Prevalence of sleep apnea syndrome among patients with essential hypertension

The purpose of this study was to investigate the prevalence of sleep apnea syndrome (SAS) among patients with essential hypertension. Sixteen of 50 patients with essential hypertension were suspected of having SAS based on their responses to a sleep questionnaire. Whole-night polysomnographic recordings revealed that 11 of the 16 patients, which is 22% of the initial sample, had SAS as defined by the occurrence of at least 10 apneas lasting 10 seconds each per hour of polygraphically defined sleep. The preponderant finding of SAS in this group indicates that the possibility of the syndrome should be taken into consideration in the clinical evaluation of these patients.     

Antihypertensive therapy versus alternative therapeutic options for prehypertension: an evidence-based approach

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) defines hypertension as systolic blood pressure (BP) ≥140 mmHg or diastolic BP ≥90 mmHg. The JNC-7 defines 'prehypertension' to include systolic BP values between 120 and 139 mmHg and diastolic BP values between 80 and 89 mmHg. Individuals with blood pressure in the prehypertension range are clearly at increased risk of developing hypertension in the future and have an increased risk of cardiovascular morbidity and mortality, compared with those with normal BP. However, there is paucity of evidence to intervene in these patients. In this article we discuss an evidence-based approach to therapeutic options in patients with prehypertension.     

Maximal Exercise Electrocardiographic Responses and Coronary Heart Disease Mortality Among Men With Metabolic Syndrome

OBJECTIVE: To examine the association between abnormal exercise electrocardiographic (E-ECG) test results and mortality (all-cause and that resulting from coronary heart disease [CHD] or cardiovascular disease [CVD]) in a large population of asymptomatic men with metabolic syndrome (MetS).PATIENTS AND METHODS: A total of 9191 men (mean age, 46.9 years) met the criteria of having MetS. All completed a maximal E-ECG treadmill test (May 14, 1979, through April 9, 2001) and were without a previous CVD event or diabetes at baseline. Main outcomes were all-cause mortality, mortality due to CHD, and mortality due to CVD. Cox regression analysis was used to quantify the mortality risk according to E-ECG responses.RESULTS: During a follow-up of 14 years, 633 deaths (242 CVD and 150 CHD) were identified. Mortality rates and hazard ratios (HRs) across E-ECG responses were the following: for all-cause mortality: HR, 1.36; 95% confidence interval (CI), 1.09-1.70 for equivocal responses and HR, 1.41; 95% CI, 1.12-1.77 for abnormal responses (P_trend<.001); for mortality due to CVD: HR, 1.29; 95% CI, 0.88-1.88 for equivocal responses and HR, 2.04; 95% CI, 1.46-2.84 for abnormal responses (P_trend<.001); and for mortality due to CHD: HR, 1.62; 95% CI, 1.02-2.56 for equivocal responses and HR, 2.45; 95% CI, 1.62-3.69 for abnormal responses (P_trend<.001). A positive gradient for CHD, CVD, and all-cause mortality rates across E-ECG categories within 3, 4, or 5 MetS components was observed (P<.001 for all).CONCLUSION: Among men with MetS, an abnormal E-ECG response was associated with higher risk of all-cause, CVD, and CHD mortality. These findings underscore the importance of E-ECG tests to identify men with MetS who are at risk of dying.ACLS = Aerobics Center Longitudinal Study; CHD = coronary heart disease; CI = confidence interval; CRF = cardiorespiratory fitness; CVD = cardiovascular disease; DM = diabetes mellitus; ECG = electrocardiography; E-ECG = exercise ECG; HR = hazard ratio; MET = metabolic equivalent; MetS = metabolic syndrome; NDI = National Death Index; SRI = stress-recovery indexMetabolic syndrome (MetS) is a clustering of cardiovascular disease (CVD) risk factors,¹ including abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, and insulin resistance,² that currently affects nearly 25% of Americans and is a growing concern because of increasing rates of obesity and hypertension.³ Because many of the components of MetS are associated with an increased risk of CVD and death, a noninvasive diagnosis of subclinical CVD in patients with MetS is important and may optimize secondary preventive interventions in this high-risk population.We showed earlier that abnormal exercise electrocardiographic (E-ECG) results during maximal exercise testing was associated with an elevated risk of incident coronary heart disease (CHD), CVD, and all-cause mortality in 2854 men with diabetes mellitus (DM).⁴ Thus, although DM is considered a CHD risk equivalent, important additional information for risk stratification can be obtained from exercise testing. We also showed that exercise testing can be used to identify women with impaired fasting glucose, a predecessor to DM and MetS, who are at high risk of all-cause mortality.⁵ Callaham et al⁶ studied 1747 US veterans with DM and showed that exercise-induced ST-segment depression was associated with more CVD events during a mean follow-up of 2 years than was observed in participants without ST-segment depression. In a study of 45 patients with exercise-induced silent ischemia, Weiner et al⁷ reported that patients with DM had worse outcomes in terms of CVD events than persons without DM.Currently, no known studies have evaluated the association between abnormal E-ECG responses and all-cause, CHD, and CVD mortality risk in men with MetS. Although sparse, some studies have examined the association between E-ECG responses and CHD risk in men with components of MetS. Ekelund et al⁸ reported that positive findings on E-ECG was an independent predictor of CVD events in men with hypercholesterolemia. Laukkanen et al⁹ reported that exercise-induced ischemia was associated with a higher risk of adverse outcomes in persons at high risk of CHD. Bigi et al¹⁰ suggested that the stress-recovery index (SRI) predicts all-cause mortality in persons with hypertension.Therefore, our study primarily aimed to evaluate the association between abnormal E-ECG test results and mortality (all-cause and that due to CHD or CVD) in a large population of asymptomatic men with MetS. We showed earlier that a maximal E-ECG test performed in asymptomatic men free of CVD can predict future risk of CHD death,¹¹ and that an abnormal test result was a more powerful predictor of risk in those with DM than those without the diagnosis.⁴ The current study will expand this earlier report and focus on men with MetS.     

