[Chronic pheochromocytoma-induced myocardial injuries: What should we expect from modern and classical echocardiographic tools?] / Apport du 2D strain et des outils échocardiographiques classiques pour la recherche d'anomalies myocardiques induites par l'exposition chronique à un phéochromocytome.

INTRODUCTION: Pheochromocytoma is a rare disease, which may manifest as severe cardiac complications. Apart from these situations, the "chronic" cardiac impact is not clearly defined. A cardiac MRI study suggests that these patients are carrying areas of fibrosis and foci of left ventricular myocarditis. Since these abnormalities are usually associated with altered left ventricular longitudinal systolic strain, we hypothesize that this strain is altered in patients with a "chronic" pheochromocytoma. METHOD: This retrospective case-control study was performed using patients from the Bordeaux University Hospital database, included between 2008 and 2016. We compared the left ventricular global longitudinal strain (GLS), radial and circumferential systolic strain and classic echocardiographic parameters between patients with pheochromocytoma and controls matched for age, sex, body mass index and systolic blood pressure. RESULTS: The analysis included 47 patients and 47 correctly matched controls. There were no statistically significant differences between the 2 groups in terms of GLS (-20.7±2.4% vs. -20.2±2.7%, P=0.40), radial strain, left ventricular mass or diastolic function. Left ventricular ejection fraction and circumferential strain were significantly higher in patients than in controls, with a significantly lower telediastolic diameter. CONCLUSION: No significant changes in GLS were observed in our pheochromocytoma patients, compared with controls. Several hypotheses may explain these results. The presence of fibrosis foci and areas of left ventricular myocarditis being associated with a poor cardiological prognosis, a systematic cardiac MRI could be discussed in these patients, until further studies are performed.

[Surgical excision of subclinical cortisol secreting incidentalomas: Impact on blood pressure, BMI and glucose metabolism]. / Bénéfices tensionnels, anthropométriques et métaboliques de l'exérèse chirurgicale des adénomes cortisoliques infracliniques.

OBJECTIVES: To compare clinical, vascular and metabolic parameters before and after surgery in patients with subclinical cortisol secreting incidentalomas. PATIENTS AND METHODS: Eight patients were investigated before and 12 months after removal of the mass on hemodynamic (blood pressure by MAPA procedure), anthropometric (body weight, body mass index), and metabolic parameters (glucose level, HbA(1c)). RESULTS: In the whole group, 75% of patients displayed decrease in blood pressure (cessation of at least one hypotensive medication) and 33% of them were definitely cured of hypertension. Seventy-one percent of patients lost body weight and 37.5% lost more than 5%. In the whole group of patients, glucose level decreased by 1.1% and medical treatment was discontinuated in two of three diabetic patients. CONCLUSION: Subclinical cortisol secreting adrenal incidentalomas are associated with cardiovascular risk factors that may be corrected after removal of the mass. Therefore, surgery may be an appropriate choice in patients with subclinical Cushing's syndrome to improve hypertension, body weight and impaired glucose level. Controlled studies comparing surgical treatment to a medical follow-up including optimal cardiovascular risk factors treatment are needed to define the usefulness of surgery in hypertensive patients with subclinical cortisol secreting incidentalomas.

Magnitude of the early morning blood pressure surge in untreated hypertensive patients: a pooled analysis.

