Association between hypertensive urgencies and subsequent cardiovascular events in patients with hypertension.

OBJECTIVE: To determine whether patients with hypertensive urgency have a higher risk for subsequent cardiovascular events compared with hypertensive patients without this event. METHODS: Overall, 384 patients with hypertensive urgency and 295 control patients were followed up for at least 2 years. Hypertensive urgency was defined as a systolic blood pressure above 220 mmHg and/or a diastolic blood pressure above 120 mmHg without any evidence of acute end-organ damage. The control group consisted of patients admitted to the emergency department with a systolic blood pressure between 135 to 180 mmHg and a diastolic blood pressure between 85-110 mmHg. The number of cardiovascular events defined as acute coronary syndrome, acute stroke, atrial fibrillation, acute left ventricular failure and aortic aneurysm were consecutively analyzed during follow-up. The median follow-up time was 4.2 years (interquartile range 2.9-5.7 years). Twenty-six patients of the urgency group and 23 patients of the control group were lost for follow-up. RESULTS: Overall, 117 (17%) patients had nonfatal clinical cardiovascular events and 13 had (2%) fatal cardiovascular events. The frequency of cardiovascular events was significantly higher in patients with hypertensive urgencies (88 vs. 42; P = 0.005). The Cox regression analysis identified age (P < 0.001) and hypertensive urgencies (P = 0.035) as independent predictors for subsequent cardiovascular events. CONCLUSIONS: Hypertensive urgencies are associated with an increased risk for subsequent cardiovascular events in patients with arterial hypertension.

Does weight force application to the lower torso have an influence on inferior vena cava and cardiovascular parameters?

OBJECTIVE: The aim of this study was to determine whether weight force application to the lower torso can lead to impairment of inferior vena cava (IVC) and cardiovascular parameters. METHODS: Using ultrasound sonography and impedance cardiography, the effects of a weight force application of 5, 10, 15, and 25 kg to the lower torso, placed in prone position, on IVC diameter and maximal blood flow, mean artery pressure, stroke volume, heart rate, cardiac index, cardiac output, oxygen saturation (SpO(2)), and acceleration index were investigated in 6 healthy volunteers. RESULTS: The following parameters showed a statistically significant correlation with the amount of weight force applied: IVC diameter: r=-0.83, P < .001; IVC maximal blood flow: r=-0.76, P < .001; cardiac index: r=-0.33, P < .05; and cardiac output: r=-0.32, P < .05. CONCLUSION: Application of moderate weight force to the lower torso can lead to major changes in IVC parameters and minor changes in cardiovascular parameters.

Effects of candesartan and lisinopril on the fibrinolytic system in hypertensive patients.

The effects of the angiotensin II receptor blocker candesartan and the angiotensin-converting enzyme inhibitor lisinopril on the fibrinolytic system were investigated in a double-blinded, prospective, randomized study. Seventy-seven hypertensive patients taking candesartan (n=41) and lisinopril (n=36) with a systolic blood pressure >130 mm Hg and/or a diastolic blood pressure >80 mm Hg obtained by 24-hour ambulatory blood pressure measurement were included in the study. Blood pressure, plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (tPA), and the molar ratio of PAI-1/tPA were determined before treatment and 6 weeks later. Blood pressure decreased in both groups (candesartan, 155/85 mm Hg to 140/84 mm Hg; P<.05; lisinopril, 152/85 mm Hg to 138/83 mm Hg; P<.05). The fibrinolytic balance was significantly different between treatment groups (molar ratio of PAI-1/tPA: candesartan, 3.66 [2.2;] lisinopril, 5.44 [2.6;] P<.05). In contrast to lisinopril, the balance between coagulation and fibrinolytic activity shifted toward fibrinolysis during candesartan treatment.

Ramipril prior to thrombolysis attenuates the early increase of PAI-1 in patients with acute myocardial infarction.

