP fluctuation in severe OSAS with and without hypertension.

Methods

Two hundred one severe OSAS subjects were divided into hypertensive and normotensive groups. BP was continuously monitored via measurement of pulse transmit time (PTT). The value of apnea-related systolic BP elevation (ΔSBP) was used to reflect the amplitude of BP fluctuation, and the SBP index (the number of ΔSBP >?10 mmHg per hour of sleep time) was used to stand for the frequency of significant BP fluctuations.

Results

Compared with the normotensive group, △SBP and SBP index were higher in the hypertensive group (13.8?±?4.4 mmHg vs 10.9?±?3.1 mmHg; 44.8?±?21.3 events/h vs 26.8?±?15.8 events/h, all p?<?0.001). Multiple regression analysis showed that percentage of sleep time with oxygen saturation <?90% (TST90) and SBP index correlated more with mean level of awakeness and sleep SBP than with apnea-hypopnea index (AHI). Analysis of all apnea events demonstrated that △SBP and the frequency of BP fluctuations were more remarkable following hypoxia than following arousal; △SBP correlated more with oxygen desaturation degree (r?=?0.388, p?<?0.01) and minimal SpO₂ (r?=?0.392, p?<?0.01) than with apnea length and desaturation duration.

Conclusions

In severe OSAS, nocturnal and awake BP levels are associated more with the nocturnal hypoxic duration and BP fluctuation than with AHI. Nocturnal BP fluctuation can be induced by both hypoxia and arousal, and especially by hypoxia.

Trial registration

NCT02876471

     

Angiotensin converting enzyme gene insertion/deletion polymorphism,angiotensinogen gene polymorphisms,family history of hypertension,and childhood blood pressure

Earlier epidemiologic studies have yielded inconsistent results on the extent and timing of the blood pressure (BP) increase in offspring of hypertensive parents. We hypothesized that a familial influence on the BP of the offspring exists from birth on, but becomes significant only later in childhood. We studied the influence of familial occurrence of hypertension on the BP of 3596 children aged 6 to 18 years during a 6-year follow-up. In addition, we examined the possible associations of BP variations with polymorphisms of two candidate genes for hypertension, ie, those coding for the angiotensin converting enzyme (ACE) and those coding for angiotensinogen.A positive family history of hypertension was reflected as the occurrence of higher systolic BP values from the age of 9 years and upward among the females and from the age of 12 years and upward among the males. The mean differences in BP varied from 3.2 to 5.8 mm Hg (systolic) and 2.1 to 5.9 mm Hg (diastolic) between the female offspring of normotensive and hypertensive parents and grandparents. The systolic BP values were significantly higher among females with a hypertensive history in two generations in comparison with females from normotensive families. Among the male offspring of hypertensive and normotensive families, the BP differences were inconsistent. The deletion/deletion males had higher systolic BP values than those with other ACE genotypes. In contrast, variation at the angiotensinogen gene locus was not significantly associated with BP.We conclude that parental history of hypertension is a risk factor for high blood pressure among the offspring from the ages of 9 to 12 years and upward, and hypertension within two generations may enhance this effect. Although the common genetic variation of ACE may influence blood pressure in male children and adolescents, our data do not suggest a role for the common variation of the angiotensinogen gene as a BP regulator during childhood.