Timing of naps: effects on post-nap sleepiness levels

The present study investigated the effects of timing of naps on nap content and sleep inertia, and the relationship between pre- and post-nap sleepiness level and nap content. Nine subjects were tested twice on the 13 min waking-7 min resisting sleep paradigm after one night of total sleep deprivation for 24 h. The ultrashort sleep-wake paradigms started at 07.00 h and were interrupted at 15.00 and 19.00 h for 2 h naps. The 2 experimental conditions were counterbalanced across subjects and separated by a 7 day rest period. The results showed that the early nap was significantly more efficient, contained more stage 3/4, and produced less sleep inertia than the late nap. The late nap was more efficient in reducing sleepiness during the last 5 h of the experiments (23.00-04.00). Only the early nap was significantly related to pre- and post-nap sleepiness levels. Overall sleepiness level and the timing of the nocturnal sleepiness gates were significantly correlated between the two parts of the study. The results were interpreted to support the priority of the ultradian phase on prior wakefulness with respect to sleep structure.     

Boceprevir and telaprevir‐based triple therapy for chronic hepatitis C: virological efficacy and impact on kidney function and model for end‐stage liver disease score

Triple therapy using telaprevir or boceprevir [hepatitis C virus (HCV)‐NS3/NS4A protease inhibitors (PI)] in association with PEG‐IFN/ribavirin has recently become the new standard of care (SOC) for treatment of HCV genotype 1 patients. Our objective was to assess the efficacy and tolerance of triple therapy in routine clinical practice. A total of 186 consecutive HCV patients initiating triple therapy were enrolled in a single centre study. Clinical, biological and virological data were collected at baseline and during follow‐up as well as tolerance and side effect details. Among 186 HCV patients initiating triple therapy, 69% received telaprevir and 31% boceprevir. Sixty‐one per cent of patients had cirrhosis. The overall extended rapid virological response (eRVR) rate and sustained virological response (SVR) rate were 57.0% and 59.7%, respectively. IL28B CC phenotype was associated with increased probability of achieving eRVR and SVR, whereas previous non‐response was associated with low eRVR and SVR rates. The SVR rate increased from 30.8% in previously non‐responders to 59.1% in partial non‐responders and 75% in relapsers. SVR rate in naive patients was 62.5%. Glomerular filtration rate assessed by MDRD after 12 weeks of therapy was significantly reduced for both PI (P < 0.001). The model for end‐stage liver disease (MELD) score was significantly increased at W12 for telaprevir (P = 0.008) and at W24 for boceprevir (P = 0.027). PI‐based triple therapy leads to high rates of virological response even in previously non‐responder patients. Renal function after triple therapy is impaired as well as MELD score in all patients. Cautious clinical monitoring should focus not only on haematological and dermatological side effects but also on renal function.     