In a placebo-controlled, double-blinded, randomized study we evaluated the effect of ramipril prior to thrombolysis on the course of PAI-1 plasma levels and on the frequency of postinfarct ischemic events in patients with acute myocardial infarction. Fifty-one out of 99 patients received 2.5 mg ramipril orally prior to thrombolysis and 12 h later. The blood samples for determination of PAI-1 plasma levels were collected on admission and 2, 4, 8, 12 and 24 h after thrombolysis. Postinfarct ischemic events were registered until coronary angiography was performed and defined as recurrent chest pain and/or evidence of ischemic signs on the ECG (ST-depression or ST-segment elevation of 1 mm in one or more inferior or anterior leads). Coronary angiography was performed within 7 days after the onset of myocardial infarction. Patients were classified into two groups: those without reperfusion of the infarct-related artery (TIMI grade 0 or 1) and those with reperfusion of the infarct-related artery (TIMI grade 2.3). On admission, PAI-1 plasma levels were similar in both groups (ramipril: 47.1 [4.8] ng/ml; placebo: 49.1 [4.8] ng/ml). The PAI-1AUC was 77.2 [6.7] ng/ml/h in the ramipril group and 95.4 [6.2] ng/ml/h in the placebo group (p = 0.013). Significant differences between groups were observed at 4, 8 and 12 h after thrombolysis (4 h: 85.5 (11.3) vs. 116 (12.3) ng/ml, p < 0.01; 8 h: 79.1 (11.2) vs. 100.9 (9.3) ng/ml, p < 0.01; 12 hrs: 71.3 (9.5) vs. 87.4 (7.7) ng/ml, p < 0.05). The relative frequency of postinfarct ischemic events was significantly lower in the ramipril group (2.5% versus 7.1%, p = 0.001). Additionally, we observed a significant higher rate of TIMI grade 2 and 3 of the infarct-related artery in patients receiving oral ramipril compared to the placebo group (73% versus 54%; p = 0.035). Our study demonstrates a favorable effect of ramipril on the fibrinolytic system after thrombolysis associated with a lower rate of postinfarct ischemic events within the first days after myocardial infarction. Therefore, the application of ramipril prior to thrombolysis appears to be a reasonable concomitant treatment which may reduce early infarct-related complications.

Increased levels of transforming growth factor-beta1 in essential hypertension.

BACKGROUND: Transforming growth factor-beta (TGF-beta) is a multifunctional cytokine that has been linked to vascular remodeling processes, myocardial hypertrophy, and renal fibrosis. Recently a correlation between serum levels of TGF-beta1 and blood pressure (BP) levels in patients with end-stage renal disease was shown. In addition, it is not clear whether TGF-beta1 is a causative factor in the pathogenesis of essential hypertension and associated with hypertensive target organ damage (TOD). METHODS: Using a TGF-beta1-specific sandwich ELISA, we compared plasma levels of active and total TGF-beta1 of 30 normotensive persons and 85 patients with essential hypertension with and without TOD, as measured by microalbuminuria or left ventricular hypertrophy. RESULTS: Active and total TGF-beta1 levels were significantly higher in plasma of patients with essential hypertension than in normotensive controls (P < .05 and P < .01, respectively). However, neither active nor total TGF-beta1 correlated with systolic or diastolic BP (R2 < 0.14 for all parameters). Levels of active and total TGF-beta1 were significantly higher in hypertensive patients with than without TOD (P < .05). CONCLUSIONS: Active and latent TGF-beta1 levels are markedly increased in plasma of hypertensive patients. We assume that TGF-beta1 contributes substantially to the development of TOD in essential hypertension, independent of BP levels.

Is fasting blood glucose a reliable parameter for screening for diabetes in hypertension?

