Morning Blood Pressure Surge, Dipping, and Risk of Coronary Events in Elderly Treated Hypertensive Patients

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Intermittent antegrade warm cardioplegia reduces oxidative stress and improves metabolism of the ischemic-reperfused human myocardium

AbstractThe aim of this study was to compare the effect of intermittent antegrade warm blood cardioplegia and intermittent antegrade cold blood cardioplegia on myocardial metabolism and free radical generation of the ischemic-reperfused human myocardium. Thirty patients undergoing mitral valve procedures were randomly allocated to two groups: group 1 (15 patients) received warm blood cardioplegia and group 2 (15 patients), cold blood cardioplegia. Myocardial metabolism was assessed before aortic clamping, 1 minute after crossclamp removal, and after 20 minutes of reperfusion, by collecting blood simultaneously from the radial artery and coronary sinus. All samples were analyzed for lactate, creatine kinase, reduced and oxidized glutathione, ascorbic acid, fluorescent products of lipid peroxidation, and leukocyte activation (elastase). In all patients, early reperfusion was associated with significant coronary sinus lactate release. In group 2, but not in group 1, significant coronary sinus release of reduced and oxidized glutathione, fluorescent products of lipid peroxidation, and creatine kinase was also found; moreover, arterial-coronary sinus difference of ascorbic acid content was increased only in group 2, suggesting a transmyocardial consumption of this antioxidant vitamin. After 20 minutes of reperfusion, coronary sinus lactate release was no longer present in group 1, whereas significant production was still evident in group 2. In this group, significant coronary sinus release of fluorescent products of lipoperoxidation and reduced and oxidized glutathione was also observed at this time. No significant release of elastase from the coronary sinus was noted in the two groups throughout the study. The left ventricular stroke work index measured at the end of the study indicated a better functional recovery in group 1 than in group 2. In conclusion, intermittent antegrade warm blood cardioplegia protects the myocardium from ischemia-reperfusion injury better than intermittent antegrade cold blood cardioplegia; this phenomenon may be partly due to the decreased tissue oxidant burden mediated by intermittent warm blood cardioplegia. (J THORAC CARDIOVASC SURG 1995;109:787-95

Meta-analysis of the relation of echocardiographic epicardial adipose tissue thickness and the metabolic syndrome

Epicardial adipose tissue (EAT) is an emerging cardiometabolic risk factor, and its thickness can be measured using echocardiography. The relation of EAT to the metabolic syndrome (MS) is still unclear. A meta-analysis of published reports was performed to provide comprehensive insight on the association of EAT thickness as assessed by echocardiography and the MS. A systematic search was conducted for reports on echocardiographic EAT thickness in patients with and without the MS. Nine studies were identified. The pooled population consisted of 2,027 subjects, of whom 1,030 had the MS. EAT thickness was significantly higher in patients with the MS than in those without (standardized difference in means 1.15 mm, 95% confidence interval 0.78 to 1.53, p = 0.0001). Subgroup meta-analysis showed no difference between patients with and those without the MS by MS criteria used and echocardiographic cardiac cycle of measurement but did show a significant difference by ethnicity, with a greater difference in Caucasian subjects (standardized difference in means 1.75 mm, 95% confidence interval 1.43 to 2.07) than in other ethnic groups. In conclusion, echocardiographic EAT thickness is significantly higher in patients with the MS than in those without, but differences exist by ethnicity

Association of clinic and ambulatory blood pressure with new‐onset atrial fibrillation: A meta‐analysis of observational studies

The aim of this study was to perform a meta‐analysis of studies evaluating the association of clinic and daytime, nighttime, and 24‐h blood pressure with the occurrence of new‐onset atrial fibrillation. We conducted a literature search through PubMed, Web of science, and Cochrane Library for articles evaluating the occurrence of new‐onset atrial fibrillation in relation to the above‐mentioned blood pressure parameters and reporting adjusted hazard ratio and 95% confidence interval. We identified five studies. The pooled population consisted of 7224 patients who experienced 444 cases of atrial fibrillation. The overall adjusted hazard ratio (95% confidence interval) was 1.05 (0.98‐1.13), 1.19 (1.11‐1.27), 1.18 (1.11‐1.26), and 1.23 (1.14‐1.32), per 10‐mmHg increment in clinic, daytime, nighttime, and 24‐h systolic blood pressure, respectively. The degree of heterogeneity of the hazard ratio estimates across the studies (Q and I‐squared statistics) were minimal. The results of this meta‐analysis strongly suggest that ambulatory systolic blood pressure prospectively predicts incident atrial fibrillation better than does clinic systolic blood pressure and that daytime, nighttime, and 24‐h systolic blood pressure are similarly associated with future atrial fibrillation