Intravenous immunoglobulin treatment following the first demyelinating event suggestive of multiple sclerosis: a randomized, double-blind, placebo-controlled trial

BACKGROUND: Intravenous immunoglobulin (IVIg) has been reported to reduce disease activity in patients with relapsing-remitting multiple sclerosis. We assessed the effect of IVIg treatment in patients after the first neurological event suggestive of demyelinative disease and evaluated the occurrence of a second attack and dissemination in time demonstrated by brain magnetic resonance imaging within the first year from onset. METHODS: We conducted a randomized, placebo-controlled, double-blind study in 91 eligible patients enrolled within the first 6 weeks of neurological symptoms. Patients were randomly assigned to receive IVIg treatment (2-g/kg loading dose) or placebo, with boosters (0.4 g/kg) given once every 6 weeks for 1 year. Neurological and clinical assessments were done every 3 months, and brain magnetic resonance imaging was performed at baseline and the end of the study. RESULTS: The cumulative probability of developing clinically definite multiple sclerosis was significantly lower in the IVIg treatment group compared with the placebo group (rate ratio, 0.36 [95% confidence interval, 0.15-0.88]; P = .03). Patients in the IVIg treatment group had a significant reduction in the volume and number of T2-weighted lesions and in the volume of gadolinium-enhancing lesions as compared with the placebo group (P = .01, P = .01, and P = .03, respectively). Treatment was well tolerated, compliance was high, and incidence of adverse effects did not differ significantly between groups. CONCLUSIONS: Intravenous immunoglobulin treatment for the first year from onset of the first neurological event suggestive of demyelinative disease significantly lowers the incidence of a second attack and reduces disease activity as measured by brain magnetic resonance imaging.     

Cough ability measurements and recurrent respiratory symptoms in individuals with Ataxia Telangiectasia

Objectives: Ataxia-Telangiectasia (A-T) individuals often present with respiratory muscle weakness, causing recurrent respiratory system infections, asthma-like symptoms, and chronic cough life-threatening events. The cough flow volume maneuver may reveal powerless airflow needed for efficient cough. The study aims to explore cough ability in relation to the flow/volume maneuver. Methods: Data collected retrospectively from clinical charts of 35 A-T patients (age 12.7?±?4.9 years) included forced expiratory and cough flow/volume maneuvers performed on the same day. Analysis compared among the maneuvers matching indices, numbers of cough-spikes, flow rate decay, and the reference data of similar ages. Adjusted to age, BMI, and number of hospitalizations prior to the tests, values were correlated with the cough indices. Results: Cough peak-flow (C-PF) was propagated within 90?±?20?ms compared with peak expiratory flow (PEF?>?200?ms). C-PF measured values were higher than expiratory peak-flow measured values (3.27?±?1.53?L/s versus 3.02?±?1.52?L/s, respectively, but C-PF (%predicted) values were significantly lower than expiratory peak-flow (%predicted) (46?±?15 versus 68?±?20 %predicted, respectively, p?<?0.002). The number of spikes/maneuver was low when compared with reference (2.0?±?0.8 versus 6–12 spikes) and cough vital-capacity was lower than expiratory vital capacity (0.95?±?0.43 versus 1.03?±?0.47; p?<?0.01). Inefficient C-PF was more prevalent in patients suffering from recurrent respiratory illness. The length of wheelchair confinement duration mostly influenced the C-VC level. Conclusions: The cough flow–volume curve can be applied as a method to follow cough ability in patients with A-T who showed a significantly reduced cough capacity. Further studies are needed to establish if the findings may aid decisions regarding cough assistance.