OBJECTIVES: A post hoc analysis was performed to assess the magnitude of the early morning blood pressure surge (EMBPS), which is associated with peak cardiovascular risk, in untreated hypertensive patients enrolled in two sister studies (Prospective, Randomised Investigation of the Safety and efficacy of MICARDIS vs. ramipril using ambulatory blood pressure monitoring I and II) with identical design. METHODS: In adults with a mild-to-moderate primary hypertension and no significant comorbidities, 24-h ambulatory blood pressure monitoring was conducted after a 2- to 4-week placebo run-in period and before treatment initiation. Individual blood pressure measurements at 20-min intervals were analysed. RESULTS: In 1419 hypertensive patients with normal sleeping times, blood pressure displayed a typical circadian rhythm, with a mean EMBPS of 29/24 mmHg. An EMBPS of >or= 25 mmHg was observed in around 60% of patients. The surge was significantly increased with smoking, alcohol consumption, longer sleep, later waking times, and increased blood pressure variability during waking and sleeping. The magnitude of the EMBPS was significantly reduced in Black vs. White patients. The surge was not affected by gender, body mass index or duration of hypertension. Further analysis showed that ethnicity, alcohol consumption and smoking were all found to have a significant impact on surge around waking and age, sleep duration and sleep blood pressure variability were all found to have an effect on the prewake surge. CONCLUSIONS: In untreated hypertensive patients, the magnitude of the EMBPS is significant when compared with the 24-h mean and is affected by individual patient characteristics. In light of these findings, physicians should understand the importance of 24-h blood pressure control and the modification of certain lifestyle factors as ways of reducing the EMBPS.

[Alteration of left ventricular longitudinal systolic function in 2D-strain in primary aldosteronism: A new target organ damage marker]. / Altération de la fonction systolique longitudinale du ventricule gauche en strain bidimensionnel dans l'hyperaldostéronisme primaire : un nouveau marqueur d'atteinte d'organe cible.

OBJECTIVE: Primary hyperaldosteronism is the leading cause of secondary hypertension, and leads to frequent cardiovascular complications. Many studies have studied left ventricular geometry and function in this population, but longitudinal systolic function is still poorly described. METHODS: We studied 35 hypertensive patients with primary aldosteronism, and 35 with essential hypertension matched for age, sex, body mass index, and 24h blood pressure. Patients benefited from an echocardiography to measure the mass and the geometry of the left ventricle, left ventricle ejection fraction, systolic longitudinal, circumferential, and radial strain, and diastolic function. RESULTS: Compared to essential hypertensive patients, patients with primary aldosteronism presented a significantly higher left ventricular mass index and relative wall thickness (60.3±16.1g/m2 vs 47.3±18.6, P=0.003, and 0.44±0.08 vs 0.36±0.06, P=0.00005, respectively), as well as a significantly reduced longitudinal systolic strain (-17.8±3,4 vs -20.3±3,6%, P=0.004). There were no significant differences in the other parameters. CONCLUSIONS: Primary aldosteronism is associated with a deterioration of longitudinal systolic function of the left ventricle compared with essential hypertensive patients. This marker of cardiac damage, reproducible and easily available in routine could help for the screening of these patients.

From malignant hypertension to hypertension-MOD: a modern definition for an old but still dangerous emergency.

The prevalence of malignant hypertension has clearly fallen with the advent of anti-hypertensive medication but has remained stable over the past 30-40 years in spite of progress in diagnosis and management of hypertension. A diagnosis of malignant hypertension is usually based on the association of severely elevated blood pressure with a Keith and Wagener stage III or IV retinopathy. We believe that this definition can be reconsidered for several reasons. Although simple and pragmatic, this definition corresponds to a time when there were few techniques for assessment of hypertensive target organ involvement, and does not take into account involvement of kidney, brain and heart; whereas the overall prognosis largely depends on how much they are affected. On the contrary, the acute blood pressure level and especially diastolic should not be a hard diagnostic criterion as it does not itself constitute the prognosis of the condition. We propose to consider that malignant hypertension with retinopathy is only one of a number of possible presentation(s) of acute hypertension with multi organ damage (hypertension multi organ damage (MOD)) and that the recognition of these hypertensive emergencies, when retinopathy is lacking, be based on acute elevation of BP associated with impairment of at least three different target organs. The objective of a new and expanded definition is to facilitate recognition of these true emergencies. The condition is more common than usually perceived and would have a much worse prognosis than the usual forms of hypertension. Early recognition and management of hypertension-MOD are fundamental to any improvement in prognosis.

Left ventricular hypertrophy--the problem and possible solutions.

