The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke

Objective: To test the hypothesis that the size of a juxtaluminal black (hypoechoic) area (JBA) in ultrasound images of asymptomatic carotid artery plaques predicts future ipsilateral ischemic stroke. Methods: A JBA was defined as an area of pixels with a grayscale value <25 adjacent to the lumen without a visible echogenic cap after image normalization. The size of a JBA was measured in the carotid plaque images of 1121 patients with asymptomatic carotid stenosis 50% to 99% in relation to the bulb (Asymptomatic Carotid Stenosis and Risk of Stroke study); the patients were followed for up to 8 years. Results: The JBA had a linear association with future stroke rate. The area under the receiver-operating characteristic curve was 0.816. Using Kaplan-Meier curves, the mean annual stroke rate was 0.4% in 706 patients with a JBA <4 mm 2, 1.4% in 171 patients with a JBA 4 to 8 mm2, 3.2% in 46 patients with a JBA 8 to 10 mm2, and 5% in 198 patients with a JBA >10 mm2 (P <.001). In a Cox model with ipsilateral ischemic events (amaurosis fugax, transient ischemic attack [TIA], or stroke) as the dependent variable, the JBA (<4 mm2, 4-8 mm2, >8 mm2) was still significant after adjusting for other plaque features known to be associated with increased risk, including stenosis, grayscale median, presence of discrete white areas without acoustic shadowing indicating neovascularization, plaque area, and history of contralateral TIA or stroke. Plaque area and grayscale median were not significant. Using the significant variables (stenosis, discrete white areas without acoustic shadowing, JBA, and history of contralateral TIA or stroke), this model predicted the annual risk of stroke for each patient (range, 0.1%-10.0%). The average annual stroke risk was <1% in 734 patients, 1% to 1.9% in 94 patients, 2% to 3.9% in 134 patients, 4% to 5.9% in 125 patients, and 6% to 10% in 34 patients. Conclusions: The size of a JBA is linearly related to the risk of stroke and can be used in risk stratification models. These findings need to be confirmed in future prospective studies or in the medical arm of randomized controlled studies in the presence of optimal medical therapy. In the meantime, the JBA may be used to select asymptomatic patients at high stroke risk for carotid endarterectomy and spare patients at low risk from an unnecessary operation

Unobserved automated office BP is similar to other clinic BP measurements: A prospective randomized study

Results of the SPRINT study have been disputed, based on the assumption that unattended BP measurements do not correlate with usual BP measurements. In this study, the authors investigated the correlation of unattended SPRINT-like measurements with other conventional measurements. All BP measurements were taken with the patient seated in a comfortable chair with the legs uncrossed and not speaking during the procedure. For the purpose of this study, sixty-five patients, mostly male (93%), were recruited from our hypertension clinic and all were on antihypertensive medication (av 3.0 ± 1.1). Patients were at high cardiovascular risk with high rates of comorbidities, av age 68 ± 12 years, 49% with diabetes, 34% with mild CKD (CKD 1-3, average eGFR 55.0 ± 13 mL/min/1.73 m2), and 20% with history of stable coronary artery disease. All BP measurements were similar with no statistically significant difference (one-way ANOVA, P = 0.621). Compared to unattended SPRINT BP values (139.77 ± 19.22/75.42 ± 11.72 mm Hg), the clinic BP measurements were numerically slightly higher but with a NS P value (P = 0.163). Similarly, unattended BP measurements were similar to values taken by the clinic physician. In a smaller cohort of 11 patients, the authors compared unobserved vs observed SPRINT-like BP measurements, and in 13 patients, the authors compared unobserved SPRINT-like BP measurements to average home BP measurements (Table 3). There were no significant differences between any of the subgroups (one-way ANOVA, P = 0.816 for systolic and P = 0.803 for diastolic). The authors conclude that unattended BP measurements taken (the SPRINT way) are similar to other conventional office blood pressure measurements. ©2018 Wiley Periodicals, Inc

Ambulatory versus home blood pressure monitoring: Frequency and determinants of blood pressure difference and diagnostic disagreement

Objectives:Out-of-office blood pressure evaluation assessed using ambulatory (ABP) or home (HBP) monitoring is currently recommended for hypertension management. We evaluated the frequency and determinants of diagnostic disagreement between ABP and HBP measurements.Methods:Cross-sectional data from 1971 participants (mean age 53.8±11.4 years, 52.6% men, 32% treated) from Greece, Finland and the United Kingdom were analyzed. The diagnostic disagreement between HBP and daytime ABP was regarded as certain when (i) the two methods diagnosed a different blood pressure phenotype, (ii) the absolute HBP-ABP difference was more than 10/5mmHg (systolic/diastolic) and (iii) ABP and HBP had a more than 5mmHg difference from the respective hypertension threshold.Results:In 1574 participants (79.9%), there was agreement between HBP and ABP in diagnosing hypertensive phenotypes (kappa 0.70). Of the remaining 397 participants (20.1%) with diagnostic disagreement, 95 had clinically irrelevant HBP-ABP differences, which reduced the disagreement to 15.3%. When cases with ABP and/or HBP differing ≤5mmHg from the respective hypertension threshold were excluded, the certain disagreement between the two methods was reduced to 8.2%. Significant determinants of the HBP-ABP difference were age, sex, study center, BMI, cardiovascular disease history, office hypertension and antihypertensive treatment. Antihypertensive drug treatment, alcohol consumption and office normotension independently increased the odds of diagnostic disagreement.Conclusion:These data suggest that there is considerable diagnostic agreement between HBP and ABP, and that these methods are interchangeable for clinical decisions in most patients. However, considerable disagreement between the two methods occurs in an appreciable minority, most likely due to methodological and patient-related factors. © 2019 Wolters Kluwer Health, Inc. All rights reserved

Phenotypes of masked hypertension: Isolated ambulatory, isolated home and dual masked hypertension

Objectives:Masked hypertension (MH) is defined as normal office blood pressure (OBP) and elevated ambulatory (ABP) or home blood pressure (HBP). This study assessed MH identified by each of these two methods.Methods:A retrospective analysis of cross-sectional data in treated and untreated adults from Greece, Finland and UK who had OBP, HBP and 24-h ABP measurements was performed. Dual MH was defined as normal OBP and elevated HBP and ABP, isolated ambulatory MH as normal OBP and HBP and elevated ABP and isolated home MH as normal OBP and ABP and elevated HBP.Results:Of 1971 participants analyzed, 445 (23%) had MH on ABP and/or HBP (age 57.1 ± 10.8 years, men 55%, treated 49%). Among participants with any MH, 215 had dual MH (48%), 132 isolated ambulatory MH (30%) and 98 isolated home MH (22%). Moreover, 55% had high-normal, 35% normal and 10% optimal OBP. In logistic regression analysis isolated ambulatory MH was predicted by younger age (OR 0.35, P < 0.01 per 10 years increase), whereas isolated home MH was predicted by older age (OR 2.05, P < 0.01 per 10 years increase).Conclusion:Masked hypertension diagnosed by ABP and not HBP monitoring or the reverse is not uncommon. Age appears to be the most important determinant of isolated ambulatory or home MH, with the former being more common in younger participants and the latter in older ones. Only half of participants with MH have high-normal OBP, whereas the rest have lower levels. © 2019-2020 Wolters Kluwer Health, Inc. All rights reserved