BACKGROUND: The aim of this study was to evaluate the sensitivity and specificity of a combination of fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA(1c)) for screening for diabetes in hypertensive patients. The oral glucose tolerance test (OGTT) served as a gold standard for the detection of diabetes. METHODS: The cross-sectional study was performed in the Hypertension Unit of the Department of Emergency Medicine in the General Hospital of Vienna between January 1999 and July 2001. The FPG, HbA(1c), and OGTT were performed in 152 hypertensive patients (77 male and 75 female) to identify those individuals with diabetes. RESULTS: A total of 33 patients were identified as diabetic based on the results of the OGTT. Diabetes was detected in 25 (16%) of 152 patients using an FPG > or =7.0 mmol/L. In addition, HbA(1c) was measured in the remaining 127 (84%) patients with an FPG <7.0 mmol/L. In these patients HbA(1c) > or =6.1% showed a sensitivity of 100% and a specificity of 75%. Cost analysis of both approaches (FPG + HbA(1c) versus OGTT in all patients) demonstrated a cost sparing effect of 31.03 $/patient (31.66$/patient) in favor of the combined use of FPG and HbA(1c). CONCLUSION: The combination of FPG and HbA(1c) is a reasonable alternative to the generally recommended OGTT for the screening of diabetes, as diabetes was correctly diagnosed in all patients by this stepwise procedure.

Intra-aortic balloon counterpulsation in the emergency department: a 7-year review and analysis of predictors of survival.

BACKGROUND: Intra-aortic balloon pump (IABP) counterpulsation in cardiogenic shock (CS) is suggested as bridging therapy to definite emergency revascularization, heart transplantation and acute valvular repair. Data concerning the use of IABP counterpulsation in an emergency department (ED) are rare. PATIENTS AND METHODS: We reviewed retrospectively the charts of patients who had been treated by IABP counterpulsation in the ED of a tertiary care university hospital during a 7-year period. We analyzed indications for IABP treatment, complications of IABP use and studied various predictors for 30-day survival. RESULTS: Overall 88 (68 male) patients, median age 60 years (IQR 53-69 years) were treated with IABP counterpulsation. CS was caused by acute coronary syndrome (ACS), acute cardiomyopathy decompensation of (CMP) and aortic stenosis (AS) in 77 (87%), ten (12%) and one (1%) patients, respectively. Complications attributed to the insertion or maintenance of IABP were observed in nine (10%) patients. Thirty four patients (38%; 24 male) survived. Compared to non-survivors, these patients were younger (56 vs. 63 years; P<0.023) and had significant lower serum lactate levels before IABP insertion (3 vs. 5.5 mmol/l; P<0.002). Logistic regression analysis identified age (P<0.04) and serum lactate serum level before IABP (P<0.01) as independent predictors for survival. In the 77 patients with ACS PTCA tended to be associated with a higher rate of survival (P<0.09). CONCLUSION: Initiation of IABP counterpulsation in patients with CS in an ED appears safe. Low levels of serum lactate and younger age were independent predictors of survival. In patients with ACS PTCA may contribute to improved outcome.

Predictors of survival in unselected patients with acute myocardial infarction requiring continuous catecholamine support.

