Resistant Hypertension and Obstructive Sleep Apnea: The Sparring Partners

Enhanced target organ damage and cardiovascular morbidity represent common issues observed in both resistant hypertension and obstructive sleep apnea. Common pathophysiological features and risk factors justify their coexistence, especially in individuals with increased upper-body adiposity. Impaired sodium handling, sympathetic activation, accelerated arterial stiffening, and impaired cardiorenal hemodynamics contribute to drug-resistant hypertension development in obstructive sleep apnea. Effective CPAP therapy qualifies as an effective “add-on” to the underlying antihypertensive pharmacological therapy, and emerging evidence underlines the favorable effect of mineralocorticoid antagonists on both resistant hypertension and obstructive sleep apnea treatment

AJCD1105001

Abstract: Periodontitis is a bacterially-induced, localized chronic inflammatory disease destroying both the connective tissue and the supporting bone of the teeth. In the general population, severe forms of the disease demonstrate a prevalence of almost 5%, whereas initial epidemiological evidence suggests an association between periodontitis and coronary artery disease (CAD). Both the infectious nature of periodontitis and the yet etiologically unconfirmed infectious hypothesis of CAD, question their potential association. Ephemeral bacteremia, systemic inflammation and immune-pathological reactions constitute a triad of mechanisms supporting a cross-talk between periodontal and vascular damage. To which extent each of these periodontitis-mediated components contribute to vascular damage still remains uncertain. More than twenty years from the initial epidemiological association, the positive weight of evidence remains still alive but rather debated, because of both the presence of many uncontrolled confounding factors and the different assessment of periodontal disease. From the clinical point of view, advising periodontal prevention or treatment targeting on the prevention of CAD it is unjustified. By contrast, oral hygiene including periodontal health might contribute to the overall well-being and healthy lifestyle and hence as might at least partially contribute to cardiovascular prevention

Ethnic and sex-related differences at presentation in apical hypertrophic cardiomyopathy: An observational cross-sectional study.

BACKGROUND: We investigated whether ethnicity and sex are associated with different clinical presentations and cardiovascular magnetic resonance (CMR) findings in individuals with apical hypertrophic cardiomyopathy (ApHCM). METHODS: A retrospective observational cohort study of consecutive ApHCM patients from a large tertiary referral center in the United Kingdom (UK). Demographic, clinical, 12‑lead electrocardiogram (ECG) and CMR findings were collected. Participants presented in our clinics between 2010 and 2020. 'Pure' ApHCM was defined as isolated apical hypertrophy and 'mixed' with both apical and septal hypertrophy but with the apical segments of a greater wall thickness. Deep T-wave inversion was defined as ≥5 mm in any electrocardiogram lead. RESULTS: A total of 150 consecutive ApHCM patients (75% men, 25% women; 37% White, 25% Black, 24% Asian and 15% of Mixed/Other ethnicity) were included. Females were diagnosed at an older age compared to men, had less prominent ECG changes, had higher left atrial area index, and were more hypertensive. Black patients had higher left ventricular mass index, more hypertension, and more of the 'mixed' type of ApHCM. The majority of hypertensive male patients showed the 'mixed' phenotype. CONCLUSIONS: Individuals of Black ethnicity and hypertensive male patients are more likely to present with mixed apical and basal hypertrophy, whereas White, Asian and non-hypertensive male patients tend to have hypertrophy limited to the apex. Females present at an older age and are less likely to have deep T wave inversion on ECG

The efficacy of antihypertensiye drugs in chronic intermittent hypoxia conditions

The authors would like to thank the Portuguese Fundacao para a Ciencia e a Tecnologia (FCT) and CEDOC (Chronic Diseases Research Centre, Lisbon, Portugal). Lucilia N. Diogo is supported by an FCT fellowship (SFRH/BD/48335/2008; PTDC/SAU-TOX/112264/2009).Sleep apnea/hypopnea disorders include centrally originated diseases and obstructive sleep apnea (OSA). This last condition is renowned as a frequent secondary cause of hypertension (HT). The mechanisms involved in the pathogenesis of HT can be summarized in relation to two main pathways: sympathetic nervous system stimulation mediated mainly by activation of carotid body (CB) chemoreflexes and/or asphyxia, and, by no means the least important, the systemic effects of chronic intermittent hypoxia (CIH). The use of animal models has revealed that CIH is the critical stimulus underlying sympathetic activity and hypertension, and that this effect requires the presence of functional arterial chemoreceptors, which are hyperactive in CIH. These models of CIH mimic the HT observed in humans and allow the study of CIH independently without the mechanical obstruction component. The effect of continuous positive airway pressure (CRAP), the gold standard treatment for OSA patients, to reduce blood pressure seems to be modest and concomitant antihypertensive therapy is still required. We focus this review on the efficacy of pharmacological interventions to revert HT associated with CIH conditions in both animal models and humans. First, we explore the experimental animal models, developed to mimic HT related to CIH, which have been used to investigate the effect of antihypertensive drugs (AHDs). Second, we review what is known about drug efficacy to reverse HT induced by CIH in animals. Moreover, findings in humans with OSA are cited to demonstrate the lack of strong evidence for the establishment of a first-line antihypertensive regimen for these patients. Indeed, specific therapeutic guidelines for the pharmacological treatment of HT in these patients are still lacking. Finally, we discuss the future perspectives concerning the non-pharmacological and pharmacological management of this particular type of HT.publishersversionpublishe

Prevalence and diagnostic significance of de-novo 12-lead ECG changes after COVID-19 infection in elite soccer players.

