Reverse Takotsubo syndrome, a case report of a rare cause for postpartum heart failure

Predominant causes for newly diagnosed postpartum heart failure are preeclampsia and peripartum cardiomyopathy. Being an anatomical variant of Takotsubo syndrome (TTS) reverse TTS in this period is rare. We present a 36 year old patient, who had delivered triplets by cesarean section. Because of postpartum bleeding she was administered sulprostone. Later she was transferred to the Intensive Care Unit with sudden development of dyspnea, tachypnea and tachycardia. Clinical symptoms, laboratory findings and chest radiograph showed signs of acute heart failure. Transthoracic echocardiography (TTE) revealed reverse TTS with moderately reduced left ventricular ejection fraction (LVEF 39%). The patient stabilized with loop diuretic, angiotensine-converting enzyme inhibitors and beta-blockade. Breast-feeding was discouraged and bromocriptine administered. Left ventricular function normalized (LVEF 60%) within four weeks. TTS should be considered in patients with early postpartum development of heart failure. Rapid cardiac recompensation after the start of adequate therapy and complete resolution of clinical symptoms and TTE findings are typical for postpartum TTS

Influence of Antihypertensive Treatment on RAAS Peptides in Newly Diagnosed Hypertensive Patients.

(1) Background: Recently, influences of antihypertensive treatment on the renin-angiotensin-aldosterone system (RAAS) has gained attention, regarding a possible influence on inflammatory and anti-inflammatory pathways. We aimed to study the effects of newly initiated antihypertensive drugs on angiotensin (Ang) II and Ang (1-7) as representers of two counter-regulatory axes. (2) Methods: In this randomized, open-label trial investigating RAAS peptides after the initiation of perindopril, olmesartan, amlodipine, or hydrochlorothiazide, Ang II and Ang (1-7) equilibrium concentrations were measured at 8 a.m. and 12 a.m. at baseline and after four weeks of treatment. Eighty patients were randomized (1:1:1:1 fashion). (3) Results: Between the four substances, we found significant differences regarding the concentrations of Ang II (p < 0.0005 for 8 a.m., 12 a.m.) and Ang (1-7) (p = 0.019 for 8 a.m., <0.0005 for 12 a.m.) four weeks after treatment start. Ang II was decreased by perindopril (p = 0.002), and increased by olmesartan (p < 0.0005), amlodipine (p = 0.012), and hydrochlorothiazide (p = 0.001). Ang (1-7) was increased by perindopril and olmesartan (p = 0.008/0.002), but not measurably altered by amlodipine and hydrochlorothiazide (p = 0.317/ 0.109). (4) Conclusion: The initiation of all first line antihypertensive treatments causes early and distinct alterations of equilibrium angiotensin levels. Given the additional AT1R blocking action of olmesartan, RAAS peptides shift upon initiation of perindopril and olmesartan appear to work in favor of the anti-inflammatory axis compared to amlodipine and hydrochlorothiazide

How Should We Measure and Deal with Office Blood Pressure in 2021?

Arterial hypertension is a major risk factor for cardiovascular disease worldwide. Office blood pressure measurements (OBPMs) are still recommended for diagnosis and follow-up by all major guidelines; however, the recommended procedures differ significantly. In analogy, major outcome studies usually apply OBPMs, again, with a variety of procedures. This variety of OBPM procedures complicates the comparability between studies and challenges daily clinical practice. In this narrative review, we compile the most recent recommendations for office blood pressure measurement together with the major limitations and strategies and how these could be overcome

Special Issue: Hypertensive Heart Disease—From Pathophysiology to Therapeutical Challenges

Arterial hypertension (AHT) is the most important risk factor for cardiovascular disease worldwide [...