Left ventricular hypertrophy (LVH), which describes pathological changes in cardiac structure, is a powerful and reversible predictor of cardiovascular risk. There is a continuous relationship between left ventricular mass (LVM) and the likelihood of cardiovascular events, with no cut-off between the absence of such events and heightened risk. A correlation between LVH and blood pressure is well established. There is a paradox, however, that the structural changes to the heart as a result of increased workload due to high blood pressure appear to promote cardiovascular disease. This may be partially explained by the fact that ambulatory blood pressure measurements correlate more closely with LVH than resting blood pressure. Blood pressure variation throughout the day is also emerging as an important correlate of LVH, and a strong association has been identified between an early morning rise in blood pressure and increased LVM. Use of anti-hypertensive agents not only lowers blood pressure, but can also bring about LVH regression. The pathological role of angiotensin II in LVH and target-organ damage within the cardiovascular continuum suggest that agents targeting the renin angiotensin-aldosterone system (RAAS), such as the angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, may prove particularly effective and may confer beneficial effects in addition to the lowering of blood pressure. The angiotensin II receptor blockers may be very appropriate treatment options because of their placebo-like tolerability and the possibility of more complete blockade of the RAAS. Within this class of anti-hypertensive agents, pharmacological differences may mean that some agents afford greater cardioprotection than others.

[Prognostic value of QKD interval corrected by QRS duration in hypertensive patients]. / Valeur pronosfique de l'intervalle QKD: intérêt d'une correction par la largeur du QRS.

OBJECTIVES: The QKD interval is measured between the onset of QRS on the ECG and detection of last Korotkoff sound by a microphone placed on the brachial artery while measuring BP. It is the sum of preejection time and pulse transmission time and thus is correlated to pulse wave velocity (PWV). This interval is automatically monitored with BP and HR every 15 minutes during 24 h with an ambulatory blood pressure monitoring device (Diasys integra, Novacor, France). The 96 measurements obtained allow to automatically calculate the QKD(100-60), QKD value for 100 mmHg SBP and 60 bpm HR. This indice of arterial stiffness has been shown to be linked to future cardiovascular (CV) events, independently of 24 h BP. However this interval may be abnormally prolonged in case of left bundle branch blocks (LBBB). METHODS: We tested the effects of simply removing QRS duration from QKD(100-60) value on the prediction of CV events in a population of 412 hypertensives (247 males: age = 53 +/- 14 years; office BP = 158 +/- 19/97 +/- 11 mmHg; 24 h BP = 133 +/- 17/86 +/- 11 mmHg) followed prospectively. RESULTS: Mean follow up was 65 months, 32 pts were lost, 49 CV events occurred including 11 deaths. Cox model showed that baseline QKD(100-60) (m = 202 +/- 19; 142-254 ms) was significantly (p < 0.05) associated to events independently of age, 24h SBP and other traditional risk factors. Removing QRS duration (m = 85 +/- 10: 61-158 ms) improves the relation to events (monovariate khi2 = 38 vs 30). CONCLUSION: Removing QRS duration from QKD(100-60) improves its predictive value of future CV events and allows using this method in patients with LBBB.

[Arterial rigidity of patients operated successfully for coarctation of the aorta without residual hypertension]. / Etude de la rigidité artérielle des patients opérés avec succès d'une coarctation de l'aorte sans hypertension résiduelle.

In patients successfully operated for coarctation of the aorta, the prevalence of hypertension is higher than that observed in the general population although the exact mechanism is not known. The hypothesis of increased arterial rigidity despite satisfactory correction of the coarctation has been proposed. The authors undertook 24 hour ambulatory blood pressure monitoring coupled with measurement of the QKD interval (pulse wave velocity) in order to evaluate the rigidity of the large arteries. These results were compared with those obtained in control patients paired with respect to gender, age, height and weight. Twenty-six patients with an average age of 14.5 +/- 2.9 years were included (age at time of surgery 6.3 +/- 3.7 years). The statistical data confirmed a higher systolic blood pressure (p<0.05) in the operated patients compared with controls. The results confirm the hypothesis of increased residual arterial rigidity in children operated for coarctation of the aorta which could predispose to secondary hypertension, especially on effort. In the long term, this could be an unquestionable cardiovascular risk factor explaining the increased cardiovascular morbid-mortality compared with the general population.