BACKGROUND: Several predictors of survival have been described in selected subgroups of patients suffering from acute myocardial infarction. However, data on unselected patients with acute myocardial infarction and cardiogenic shock, including patients with out-of hospital cardiac arrest, are missing. We aimed to assess predictors of survival for an unselected cohort of patients representative of clinical practice who experienced acute myocardial infarction and required continuous catecholamine support for circulatory failure. METHODS: The study was performed at a 2000 bed university hospital. All consecutive patients admitted to our emergency department with acute myocardial infarction were prospectively enrolled in a clinical trial from 1993 to 2000. DESIGN: A retrospective cohort study was performed on patients with myocardial infarction requiring catecholamine support within the first 24 h. Primary endpoint was in-hospital mortality. RESULTS: The analysis was carried out on 262 patients, 189 men (72%), median age 65 years (IQR 53-73). Out-of-hospital cardiac arrest was reported in 47% (122/262). In-hospital mortality was 53% (138/262). Survivors as compared to non-survivors exhibited significant differences with respect to age (60 vs. 68 years, P<0.0001), systolic and diastolic blood pressure on admission (110 vs. 102 mmHg, P=0.01 and 64 vs. 58 mmHg, P=0.006, respectively), initial blood serum lactate (6.8 vs. 8.3, P=0.01), peak CKMB level (93 vs. 138 U/l, P=0.005), use of adrenaline (epinephrine) (38 vs. 68%, P<0.0001) and any attempt of revascularisation (76 vs. 63%, P=0.03). In a multivariate model younger age [OR 1.06 (CI 1.03-1.10), P<0.001], no use of adrenaline [OR 2.63 (CI 1.35-5.26) P=0.005] and lower peak CKMB [OR 1.01 (CI 1.01-1.01), P<0.0001] were independently associated with in-hospital survival. CONCLUSION: In unselected patients including CPR survivors with acute myocardial infarction requiring continuous catecholamine support, younger age, the absence of continuous adrenaline administration and a lower peak CKMB were independently associated with increased in-hospital survival.

Severe accidental hypothermia with or without hemodynamic instability: rewarming without the use of extracorporeal circulation.

BACKGROUND: The optimal rewarming technique for patients in deep accidental hypothermia with core temperatures below 28 degrees C is not established. Several authors believe that extracorporeal rewarming is essential, especially for patients with hemodynamic instability. Others believe that invasive rewarming ought to be reserved for patients in cardiac arrest. We describe our experience with a strictly conservative technique without the use of invasive rewarming devices in patients with severe accidental hypothermia and a sustained perfusion rhythm. METHODS: A cohort study extending from 1991 to 2000, including all patients received at the emergency department of the University Hospital of Vienna with severe hypothermia, a core temperature of maximum 28 degrees C and no preclinical cardiac arrest. RESULTS: 36 patients with deep hypothermia were included in the study. Their core temperatures ranged from 20.2 degrees C to 28 degrees C; the median temperature was 25.75 degrees C (25th and 75th percentile, 24.2/27.3). Fourteen patients were intoxicated and their multimorbidity was high. All of 19 patients with stable hemodynamics and 14 of 17 patients with unstable hemodynamics were successfully rewarmed to normothermia with warmed infusions, inhalation rewarming and forced air rewarming. The rewarming process took 9.5 hours (8/10.5) and required a volume load of 4820 ml (2735/5770). The rewarming rate was 1.09 degrees C per hour (0.94/1.25). Although 92% of the patients were successfully rewarmed to normothermia, in-hospital mortality was 42%, but was largely related to comorbidity. DISCUSSION: A conservative approach is highly successful in achieving normothermia in patients with deep hypothermia with or without stable hemodynamics. In-hospital mortality of severe accidental hypothermia in urban conditions is high; comorbidity might play a major role. The influence of the rewarming strategy on late in-hospital mortality remains unclear.

Wine ingestion has no effect on lipid peroxidation products.

OBJECTIVE: Moderate alcohol consumption has been associated with beneficial effects on coronary heart disease. This positive effect has been partly attributed to the flavonol contents which promote vasodilatory, anti-aggregatory and antioxidative effects and protect low-density lipoprotein (LDL) cholesterol from oxidation. Thus, the present study was carried out to determine the acute effects of different wines on LDL oxidization in healthy volunteers. METHODS: Healthy male and female subjects (15/group) on a flavonol-restricted diet were randomly assigned to drink 300 ml wine from one of four different grapes and fermentation processes. Conjugated fatty acid dienes and thiobarbituric acid reactive substances (TBARS) were determined as a measure of LDL oxidation in serum at baseline and up to 96 h after wine ingestion. RESULTS: At baseline, mean conjugated dienes in serum were 12.5+/-6.2 micromol/l and mean TBARS in serum were 15.7+/-8.1 micromol/l. There were no differences between the groups and no effect of any wine type on conjugated dienes (p=0.15) or TBARS (p=0.38) over time. 96 h following wine ingestion, the mean conjugated dienes were 12.1+/-4.12 micromol/l and mean TBARS were 16.4+/-8.8 micromol/l (pooled data, n=60). CONCLUSION: Ingestion of 300 ml wine does not protect LDL from oxidation in vivo in healthy subjects. However, this does not exclude an effect of habitual wine consumption on LDL plasma oxidation.

