White coat hypertension is not a benign entity: a cross-sectional study at a tertiary care hospital in Pakistan

OBJECTIVES: To determine the frequency of White Coat Hypertension in patients undergoing ambulatory blood pressure monitoring at a tertiary care center and to compare ambulatory blood pressure profiles of normotensives, white coat hypertensives and hypertensives.METHODS: A descriptive cross-sectional study was conducted which included all adult patients undergoing ambulatory blood pressure monitoring over a 3-year period. Those patients with incomplete data, less than 85% successful BP readings and inadequate number of daytime and nighttime readings were excluded from the study. The data on ambulatory blood pressure monitoring comprised of demographics, blood pressure, pulse pressure and mean arterial pressure readings at every 30 minutes interval and also a graphical representation of patients\u27 24-hour blood pressure recording. SPSS was used for data analysis. Chi-square test and analysis of variance (ANOVA) was used for qualitative and quantitative variables respectively.RESULTS: A total of 277 patients with a mean age of 48.98 +/- 17.52 years were included. There were 189 (58%) males included in the study. Out of the total, 46 (16.6%) patients had White Coat Hypertension, 59 (21.3%) were Normotensive and 172 (62.1%) had Hypertension. The mean age of Normotensives was 40.80 +/- 14.11 years, White Coat Hypertensives was 37.72 +/- 14.58 years and Hypertensives was 54.80 +/- 16.76 years (

Nocturnal non-dipping pattern in untreated hypertensives at different cardiovascular risk according to the 2003 ESH/ESC guidelines.

To evaluate in a large population of untreated, uncomplicated essential hypertensives the relationship between alterations in nocturnal blood pressure (BP) profile, i.e. non-dipping pattern, and total cardiovascular risk.A total of 580 consecutive patients with grade 1 or 2 hypertension, referred to our outpatient clinic, underwent the following procedures: (i) clinical and routine laboratory examinations; (ii) 24-h ambulatory BP monitoring; (iii) 24-h collection for microalbuminuria; (iv) echocardiography; and (v) carotid ultrasonography. Cardiovascular risk was assessed according to the stratification scheme suggested by the 2003 ESH/ESC guidelines.According to this classification, 16.2% of the 580 patients were considered at low added risk, 42.4% at medium added risk and 41.4% at high added risk; 38.5% of the overall population was classified in the high-risk stratum because of at least one manifestation of target organ damage (TOD) and 6.3% for the presence of three or more risk factors. The prevalence rates of a non-dipping pattern (decrease in BP at nightor = 10% compared with the average daytime values) were 28.5% in low-risk, 32.6% in medium-risk and 42.2% in high-risk patients, respectively. CONCLUSIONS. Our findings show that the prevalence of a non-dipping profile is significantly greater in patients stratified at high compared with those at low and medium added risk

Associations of Blood Pressure Dipping Patterns With Left Ventricular Mass and Left Ventricular Hypertrophy in Blacks: The Jackson Heart Study

Background: Abnormal diurnal blood pressure (BP), including nondipping patterns, assessed using ambulatory BP monitoring, have been associated with increased cardiovascular risk among white and Asian adults. We examined the associations of BP dipping patterns (dipping, nondipping, and reverse dipping) with cardiovascular target organ damage (left ventricular mass index and left ventricular hypertrophy), among participants from the Jackson Heart Study, an exclusively black population–based cohort. Methods and Results: Analyses included 1015 participants who completed ambulatory BP monitoring and had echocardiography data from the baseline visit. Participants were categorized based on the nighttime to daytime systolic BP ratio into 3 patterns: dipping pattern (≤0.90), nondipping pattern (>0.90 to ≤1.00), and reverse dipping pattern (>1.00). The prevalence of dipping, nondipping, and reverse dipping patterns was 33.6%, 48.2%, and 18.2%, respectively. In a fully adjusted model, which included antihypertensive medication use and clinic and daytime systolic BP, the mean differences in left ventricular mass index between reverse dipping pattern versus dipping pattern was 8.3±2.1 g/m2 (P<0.001) and between nondipping pattern versus dipping pattern was −1.0±1.6 g/m2 (P=0.536). Compared with participants with a dipping pattern, the prevalence ratio for having left ventricular hypertrophy was 1.65 (95% CI, 1.05–2.58) and 0.96 (95% CI, 0.63–1.97) for those with a reverse dipping pattern and nondipping pattern, respectively. Conclusions: In this population‐based study of blacks, a reverse dipping pattern was associated with increased left ventricular mass index and a higher prevalence of left ventricular hypertrophy. Identification of a reverse dipping pattern on ambulatory BP monitoring may help identify black at increased risk for cardiovascular target organ damage