[Biochemical detection of Conn's adenoma: definition of criteria and reference values]. / Dépistage biologique des adénomes de Conn: definition des critères et des seuils.

Primary hyperaldosteronism is a diagnosis which should be considered in refractory hypertension even in the absence of any hypokalaemia. Its detection relies above all on the levels of renin and aldosterone. The aldosterone/renin ratio has been proposed as the most sensitive criterium. The reference values used for the diagnosis of primary hyperaldosteronism are very variable in the literature, depending not only on the method used but also on the criteria used for their determination. In this study we evaluated the defined reference values prospectively by studying a population of patients with a Conn's adenoma treated surgically. The study included an initial retrospective period which allowed identification of 29 cases of Conn's adenoma treated surgically, and a 9 month prospective period during which 212 reports were collected. During this prospective period a further 9 cases of Conn's adenoma were detected, which were successfully treated with surgery. Analysis to discriminate the 38 Conn's adenomata from the rest showed that 3 parameters contributed significantly and independently to the diagnosis: supine plasma renin activity (ARPc), supine aldosteronaemia and the erect aldosterone/renin ratio, allowing correct classification in 88% of the cases. The reference ranges of these 3 parameters were calculated in order to give a sensitivity of 100% and the best possible specificity, therefore allowing a combined criterium involving all 3 parameters to be defined: ARPc < 0.45 ng/ml/h, supine aldosteronaemia >417 pmol/l, and erect aldosterone/renin >1180.

'White coat' hypertension. No harm for the heart.

The superiority of ambulatory blood pressure monitoring over casual blood pressure measurement for the prediction of target-organ damage is now well established, although the significance of "white coat" hypertension is still controversial. Is an office blood pressure measurement that is higher than the mean ambulatory value an added risk? Because left ventricular hypertrophy is a potent risk factor, the effect of hypertension on left ventricular mass merits attention. Left ventricular mass indexed for height was measured by M-mode echocardiography in 204 essential hypertensive patients (140 males, 64 females; mean age [SD], 50 [11] years). Blood pressure over 24 hours was monitored routinely with a noninvasive auscultatory device. Office blood pressure after 10 minutes of the subject in the supine position was measured by the same physician under the same conditions. The white coat effect was defined as the difference between the office and average daytime values of systolic and diastolic blood pressures. Patients were divided into four quartiles according to their office and daytime blood pressures. Two-way analysis of variance was used to assess the influence of the white coat effect at a given level of daytime blood pressure on left ventricular mass. Left ventricular mass increased significantly (P < .001) with daytime systolic blood pressure but was independent of white coat effect for both the whole population and the 143 untreated patients. We conclude that the white coat effect has no influence on left ventricular mass, favoring the view that white coat hypertension is a benign condition.

Nocturnal blood pressure fall on ambulatory monitoring in a large international database. The "Ad Hoc' Working Group.