Association between course of blood pressure within the first 24 hours and functional recovery after acute ischemic stroke.

STUDY OBJECTIVE: The relation between course of blood pressure within the first 24 hours after acute stroke and early neurologic outcome remains a matter of dispute. We investigate this relation with adjustment for other influencing variables. METHODS: Three hundred seventy-two patients with the diagnosis of ischemic stroke were included to evaluate the relation between blood pressure course and early neurologic outcome. The following data were collected: age; sex; history of hypertension, diabetes mellitus, hyperlipidemia, coronary heart disease, peripheral vascular disease, and stroke; smoking habits; preadmission blood pressure, blood pressure on admission, and blood pressure 24 hours later; antihypertensive treatment; and stroke localization. We assessed outcome at day 5 after admission as dependent or independent (Rankin Scale score

Microalbumin measurement alone or calculation of the albumin/creatinine ratio for the screening of hypertension patients?

BACKGROUND: Spot urine sampling seems to be a reliable screening method for the detection of microalbuminuria in hypertensive patients. It remains unclear whether microalbumin measurement alone or calculation of the albumin/creatinine ratio (ACR) are more reliable for the detection of microalbuminuria in non-selected hypertensive patients. METHODS: Following collection of a spot, midstream urine sample, urine was collected for 24 h for the measurement of microalbumin in 264 hypertensive patients. We compared microalbumin concentration in the spot urine with microalbumin measured in the 24-h urine sample and examined the utility of the ACR in evaluating microalbuminuria in hypertensive patients. Pathologic microalbuminuria was assumed when the microalbumin concentration exceeded 30 mg/l in the 24-h urine sample. Diagnostic performance is expressed in terms of specificity, sensitivity, positive (PPV) and negative predictive value (NPV), and area under receiver operating characteristics curve (AUC). RESULTS: A total of 47 samples (17.8%) showed pathologic microalbuminuria in the 24-h urine sample. The diagnostic performance expressed as AUC was 0.94 (95% CI 0.90-0.98) for microalbumin measurement alone and 0.94 (95% CI 0.89-0.97) for ACR. The PPV and NPV were 44.2 and 97.9% for microalbumin measurement alone. ACR revealed a PPV of 29.3% and a NPV of 96.2% for males and 42.9 and 98% for females, if a cut-off value of 2.5 mg/mmol for males and of 4.0 mg/mmol for females was used. CONCLUSIONS: The ACR did not provide any advantage compared with microalbumin measurement alone, but requires an additional determination of creatinine and the use of gender-specific cut-off values. Therefore, measurement of microalbuminuria alone in the spot urine sample is more convenient in daily clinical practice and should be used as the screening method for hypertensive patients.

Classification of blood pressure levels by ambulatory blood pressure in hypertension.

