Resistant hypertension: Renal denervation or pharmacovigilance? Insights from a renal denervation screening program

BACKGROUND: With emerging new therapeutic concepts including renal denervation (RDN), there is a renewed interest in resistant hypertension (ResH). Among patients suspected of having ResH, a definitive diagnosis needs to be established. OBJECTIVES: This study presents observations from a standardized single-center screening program for RDN candidates, including medical therapy modification and reassessment. MATERIAL AND METHODS: All patients referred to our center for RDN underwent a standardized screening protocol. Candidates were recruited from among patients receiving no less than 3 antihypertensive drugs, including diuretics with office blood pressure (BP) \u3e140/90 mm Hg. The assessment included 2 measurements of BP and ambulatory BP monitoring (ABPM). If needed, pharmacotherapy was intensified and the diagnosis of ResH was reconfirmed after 6 weeks. If ResH was persistent, patients were hospitalized with repeated ABPM on day 4. Further, renal CT-angio was performed and a multidisciplinary team discussed the patients\u27 suitability for RDN. RESULTS: A total of 87 patients with a ResH diagnosis were referred for RDN. Mean office BP was 159/92 (±7.0/6.5) mm Hg and mean ABPM was 154/90 (±9.0/4.8) mm Hg. The initial medication included angiotensin convertase inhibitors (ACE-I, 78%), angiotensin receptor blockers (12%), β-blockers (85%), calcium channel blockers (36%), and diuretics (93%). During the 18 months of the RDN program, 5 patients underwent RDN and 2 further had ineligible renal anatomy. A new diagnosis of secondary hypertension was made in 21 patients. However, in 59 patients, BP control was achieved after optimization of medical therapy, with a mean ABPM of 124/74 mm Hg. The final treatment included ACE-I (100%), β-blockers (92%), indapamide (94%), amlodipine (72%), and spironolactone (61%). Medication in most of these patients (88%) included single-pill triple combination (52.5%) or double combination (35.6%). CONCLUSIONS: Patients with elevated BP screened for RDN require a rigorous diagnostic workup. Up to 2/3 of patients can be managed with strict pharmacotherapy compliance and pharmaceutical intensification, including single-pill combinations and improved drug compliance. Hasty use of RDN may be a result of poor drug optimization and/or compliance. It does remain a viable treatment option in thoroughly vetted ResH patients

Ostra zatorowość płucna przebiegająca pod maską ostrego zespołu wieńcowego - opis przypadku

Zatorowość płucna jest jedną z najczęstszych przyczyn zgonów sercowo-naczyniowych. Wczesne leczenie pozwala istotnie zmniejszyć ryzyko zgonu, nadal jednak pozostaje niepokojąco duży odsetek nierozpoznanych i nieleczonych przypadków. U wielu pacjentów z rozpoznanym zatorem tętnicy płucnej, mimo dobrze poznanych czynników predysponujących do rozwoju żylnej choroby zakrzepowo-zatorowej, nie udaje się ustalić przyczyny. Objawy zatorowości płucnej są mało swoiste i często obecne w wielu innych chorobach układu krążenia i układu oddechowego. Tym niemniej właściwie wykonane i zinterpretowane proste badania diagnostyczne, wsparte przesłankami klinicznymi pozwalają na prawidłowe rozpoznanie

Relationship between echocardiographic parameters and exercise test duration in patients after myocardial infarction

Background: The interdependence between echocardiographic parameters of left ventricle function, severity of heart failure (HF) and exercise test duration has not been thoroughly examined. Methods: We compared echocardiographic data in patients after myocardial infarction divided according to NYHA class to mild (class I and II, group 1 = 24 subjects) and advanced HF group (III and IV, group 2 = 36) and assessed their correlation with exercise duration (ED) in a symptom-limited treadmill test. Then we tried to determine independent predictors of ED. Results: The group with advanced HF had lower left ventricle ejection fraction, shorter duration and deceleration times of both mitral inflow waves (Et and At, Edt and Adt) and higher E/A ratio (1.4 &#177; 1.1 vs. 0.9 &#177; 0.4; p < 0.05) with more frequent restriction and pseudonormalization pattern (56% vs. 12%). Also early wave propagation (21 &#177; 7 vs. 29 &#177; 11 cm/s; p < 0.001) and all tissue Doppler velocities were lower, but ratio of early wave peak velocity to early diastolic velocity of mitral annulus was higher (E/E&#8217; 10.5 &#177; 5 vs. 6.1 &#177; 1.3 for velocity ratio; p < 0.001) in subjects with more severe clinical symptoms. Significant negative correlation with ED was observed for difference between duration of pulmonary vein atrial reversal flow and atrial wave of mitral inflow (&#8710;At; r = &#8211;0.54) and for E/E&#8217; ratio (r = &#8211;0.48), the highest positive correlation for left ventricular ejection fraction and duration of mitral inflow atrial phase (EF; r = 0.48, At; r = 0.46). In multivariate stepwise regression analysis two independent predictors of ED were identified: age and &#8710;At (Art&#8211;At). Conclusions: Diastolic parameters showing the strongest correlation with ED (&#8710;At and E/E&#8217;) are connected with restrictive left ventricle physiology. The only independent predictors of exercise duration in patients after myocardial infarction were: age and &#8710;At

Conscious sedation for transcatheter implantation of atrial septal occluders with two- and three-dimensional transoesophageal echocardiography guidance — a feasibility and safety study