A wide range of definitions is used to distinguish subjects in whom blood pressure (BP) falls at night (dippers) from their counterparts (nondippers). In an attempt to standardize the definition of nondipping, we determined the nocturnal BP fall and night-day BP ratio by 24-hour ambulatory monitoring in 4765 normotensive and 2555 hypertensive subjects from 10 to 99 years old. In all subjects combined, the systolic/diastolic nocturnal fall and corresponding ratio averaged (+/- SD) -16.7 +/- 11.0/ -13.6 +/- 8.1 mm Hg and 87.2 +/- 8.0%/83.1 +/- 9.6%, respectively. In normotensive subjects, the 95th percentiles were -0.3/-1.1 mm Hg for the nocturnal fall and 99.7%/98.3% for the night-day ratio. Both the fall and ratio showed a curvilinear correlation with age. The smallest fall and largest ratio were observed in older (> or = 70 years) subjects. A higher BP on conventional sphygmomanometry was associated with a larger systolic (partial r = .11) and diastolic (r = .12) nocturnal BP fall. The diastolic (r = .08) but not the systolic night-day ratio increased with higher conventional BP. The nocturnal BP fall was larger and the corresponding night-day ratio smaller in oscillometric (n = 5884) than in auscultatory (n = 1436) recordings, in males (n = 3730) than in females (n = 3590), and in Europe (n = 4556) than in the other continents (n = 2764). The distributions of the nocturnal BP fall and night-day ratio showed considerable overlap among normotensive and hypertensive subjects, but the overlap tended to be larger for the ratio than for the fall. Of all subjects, 3.2% had systolic and diastolic ratios of 100% or more. With adjustments applied for confounders, the probability of being a nondipper increased 2.8 times (95% confidence interval, 2.0-4.0) from 30 to 60 years and 5.7 times (4.4-7.4) from 60 to 80 years. The odds ratios were 1.0 (0.8-1.4) for males versus females. 1.6 (1.2-2.1) for subjects with definite hypertension versus normotensive subjects, 2.4 (1.2-4.7) for Asians (n = 2213, 96% Japanese) versus inhabitants of the other continents, and 2.4 (1.5-3.8) for subjects examined with auscultatory versus oscillometric devices. In conclusion, the mathematical definition of nondipping, ie, having a night-day ratio of 100% or more for systolic and diastolic BPs, closely approximated the 95th percentiles of the night-day ratio in normotensive subjects. The ratio depends less on BP level than the nocturnal BP fall and is therefore to be preferred in the definition of dipping status. Notwithstanding the present findings, the reproducibility of nondipping and its prognostic significance need further clarification.

Relationship between left ventricular mass and serum cholesterol level in the untreated hypertensive.

OBJECTIVE: To study the relationship between serum cholesterol level and left ventricular mass for a population of untreated hypertensive patients. DESIGN: A cross-sectional study. PATIENTS: We studied 273 untreated hypertensive patients without associated diseases consecutively referred for evaluation of blood pressure. All patients underwent M-mode echocardiographic assessment of left ventricular mass, office blood pressure measurement and 24 h ambulatory blood pressure monitoring. Fasting plasma glucose and total cholesterol levels were measured on the same day. RESULTS: We found a weak but significant correlation (r = 0.20-0.26, P < 0.01) between serum cholesterol level and left ventricular wall thickness or left ventricular mass irrespective of the mode of indexation used (height, height2.7 and body surface area). In multivariate analysis this relation remained significant after introduction of sex, age, weight, height, blood pressure and blood glucose level. When data for men and women were analysed separately the relationship between left ventricular mass and cholesterol remained significant for men only. CONCLUSION: There is a significant and independent positive relationship between serum cholesterol level and left ventricular mass that could contribute to the prognostic value of left ventricular hypertrophy.

Centralized echocardiogram quality control in a multicenter study of regression of left ventricular hypertrophy in hypertension.

OBJECTIVE: To test the feasibility and utility of instituting centralized echocardiographic quality control during a multicenter study of regression of left ventricular hypertrophy in hypertension. DESIGN AND METHODS: The LIVE (Left Ventricular Hypertrophy: Indapamide Versus Enalapril) study is an ongoing multicenter, double-blind, controlled study of regression of echocardiographic left ventricular mass index in hypertensive patients with left ventricular hypertrophy (left ventricular mass indexes > 100 g/m2 for women and > 120 g/m2 for men) treated for 1 year with 1.5 mg indapamide sustained-release coated tablets versus 20 mg enalapril. A centralized evaluation committee has validated a prestudy sample echocardiogram from each center, and is now reviewing all videotapes recorded during this study for quality control; final results will be based on a further randomized blinded analysis by this centralized evaluation committee. RESULTS: Since December 1994, 878 patients have been preselected (videoechocardiographic recordings sent for assessment), 645 selected (videoechocardiographic recordings validated), and 576 randomly allocated to treatment. After preliminary quality control, 27% (233) of baseline echocardiograms were rejected by our centralized evaluation committee, and 22% (142) of postinclusion echocardiographic measurements had to be repeated, mainly because they were of poor echogenic quality. Analysis of approved baseline echocardiograms for the first 274 randomly allocated patients with digitized data showed that there was a significant correlation between centralized evaluation committee and investigator calculations of left ventricular mass index (r = 0.76, P < 0.001), with consistently higher values for investigator calculations, independently of level of left ventricular mass index (correlation between difference and mean of investigator and centralized evaluation committee measurements, r = 0.08, P = 0.28). The mean difference was 8 +/- 20 g/m2 (P < 0.001). CONCLUSION: Early results of the LIVE study quality control showed that real-time 'live', centralized echocardiographic reading was not only feasible, but also useful for avoiding unquantifiable echocardiograms and overestimation of left ventricular mass index. Thus, real-time, centralized echocardiographic quality control should be recommended for multicenter studies of regression of left ventricular hypertrophy.