Spinal cord injury: assessment of autonomic state-dependent control of cardiovascular system and body core temperature

Spinal cord injury (SCI) results not only in paralysis; but it is also associated with a range of autonomic dysregulation that can interfere with cardiovascular, bladder, bowel, temperature, and sexual function. The entity of the autonomic dysfunction is related to the level and severity of injury to descending autonomic (sympathetic) pathways. For many years there was limited awareness of these issues and the attention given to them by the scientific and medical community was scarce. Yet, even if a new system to document the impact of SCI on autonomic function has recently been proposed, the current standard of assessment of SCI (American Spinal Injury Association (ASIA) examination) evaluates motor and sensory pathways, but not severity of injury to autonomic pathways. Beside the severe impact on quality of life, autonomic dysfunction in persons with SCI is associated with increased risk of cardiovascular disease and mortality. Therefore, obtaining information regarding autonomic function in persons with SCI is pivotal and clinical examinations and laboratory evaluations to detect the presence of autonomic dysfunction and quantitate its severity are mandatory. Furthermore, previous studies demonstrated that there is an intimate relationship between the autonomic nervous system and sleep from anatomical, physiological, and neurochemical points of view. Although, even if previous epidemiological studies demonstrated that sleep problems are common in spinal cord injury (SCI), so far only limited polysomnographic (PSG) data are available. Finally, until now, circadian and state dependent autonomic regulation of blood pressure (BP), heart rate (HR) and body core temperature (BcT) were never assessed in SCI patients. Aim of the current study was to establish the association between the autonomic control of the cardiovascular function and thermoregulation, sleep parameters and increased cardiovascular risk in SCI patients

Respuesta presora al estrés como marcador pronóstico de hipertensión futura

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina. Fecha de lectura: 8 de Noviembre de 2013

Variabilidade da pressão arterial : desempenho de diferentes métodos de avaliação e relação com desfechos cardiovasculares

Admite-se que a variabilidade da pressão arterial (PA) tem correlação direta com eventos cardiovasculares e o desenvolvimento de lesão em órgãos alvo. Contudo, as evidências ainda são limitadas sobre a utilização da variabilidade da PA como objetivo terapêutico anti-hipertensivo. Além disso, permanecem lacunas a respeito da real associação, independente das médias pressóricas ou outros fatores de confusão, entre os diferentes índices de variabilidade da PA obtidos pela monitorização ambulatorial de pressão arterial de 24 horas (MAPA-24h) e dano cardiovascular, além de ainda não existir critérios de normalidade para estes índices. Por esta razão, sua aplicabilidade clínica ainda não está totalmente definida na avaliação do risco cardiovascular mesmos em indivíduos de alto risco (hipertensos e diabéticos, por exemplo). No presente trabalho realizamos uma revisão sistemática com metanálise de estudos observacionais objetivando avaliar a associação entre a variabilidade da PA aferida por diferentes índices e métodos de monitorização da PA e a ocorrência de desfechos cardiovasculares e desenvolvemos um estudo transversal que analisou a associação entre diferentes parâmetros de variabilidade pressórica incluindo índice “time rate” aferido por MAPA-24h e parâmetros ecocardiográficos em indivíduos com hipertensão e diabetes mellitus. A revisão sistemática e metanálise incluiu estudos prospectivos que utilizavam alguma medida de variabilidade da PA a curto prazo (nas 24h) e a muito curto prazo (batimento a batimento) obtidos pela MAPA-24h e registros contínuos da PA. Os desfechos primordiais foram: mortalidade por todas as causas, mortalidade cardiovascular e eventos cardiovasculares, incluindo acidente vascular cerebral (AVC) e doença vascular periférica. Os desfechos substitutos escolhidos foram: hipertrofia ventricular esquerda (HVE) e comprometimento da função renal. Observou-se grande diversidade entre os estudos disponíveis nos protocolos variabilidade da PA, nos índices selecionados para quantificar a variabilidade da PA e nos desfechos utilizados para a avaliação. Os resultados vão ao encontro das recomendações da Sociedade Europeia de Hipertensão a qual preconiza que a variabilidade da PA a curto prazo dentro de 24 h pode ser considerada para a estratificação de risco em estudos populacionais e de coorte mas questões fundamentais permanecem sem resposta. No estudo transversal avaliamos a associação entre a variabilidade da PA medida pelos índices da MAPA 24h e variáveis ecocardiográficas em 305 pacientes hipertensos e diabéticos. O índice time-rate o qual é obtido pela MAPA-24-h e indica a variação pressórica a cada medida ao longo do tempo, não se associou independentemente com variáveis ecocardiograficas no modelo linear múltiplo quando ajustado para idade, MAPA 24h, duração do diabetes e HbA1c