Hypertensive Heart Disease: A Narrative Review Series—Part 1: Pathophysiology and Microstructural Changes

Sustained hypertension causes structural, functional, and neurohumoral abnormalities in the heart, a disease commonly termed hypertensive heart disease (HHD). Modern concepts of HHD, including processes of remodeling leading to the development of various LVH patterns, HF patterns accompanied by micro- and macrovasculopathies, and heart rhythm and conduction disturbances, are missing in the available definitions, despite copious studies being devoted to the roles of myocardial and vascular fibrosis, and neurohumoral and sympathetic regulation, in HHD development and progression. No comprehensive and generally accepted universal definition and classification of HHD is available to date, implementing diagnostic criteria that incorporate all the possible changes and adaptions to the heart. The aim of this review series is to summarize the relevant literature and data, leading to a proposal of a definition and classification of HHD. This first article reviews the processes of initial myocardial remodeling, and myocardial and vascular fibrosis, occurring in HHD. We discuss important pathophysiological and microstructural changes, the different patterns of fibrosis, and the biomarkers and imaging used to detect fibrosis in HHD. Furthermore, we review the possible methods of targeting myocardial fibrosis in HHD, and highlight areas for further research

A model for early failure prediction of blood pressure measurement devices in a stepped validation approach

Abstract Blood pressure monitoring (BPM) devices have to be validated according to strict international validation protocols. Each protocol requests a specific number of participants to be included. All protocols use vast amounts of resources, as three people have to be present for every measurement, making trials costly, especially when the manufacturer has no intention to execute a validation study, reflected in the low share of validated in the commercially available BPM devices. The aim of our study was to develop criteria, which could detect low accuracy devices that could not pass a validation protocol early in the course of the validation process. The 2010 European Society of Hypertension International Protocol (ESH‐IP) and the Universal Standard for Validation of BPM devices (AAMI/ESH/ISO) were scrutinized for criteria which can be used for preclusion of passing. Based on this, we developed a fail model. We found that a BPM device cannot pass the ESH‐IP protocol, if there are ≥27, 13, or 4 single measurements differing more than 5, 10, or 15 mmHg, respectively, from the reference. For the AAMI/ESH/ISO protocol, we developed a model, which calculates best‐case standard deviations (SDs) to detect SDs which would prevent the passing of the protocol before its completion, making a stepwise validation process possible. In conclusion, we found that our model is able to predict failure of low‐accuracy BPM devices early during a validation protocol if used in a stepwise‐approach. This can be useful to keep costs of validation studies low and to enable investigator‐initiated trials

Reply to Hungerford, S.; Bart, N. Blood-Pressure-Monitoring Smartphone Applications: Ushering in a New Era of Wearable Cardiac Devices? Comment on “Vischer et al. Comparability of a Blood-Pressure-Monitoring Smartphone Application with Conventional Measurements—A Pilot Study. <i>Diagnostics</i> 2022, <i>12</i>, 749”

We would like to thank Drs. Hungerford and Bart for their kind comment [...

Prevalence and Characterisation of Severe Left Ventricular Hypertrophy Diagnosed by Echocardiography in Hypertensive Patients

Background: Arterial hypertension (AHT) is the leading preventable cause of death worldwide. Left ventricular hypertrophy (LVH) is one of the most important prognostic markers in hypertension and a predictor for mortality. The goals of this study were to examine the prevalence of LVH detected by echocardiography in patients with AHT and to describe patients with severe LVH. Methods: This is a retrospective monocentric study including patients treated at a tertiary hypertension clinic. Echocardiographic data were taken from written reports from our hospital’s echocardiography laboratories. We compared patients with severe LVH (septum thickness ≥ 15 mm) with patients with normal left ventricular (LV) geometry and with patients with concentric or eccentric hypertrophy regarding age, gender, comorbidities, medication, duration of hypertension, blood pressure (BP) and ECG changes at time of echocardiography. Results: Twenty-nine patients (7.3%) out of four hundred patients showed severe LVH and one hundred and eighty-nine (47.3%) a normal geometry. In comparison to patients with normal geometry, patients with severe LVH were more likely to be male, older, and with more uncontrolled BP, especially regarding asleep values, multi-drug antihypertensive treatment and comorbidities. In comparison to patients with concentric or eccentric hypertrophy, patients with severe LVH had a significantly higher diastolic BP in the 24 h mean, awake and asleep values. A positive Sokolow-Lyon index did not predict LVH. However, patients with severe LVH were more likely to have T-wave-inversions V4–V6 in at least one lead. Conclusions: More than half of the patients with AHT have an abnormal geometry in our study (52.5%) and 7.3% a severe LVH. Patients with severe LVH have more often an uncontrolled AHT than patients with a normal LV geometry, despite more antihypertensive treatment. The Sokolow-Lyon index seems to be insufficient to detect LVH