Background: General anaesthesia may have negative impact on patient mortality and morbidity, as well as overall procedure costs, in atrial septal occluder (ASO) implantation. Aim: We sought to evaluate the safety, efficacy, and feasibility of conscious sedation for transcatheter implantation of ASOs. Methods: A total of 122 patients referred for transcatheter implantation of ASO were included. Mean patient age was 51 ± 15 years, and 43 (35%) patients were male. The initial dose of midazolam was 2 mg and fentanyl dose was 25 μg. Additional doses of midazolam and fentanyl were administered, if necessary. Patient responsiveness was assessed every 10 min, and the sedatives doses were titrated in order not to exceed grade 3 sedation in the Ramsey scale. Results: Atrial septal occluders were successfully implanted in the majority of patients (98.4%). In two (1.6%) cases the proce­dure failed because of too small patent foramen ovale (PFO) diameter (n = 1, 0.8%) or device instability (n = 1, 0.8%). The mean duration of procedure was 47.6 ± 28.4 min and was similar for ASD and PFO closure (p = 0.522). The overall mean dose of midazolam was 4.7 ± 2.2 mg (63.9 ± 32.5 μg/kg) and fentanyl was 30.0 ± 11.9 μg (0.43 ± 0.17 μg/kg). Median entrance dose of radiation at the patient plane was 25 (interquartile range: 16–57) mGy, and did not differ between ASD and PFO procedures (p = 0.614). The majority of patients were free of complications (91.0%). The following early complications were observed: transient ischaemic attack (n = 2, 1.6%), supraventricular arrhythmias (n = 4, 3.3%), left atrial thrombus formation (n = 1, 0.8%), symptomatic bradycardia (n = 1, 0.8%), and femoral venous bleeding (n = 5, 4.1%). After mean follow-up of 386 days residual shunt was observed in eight (6.6%) patients. Conclusions: Conscious sedation for transcatheter implantation of ASO is a feasible, safe, and efficient technique, allowing successful PFO and ASD closure in the majority of patients.Background: General anaesthesia may have negative impact on patient mortality and morbidity, as well as overall procedure costs, in atrial septal occluder (ASO) implantation. Aim: We sought to evaluate the safety, efficacy, and feasibility of conscious sedation for transcatheter implantation of ASOs. Methods: A total of 122 patients referred for transcatheter implantation of ASO were included. Mean patient age was 51 ± 15 years, and 43 (35%) patients were male. The initial dose of midazolam was 2 mg and fentanyl dose was 25 μg. Additional doses of midazolam and fentanyl were administered, if necessary. Patient responsiveness was assessed every 10 min, and the sedatives doses were titrated in order not to exceed grade 3 sedation in the Ramsey scale. Results: Atrial septal occluders were successfully implanted in the majority of patients (98.4%). In two (1.6%) cases the proce­dure failed because of too small patent foramen ovale (PFO) diameter (n = 1, 0.8%) or device instability (n = 1, 0.8%). The mean duration of procedure was 47.6 ± 28.4 min and was similar for ASD and PFO closure (p = 0.522). The overall mean dose of midazolam was 4.7 ± 2.2 mg (63.9 ± 32.5 μg/kg) and fentanyl was 30.0 ± 11.9 μg (0.43 ± 0.17 μg/kg). Median entrance dose of radiation at the patient plane was 25 (interquartile range: 16–57) mGy, and did not differ between ASD and PFO procedures (p = 0.614). The majority of patients were free of complications (91.0%). The following early complications were observed: transient ischaemic attack (n = 2, 1.6%), supraventricular arrhythmias (n = 4, 3.3%), left atrial thrombus formation (n = 1, 0.8%), symptomatic bradycardia (n = 1, 0.8%), and femoral venous bleeding (n = 5, 4.1%). After mean follow-up of 386 days residual shunt was observed in eight (6.6%) patients. Conclusions: Conscious sedation for transcatheter implantation of ASO is a feasible, safe, and efficient technique, allowing successful PFO and ASD closure in the majority of patients

FEBUKO and MODMEP: Field measurements and modelling of aerosol and cloud multiphase processes

An overview of the two FEBUKO aerosol–cloud interaction field experiments in the Thüringer Wald (Germany) in October 2001 and 2002 and the corresponding modelling project MODMEP is given. Experimentally, a variety of measurement methods were deployed to probe the gas phase, particles and cloud droplets at three sites upwind, downwind and within an orographic cloud with special emphasis on the budgets and interconversions of organic gas and particle phase constituents. Out of a total of 14 sampling periods within 30 cloud events three events (EI, EII and EIII) are selected for detailed analysis. At various occasions an impact of the cloud process on particle chemical composition such as on the organic compounds content, sulphate and nitrate and also on particle size distributions and particle mass is observed. Moreover, direct phase transfer of polar organic compound from the gas phase is found to be very important for the understanding of cloudwater composition. For the modelling side, a main result of the MODMEP project is the development of a cloud model, which combines a complex multiphase chemistry with detailed microphysics. Both components are described in a fine-resolved particle/drop spectrum. New numerical methods are developed for an efficient solution of the entire complex model. A further development of the CAPRAM mechanism has lead to a more detailed description of tropospheric aqueous phase organic chemistry. In parallel, effective tools for the reduction of highly complex reaction schemes are provided. Techniques are provided and tested which allow the description of complex multiphase chemistry and of detailed microphysics in multidimensional chemistry-transport models