Circadian Rhythm of Blood Pressure and its Modulation by the Antihypertensive Drugs in Hypertensive Patients of South Tamilnadu

Blood Pressure in humans exhibits a characteristic circadian rhythm with a nocturnal decline ranging between 10% - 20% of daytime values. This nocturnal decline has a high significance as its absence or diminution commonly known as non-dipping phenomenon is implicated in cardiovascular and cerebrovascular complications. Hence, the present study investigated the incidence of dipping (DP) and non-dipping phenomenon (NDP) in a normotensive and hypertensive population of South Tamil Nadu. NDP was observed in the normotensive population also. However the incidence was higher in hypertetnsive population than in normotensive population. In the normotensive population the incidence of DP was higher than NDP as it was high in normotensives aged below 50 and normotensives unemployed. Hence the higher prevalence of DP was dependent ton age and job strain. As unemployed are free from job strain, the incidence of DP was high in them against their employed counterparts and this freedom from job strain contributed to higher incidence of DP in normotensives. DP was lower than NDP in hypertensive population. The same effect was observed in all the subpopulations. So factors like sex, age and freedom from job strain could not reduce the prevalence of NDP in the hypertensive population. So it was concluded that the high NDP did not depend on age, sex and job strain. So it could be due to hypertension itself. Between the normotensive and hypertensive populations the prevalence of DNP was higher in hypertensive population than in normotensive population further suggesting the role of hypertension in NDP. From this study it is clear that antihypertensive drugs cannot fully restore the DP. Hence, search for antihypertensive drugs/formulations which could increase the DP in hypertensive population could be a potential area of research

Association entre les mouvements périodiques des jambes au cours du sommeil et l’intégrité de la matière blanche cérébrale

Les mouvements périodiques des jambes au cours du sommeil (MPJS) sont une activité motrice répétée et stéréotypée qui se caractérise par une dorsiflexion des orteils et de la cheville. Des travaux récents ont démontré une association temporelle entre les MPJS et une activation du système nerveux sympathique, qui se manifeste par une augmentation répétée de la tension artérielle et du rythme cardiaque. Avec l’âge, les MPJS pourraient donc favoriser l’apparition d’atteintes cérébrales via un processus d’artériolosclérose. Dans cette étude, trente-sept individus âgés entre 55 et 82 ans et présentant différents niveaux de sévérités de MPJS ont été inclus. Nous avons utilisé l'imagerie par résonance magnétique associée à la morphométrie basée sur les voxels et l’imagerie du tenseur de diffusion pour estimer la présence de changements en regard de la matière blanche et de la matière grise. Des analyses corrélationnelles ont été effectuées entre les marqueurs de sévérité des MPJS (indice de MPJS, intervalle inter-mouvement, durée des mouvements, association avec les micro-éveils) et les variables de neuroimagerie (hyperintensités, intégrité de la matière blanche et volume de la matière grise). Nos résultats ont démontré que des indices plus élevés de MPJS et des MPJS associés aux micro-éveils étaient associés à des réductions de l’intégrité de la matière blanche dans les régions fronto-temporo-pariétales. Une corrélation a été observée entre une réduction du volume de matière grise et un intervalle inter-mouvement plus long dans le gyrus frontal médian. Les associations observées dans notre échantillon soulèvent l’hypothèse que les MPJS puissent modifier la microstructure du cerveau et avoir un impact sur l’intégrité cérébrovasculaire chez des individus d’âge moyen ou plus âgé.Periodic leg movements during sleep (PLMS) are repeated and stereotyped nocturnal motor activity characterized by dorsiflexion of the toes and ankle. Recent studies showed a temporal association between PLMS and activation of the sympathetic nervous system, characterized by a repeated increase in blood pressure and heart rate. The PLMS might be involved in the genesis of cardiovascular damage and favor the occurrence of cerebral injuries via an arteriolosclerosis process. In the present study, thirty-seven healthy subjects aged between 55 and 82 years old were recorded for one night of in-laboratory polysomnography and participated to a brain magnetic resonance imaging (MRI) session. Regression analysis were performed between the four PLMS severity variables, namely the PLMS index (PLMSI), the average time interval between PLMS, the PLMS mean duration and the number of PLMS associated with a micro-arousal (PLMS-MA) and neuroimaging variables (white matter hyperintensities, white matter structure through diffusion tensor imaging (DTI) and gray matter volume through voxel-based morphometry (VBM). Our results showed that a higher PLMSI and PLMS-ME have been associated with reductions in white matter integrity in fronto-temporo-parietal regions. Also, reduction in grey matter volume was associated with a longer time interval between PLMS in the middle frontal gyrus. Associations observed in our sample suggest that PLMS may modify the microstructure of the brain and affect cerebrovascular integrity in middle-aged and older individuals