BACKGROUND AND AIM: The efficacy of pre-COVID-19 and post-COVID-19 infection 12-lead ECGs for identifying athletes with myopericarditis has never been reported. We aimed to assess the prevalence and significance of de-novo ECG changes following COVID-19 infection. METHODS: In this multicentre observational study, between March 2020 and May 2022, we evaluated consecutive athletes with COVID-19 infection. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes. RESULTS: 511 soccer players (median age 21 years, IQR 18-26 years) were included. 17 (3%) athletes demonstrated de-novo ECG changes, which included reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7); and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed evidence of inflammatory cardiac sequelae. All 30 athletes who underwent a mandatory CMR scan had normal findings. Athletes revealing de-novo ECG changes had a higher prevalence of cardiac symptoms (71% vs 12%, p<0.0001) and longer median symptom duration (5 days, IQR 3-10) compared with athletes without de-novo ECG changes (2 days, IQR 1-3, p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 20%. CONCLUSIONS: 3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with cardiac inflammation. Most affected athletes exhibited cardiac symptoms; however, de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms

Prevalence and diagnostic significance of de-novo 12-lead ECG changes after COVID-19 infection in elite soccer players.

Background and aim: The efficacy of pre-COVID-19 and post-COVID-19 infection 12-lead ECGs for identifying athletes with myopericarditis has never been reported. We aimed to assess the prevalence and significance of de-novo ECG changes following COVID-19 infection. Methods: In this multicentre observational study, between March 2020 and May 2022, we evaluated consecutive athletes with COVID-19 infection. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes. Results: 511 soccer players (median age 21 years, IQR 18-26 years) were included. 17 (3%) athletes demonstrated de-novo ECG changes, which included reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7); and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed evidence of inflammatory cardiac sequelae. All 30 athletes who underwent a mandatory CMR scan had normal findings. Athletes revealing de-novo ECG changes had a higher prevalence of cardiac symptoms (71% vs 12%, p<0.0001) and longer median symptom duration (5 days, IQR 3-10) compared with athletes without de-novo ECG changes (2 days, IQR 1-3, p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 20%. Conclusions: 3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with cardiac inflammation. Most affected athletes exhibited cardiac symptoms; however, de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms

The effect of continuous positive airway pressure (CPAP) and the role of chronotherapy in blood pressure control in hypertensive patients with obstructive sleep apnea-hypopnea syndrome