Whereas clinic blood pressure (CBP) above normality is divided into stages, no corresponding classifications are available for 24-hour ambulatory blood pressure (ABP). We conducted a study (1) to define stages of hypertension by ABP corresponding to CBP stages and (2) to evaluate if these stages have prognostic impact similar to CBP stages. Seven hundred thirty-six hypertensive patients were included. Mean systolic blood pressure was 149+/-15.2/87+/-8.6 mm Hg for CBP and 135+/-13/79+/-9.7 mm Hg for ABP. The mean bias between both methods was -13.3 mm Hg (95% CI, -14.3 to -12.2; 1.96xSD limits of agreement, 15.7 to -42.3) and -7.3 mm Hg (95% CI, -7.9 to -6.6; 1.96xSD limits of agreement, 9.8 to -24.3) for systolic and diastolic blood pressure (P>0.0001 for both), respectively. Classification of hypertension by ABP revealed lower cutoff values for the different stages of hypertension compared with the corresponding cutoff values for CBP (CBP versus ABP: 140/90 versus 132/81 mm Hg; 160/100 versus 140/88 mm Hg; 180/110 versus 148/94 mm Hg, P<0.001). Overall, 82 (11.1%) patients had nonfatal clinical cardiovascular events and 9 (1.2%) patients died of a cardiovascular cause during follow-up. The distribution of cardiovascular events was significantly associated with increasing ABP value (P<0.006). Staging of hypertension by ABP may facilitate the use of this method in daily clinical practice, as ABP can now be used not only to confirm the diagnosis of hypertension but also to assess the severity and prognosis of hypertensive disease.

Factors influencing the accuracy of oscillometric blood pressure measurement in critically ill patients.

OBJECTIVE: Comparison of oscillometric blood pressure measurement with two different devices (M3000A using a new algorithm and M1008A using an established algorithm, both Hewlett Packard) and evaluation of current recommendations concerning the relation between cuff size and upper arm circumference in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department in a 2000-bed inner-city hospital. PATIENTS: A total of 30 patients categorized into three groups according to their upper arm circumference (I, 18-25 cm; II, 25.1-33 cm; III, 33.1-47.5 cm) were enrolled in the study protocol. INTERVENTIONS In each patient, two noninvasive blood pressure devices with three different cuff sizes were used to perform oscillometric blood pressure measurement. Invasive mean arterial blood pressure measurement was done by cannulation of the radial artery. MEASUREMENT AND MAIN RESULTS: Overall, 1,011 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 30 patients (group I, n = 10; group II, n = 10; group III, n = 10). The overall discrepancy between both methods with the M3000A was -2.4 +/- 11.8 mm Hg (p <.0001) and, with the M1008A, -5.3 +/- 11.6 mm Hg (p <.0001) if the recommended cuff size according to the upper arm circumference was used (352 measurements). If smaller cuff sizes than recommended were used (308 measurements performed in group II and III), the overall discrepancy between both methods with the M3000A was 1.3 +/- 13.4 mm Hg (p <.024) and, with the M1008A, -2.3 +/- 11.5 mm Hg (p <.0001). CONCLUSION: The new algorithm reduced the overall bias of the oscillometric method but still showed a significant discrepancy between both methods of blood pressure measurement, primarily due to the mismatch between upper arm circumference and cuff size. The improvement of the algorithm alone could not result in a sufficient improvement of oscillometric blood pressure measurement. A reevaluation of the recommendations concerning the relation between upper arm circumference and cuff size are urgently required if oscillometric blood pressure measurement should become a reasonable alternative to intra-arterial blood pressure measurement in critically ill patients.

Active epistaxis at ED presentation is associated with arterial hypertension.

Epistaxis and hypertension are frequent in the general population, but an association is still controversial. Aim of this retrospective cohort study was to test if active epistaxis at emergency department (ED) presentation is associated with hypertension. Patients with active epistaxis at ED presentation (n = 271; 73%) were compared with controls without active bleeding (n = 101; 27%). By multivariate logistic regression modeling we found that active epistaxis was independently associated with history of hypertension (odds ratio 2.8 [95% CI 1.4 to 5.6; P =.004] adjusted for age, gender, rhinitis, diffuse bleeding, and malignant diseases). Patients with active epistaxis had higher blood pressure at presentation compared with controls (systolic blood pressure 165 v 153 mmHg, P <.001, diastolic blood pressure 85 v 77 mmHg, P <.001). Active epistaxis at ED presentation is associated with arterial hypertension.