How should we measure blood pressure? Implications of the fourth blood pressure measurement in office blood pressure

Abstract According to the European Hypertension Guidelines regarding office blood pressure measurements (OBPMs), the mean between second/third or third/fourth OBPM should be taken if the first two readings differ by ≤10 or >10 mmHg, respectively. Our aim was to explore the value of the fourth OBPM and determine whether a simplified OBPM procedure is feasible without loss of quality. In this cross‐sectional study, four standard OBPMs were taken. The mean of the second/third OBPM (S2S3/D2D3) and third/fourth OBPM (S3S4/D3D4) for systolic/diastolic values was calculated. Correlation, agreement, and differences regarding BP classification were explored for the entire cohort and subsets with a difference between the first/second OBPM (S1S2/D1D2) ≤10 and >10 mmHg. Overall (n = 802) and for the subsets with an S1S2 (n = 596) and D1D2 (n = 742) difference ≤10 mmHg, S3S4/D3D4 was in median 0.5 mmHg lower than S2S3/D2D3, respectively (p 10 mmHg, S3S4/D3D4 differed numerically from S2S3/D2D3, respectively (p > .1 for all). Overall and for all subsets with an S1S2/D1D2 difference ≤10/>10 mmHg, less subjects were numerically classified as hypertensive with S3S4/D3D4 than with S2S3/D2D3 (p > .04), but BP reclassification occurred in both directions in 1.0%‐10.0%, depending on the cohort. In conclusion, the third/fourth OBPM results in lower BP values than the second/third measurement, regardless of the difference between first/second OBPM, whereby BP reclassifications occurred in both directions. Therefore, the cutoff of >10 versus ≤10mmHg difference between first/second OBPM to implement a fourth BPM harbors the risk of distorted results. We therefore recommend using the second/third BPM for standardized OBPM. Trial registration: Registered on clinicaltrials.gov (NCT02552030)

Accuracy of abbreviated protocols for unattended automated office blood pressure measurements, a retrospective study.

BackgroundBlood pressure measurement (BPM) is one of the most often performed procedures in clinical practice, but especially office BPM is prone to errors. Unattended automated office BPM (AOBPM) is somewhat standardised and observer-independent, but time and space consuming. We aimed to assess whether an AOBPM protocol can be abbreviated without losing accuracy.DesignIn our retrospective single centre study, we used all AOBPM (AOBPM protocol of the SPRINT study), collected over 14 months. Three sequential BPM (after 5 minutes of rest, spaced 2 minutes) were automatically recorded with the patient alone in a quiet room resulting in three systolic and diastolic values. We compared the mean of all three (RefProt) with the mean of the first two (ShortProtA) and the single first BPM (ShortProtB).ResultsWe analysed 413 AOBPM sets from 210 patients. Mean age was 52±16 years. Mean values for RefProt were 128.3/81.3 mmHg, for ShortProtA 128.4/81.4 mmHg, for ShortProtB 128.8/81.4 mmHg. Mean difference and limits of agreement for RefProt vs. ShortProtA and ShortProtB were -0.1±4.2/-0.1±2.8 mmHg and -0.5±8.1/-0.1±5.3 mmHg, respectively. With ShortProtA, 83% of systolic and 92% of diastolic measurements were within 2 mmHg from RefProt (67/82% for ShortProtB). ShortProtA or ShortProtB led to no significant hypertensive reclassifications in comparison to RefProt (p-values 0.774/1.000/1.000/0.556).ConclusionBased on our results differences between the RefProt and ShortProtA are minimal and within acceptable limits of agreement. Therefore, the automated procedure may be shorted from 3 to 2 measurements, but a single measurement is insufficient