Objective: Patients with Obstructive Sleep Apnea (OSA) are often hypertensive, and Continuous Positive Airway Pressure (CPAP) may improve levels and nighttime behavior of blood pressure (BP). As asymptomatic patients with OSA often refuse to follow CPAP treatment, we investigated the efficacy of different dosing times of antihypertensive drugs on BP management in this setting.Design and Method: In this prospective, 16-week, open-label, cross-over, stable-dose chronotherapy trial, we studied 41 patients (aged 52±8 years, 78% males) with newly diagnosed hypertension and never treated, at least moderate OSA (apnea-hypopnea index-AHI:37±20/hour), without daytime sleepiness (Epworth Sleepiness Scale Score≤10 points). Patients were first applied treatment with valsartan (stage I hypertension) or combined valsartan/amlodipine (stage II hypertension) in a single morning dose for 8-weeks. In a second period of 8-weeks, patients were assigned to receive the same regimen in a single evening dose before bedtime. Office and ambulatory BP were measured at baseline and after each treatment phase. Based on concurrent start of CPAP application, patients were divided into two groups: on-CPAP (n=20) and off-CPAP (n=21).Results: Sixteen patients had stage I and 25 patients had stage II hypertension. Office BP was significantly reduced at the end of both the morning and evening dosing phases compared to baseline (by 19.4±11.0/15.0±8.6mmHg and 23.1±11/16.7±8.4mmHg, repeated measures ANOVA p<0.001). Evening dosing was accompanied by a significant further decrease of office systolic BP (by 3.7±6.5mmHg, p=0.002). The decrease in 24-hour BP was significant but similar in the two dosing times (by 16.4±11/11.0±7.5mmHg and 18.4±11/12.1±7.5mmHg, p<0.001). However, evening compared to morning dosing caused a further reduction in nighttime BP by 4.4±8.6/2.9±5.6mmHg (p=0.007 and 0.006 respectively). Prevalence of nighttime dipping increased from 24% at baseline modestly to 34% with the morning dose and significantly to 61% with the evening dose. There was no significant association between CPAP application and changes in BP parameters. BP variability and morning surge were similar among the treatment phases. Conclusions: Evening compared to morning dosing of antihypertensive treatment is more effective in improving nighttime BP levels and dipping status in non-sleepy patients with OSA, irrespective of application of CPAP. The effect of CPAP on BP is not identifiable over the application of conventional antihypertensive treatment.Σκοπός: Να διερευνηθεί η αποτελεσματικότητα της εφαρμογής αρχών χρονοθεραπείας στην αντιυπερτασική αγωγή σε υπερτασικούς ασθενείς με Αποφρακτική Υπνική Άπνοια και χωρίς ημερήσια υπνηλία σε συνδυασμό με τη χρήση Συνεχούς Θετικής Πίεσης Αεραγωγών (CPAP). Υλικό και Μέθοδοι: Σε μία προοπτική, ανοικτή, διασταυρούμενη μελέτη χρονοθεραπείας σταθερής δόσης διάρκειας 16 εβδομάδων, παρακολουθήθηκαν 41 ασθενείς (ηλικίας 52±8 ετών, 78% άνδρες) με ιδιοπαθή υπέρταση και τουλάχιστον μέτριας βαρύτητας ΑΥΑ (δεικτής άπνοιας-υπόπνοιας-ΔΑΥ:37±20/ώρα), χωρίς ημερήσια υπνηλία (κλίμακα ημερήσιας υπνηλίας Epworth≤10 βαθμοί). Σε δύο διαδοχικές περιόδους 8 εβδομάδων έκαστη, χορηγήθηκε θεραπεία με βαλσαρτάνη (υπέρταση σταδίου Ι) ή συνδυασμένη θεραπεία με βαλσαρτάνη και αμλοδιπίνη (υπέρταση σταδίου ΙΙ) σε μία πρωινή και μία βραδυνή ημερήσια δόση αντίστοιχα. Στην αρχική επίσκεψη και στο πέρας κάθε περιόδου πραγματοποιήθηκε μέτρηση ΑΠ ιατρείου και 24ωρης ΑΠ. Βάσει της αποδοχής της θεραπείας με CPAP οι ασθενείς διαχωρίσθηκαν σε δύο ομάδες: υπό-CPAP (n=20) και άνευ-CPAP (n=21).Αποτελέσματα: Δεκαέξι ασθενείς είχαν υπέρταση σταδίου Ι και 25 ασθενείς υπέρταση σταδίου ΙΙ. Η ΑΠ ιατρείου μειώθηκε σημαντικά μετά από τις περιόδους πρωινής και βραδυνής δόσης σε σχέση με τα αρχικά επίπεδα (κατά 19.4±11/15.0±8.6mmHg και 23.1±11/16.7±8.4mmHg, ANOVA p<0.001). Η βραδυνή δόση οδήγησε σε σημαντικά μεγαλύτερη μείωση της συστολικής ΑΠ (κατά 3.7±6.5mmHg, p=0.002) σε σχέση με την πρωινή δόση. Η μείωση της 24ωρης ΑΠ ήταν σημαντική αλλά παρόμοια στους δύο δοσολογικούς χρόνους (κατά 16.4±11/11.0±7.5 mmHg και 18.4±11/12.1±7.5 mmHg, p<0.001). Η βραδυνή δόση προκάλεσε περαιτέρω μείωση της νυκτερινής ΑΠ κατά 4.4±8.6/2.9±5.6 mmHg (p=0.007 και 0.006 αντίστοιχα). Ο επιπολασμός του νυκτερινού dipping αυξήθηκε από 24% στην αρχική επίσκεψη σε 34% με την πρωινή δόση και σε 61% με τη βραδυνή δόση. Δεν παρατηρήθηκε συσχέτιση μεταξύ της εφαρμογής CPAP και των μεταβολών στα επίπεδα της ΑΠ ιατρείου και της 24ωρης, ημερήσιας και νυκτερινής ΑΠ. Η μεταβλητότητα της ΑΠ και η πρωινή αιχμή της συστολικής ΑΠ δε μεταβλήθηκαν σημαντικά στις διαδοχικές φάσεις της μελέτης.Συμπεράσματα: Η βραδυνή έναντι της πρωινής χορήγησης της αντιυπερτασικής αγωγής είναι αποτελεσματικότερη στη βελτίωση της νυκτερινής ΑΠ και της κατάστασης dipping, σε υπερτασικούς ασθενείς με ΑΥΑ χωρίς ημερήσια υπνηλία, ανεξάρτητα της εφαρμογής CPAP. Η επίδραση της CPAP στις παραμέτρους της ΑΠ δεν είναι εμφανής όταν επιπροστίθεται στην κλασσική αντιυπερτασική αγωγή