Ambulatory Resistant Hypertension and Risk of Heart Failure in the Elderly

(1) Background: The aim of the study was to assess the risk of heart failure (HF) in elderly treated hypertensive patients with white coat uncontrolled hypertension (WUCH), ambulatory nonresistant hypertension (ANRH) and ambulatory resistant hypertension (ARH), when compared to those with controlled hypertension (CH). (2) We studied 745 treated hypertensive subjects older than 65 years. CH was defined as clinic blood pressure (BP) < 140/90 mmHg and 24-h BP < 130/80 mmHg; WUCH was defined as clinic BP ≥ 140/90 mmHg and 24-h BP < 130/80 mmHg; ANRH was defined as 24-h BP ≥ 130/80 mmHg in patients receiving ≤2 antihypertensive drugs; ARH was defined as 24-h BP ≥ 130/80 mmHg in patients receiving ≥3 antihypertensive drugs. (3) Results: 153 patients had CH, 153 had WUCH, 307 had ANRH and 132 (18%) had ARH. During the follow-up (8.4 ± 4.8 years), 82 HF events occurred. After adjustment for various covariates, when compared to CH, the hazard ratio (95% confidence interval) for HF was 1.30 (0.51–3.32), 2.14 (1.03–4.43) and 3.52 (1.56–7.96) in WUCH, ANRH and ARH, respectively. (4) Conclusions: among elderly treated hypertensive patients, those with ARH are at a considerably higher risk of developing HF when compared to CH

Metabolic Syndrome and Cardiovascular Risk in Elderly Treated Hypertensive Patients

Abstract BACKGROUND The independent prognostic significance of the metabolic syndrome (MetS) in the elderly is not yet clear. We investigated the association between MetS and cardiovascular risk (composite endpoint of stroke and coronary events) in elderly treated hypertensive patients. METHODS Cardiovascular outcome was evaluated in 1,191 elderly treated hypertensive patients (≥60 years). Among them, 578 (48.5%) had MetS according to a modified joint interim statement definition (body mass index in place of waist circumference). RESULTS During the follow-up (9.1±4.9 years, range 0.4–20 years), 139 strokes and 120 coronary events occurred. In univariate analysis, patients with MetS had higher risk of the composite endpoint (hazard ratio (HR) 1.322, 95% confidence interval (CI) 1.035–1.688, P &lt; 0.05). Among the single components of MetS, only blood pressure (BP) level and impaired fasting glucose/diabetes were significantly associated with increased cardiovascular risk. After adjustment for age, previous events, estimated glomerular filtration rate (eGFR), left ventricular (LV) hypertrophy and left atrial (LA) enlargement, the prognostic relevance of MetS was attenuated (HR 1.245, 95% CI 0.974–1.591, P = 0.08). After further adjustment for the above-mentioned variables and ambulatory BP parameters and impaired fasting glucose/diabetes, Cox regression analysis showed that MetS was not independently associated with increased cardiovascular risk (HR 1.090, 95% CI 0.805–1.475, P = 0.58). CONCLUSIONS In elderly treated hypertensive patients, MetS is associated with increased cardiovascular risk, but not independently of BP and glucose levels and of organ damage

Prognostic value of non‐resistant and resistant masked uncontrolled hypertension detected by ambulatory blood pressure monitoring

Abstract Masked uncontrolled hypertension (MUCH) is at higher cardiovascular risk than controlled hypertension (CH). In previous studies, patients with MUCH were considered as a unique group though those receiving ≤2 drugs could be defined as having nonresistant MUCH (NRMUCH) and those receiving ≥3 drugs as having resistant MUCH (RMUCH). The aim of this study was to assess the prognostic value of NRMUCH and RMUCH detected by ambulatory blood pressure (BP) monitoring. Cardiovascular risk was evaluated in 738 treated hypertensive patients with normal clinic BP. Patients were classified as having CH or MUCH if daytime BP < or ≥ 135/85 mmHg, respectively, regardless of nighttime BP, or CH or MUCH if 24‐h BP < or ≥ 130/80 mmHg, respectively, regardless of daytime or nighttime BP. By daytime or 24‐h BP, the authors detected 523 (71%), 178 (24%), and 37 (5%) or 463 (63%), 231 (31%), and 44 (6%) patients with CH, NRMUCH, and RMUCH, respectively. During the follow‐up (median 10 years), 148 events occurred. After adjustment for covariates, compared to CH, the hazard ratio (HR), 95% confidence interval (CI), for cardiovascular events was 1.81, 1.27–2.57, and 2.99, 1.73–5.16, in NRMUCH and RMUCH defined by daytime BP, respectively, and 1.58, 1.12–2.23, and 2.21, 1.27–3.82, in NRMUCH and RMUCH defined by 24‐h BP, respectively. If RMUCH was compared with NRMUCH, the risk tended to be higher in RMUCH but did not attain statistical significance (P = .08 and P = .23 by daytime and 24‐h BP thresholds, respectively). In conclusion, both NRMUCH and RMUCH are at increased cardiovascular risk than CH

Ambulatory blood pressure and risk of new‐onset atrial fibrillation in treated hypertensive patients

Abstract The aim of this study was to evaluate the influence of clinic and ambulatory blood pressure (BP) on the occurrence of new‐onset atrial fibrillation (AF) in treated hypertensive patients. We studied 2135 sequential treated hypertensive patients aged >40 years. During the follow‐up (mean 9.7 years, range 0.4–20 years), 116 events (new‐onset AF) occurred. In univariate analysis, clinic, daytime, nighttime, and 24‐h systolic BP were all significantly associated with increased risk of new‐onset AF, that is, hazard ratio (95% confidence interval) per 10 mm Hg increment 1.22 (1.11–1.35), 1.36 (1.21–1.53), 1.42 (1.29–1.57), and 1.42 (1.26–1.60), respectively. After adjustment for various covariates in multivariate analysis, clinic systolic BP was no longer associated with increased risk of new‐onset AF, whereas daytime, nighttime, and 24‐h systolic BP remained significantly associated with outcome, that is, hazard ratio (95% confidence interval) per 10 mm Hg increment 1.09 (0.97–1.23), 1.23 (1.10–1.39), 1.16 (1.03–1.31), and 1.22 (1.06–1.40), respectively. Daytime, nighttime, and 24‐h systolic BP are superior to clinic systolic BP in predicting new‐onset AF in treated hypertensive patients. Future studies are needed to evaluate whether a better control of ambulatory BP might be helpful in reducing the occurrence of new‐onset AF

Prediction of Masked Uncontrolled Hypertension Detected by Ambulatory Blood Pressure Monitoring

The aim of this study was to provide prediction models for masked uncontrolled hypertension (MUCH) detected by ambulatory blood pressure (BP) monitoring in an Italian population. We studied 738 treated hypertensive patients with normal clinic BPs classified as having controlled hypertension (CH) or MUCH if their daytime BP was &lt; or &ge;135/85 mmHg regardless of nighttime BP, respectively, or CH or MUCH if their 24-h BP was &lt; or &ge;130/80 mmHg regardless of daytime or nighttime BP, respectively. We detected 215 (29%) and 275 (37%) patients with MUCH using daytime and 24-h BP thresholds, respectively. Multivariate logistic regression analysis showed that males, those with a smoking habit, left ventricular hypertrophy (LVH), and a clinic systolic BP between 130&ndash;139 mmHg and/or clinic diastolic BP between 85&ndash;89 mmHg were associated with MUCH. The area under the receiver operating characteristic curve showed good accuracy at 0.78 (95% CI 0.75&ndash;0.81, p &lt; 0.0001) and 0.77 (95% CI 0.73&ndash;0.80, p &lt; 0.0001) for MUCH defined by daytime and 24 h BP, respectively. Internal validation suggested a good predictive performance of the models. Males, those with a smoking habit, LVH, and high-normal clinic BP are indicators of MUCH and models including these factors provide good diagnostic accuracy in identifying this ambulatory BP phenotype