Regression of left ventricular hypertrophy in hypertensive patients treated with indapamide SR 1.5 mg versus enalapril 20 mg: the LIVE study.

OBJECTIVE: To compare the efficacy of indapamide sustained release (SR) 1.5 mg and enalapril 20 mg at reducing left ventricular mass index (LVMI) in hypertensive patients with left ventricular hypertrophy (LVH). DESIGN: The LIVE study (left ventricular hypertrophy regression, indapamide versus enalapril) was a 1 year, prospective, randomized, double-blind study. For the first time, a committee validated LVH before inclusion, provided on-going quality control during the study, and performed an end-study reading of all echocardiograms blinded to sequence. SETTING: European hospitals, general practitioners and cardiologists. PATIENTS: Hypertensive patients aged > or = 20 years with LVH (LVMI in men > 120 g/m2; LVMI in women > 100 g/m2). Data were obtained from 411 of 505 randomized patients. INTERVENTIONS: Indapamide SR 1.5 mg, or enalapril 20 mg, daily for 48 weeks. MAIN OUTCOME MEASURES: LVMI variation in the perprotocol population. RESULTS: Indapamide SR 1.5 mg significantly reduced LVMI (-8.4 +/- 30.5 g/m2 from baseline; P< 0.001), but enalapril 20 mg did not (-1.9 +/- 28.3 g/m2). Indapamide SR 1.5 mg reduced LVMI significantly more than enalapril 20 mg: -6.5 g/m2, P = 0.013 (-4.3 g/m2 when adjusted for baseline values; P = 0.049). Both drugs equally and significantly reduced blood pressures (P< 0.001), without correlation with LVMI changes. Indapamide SR progressively reduced wall thicknesses throughout the 1-year treatment period. In contrast, the effect of enalapril observed at 6 months was not maintained at 12 months. CONCLUSIONS: Indapamide SR 1.5 mg was significantly more effective than enalapril 20 mg at reducing LVMI in hypertensive patients with LVH.

Short- and long-term treatment of mild to moderate hypertension with verapamil.

Forty-three patients with mild to moderate hypertension (supine diastolic blood pressure 95 to 115 mm Hg) were entered into a short-term (3 months) study. All received verapamil, 120 mg 3 times a day. After 1 month of treatment on verapamil alone, supine diastolic blood pressure was normalized (less than 95 mm Hg) in 29 patients (67%). These patients continued with verapamil at the same dosage. In 14 nonresponders (supine diastolic blood pressure greater than 95 mm Hg) a combination of althiazide (15 mg/day) and spironolactone (25 mg/day) was added. This resulted in diastolic blood pressure normalization in 9 additional patients. Verapamil induced a slight but moderate decrease in heart rate after 1 month, but no further decrease was observed thereafter. During the trial, 21% of patients reported adverse effects, mostly transient and mild. No patient had to discontinue treatment because of them. Twenty-six patients on verapamil alone were followed for 1 year. Systolic and diastolic blood pressure was adequately controlled in all patients except 1. In 13 the dosage was decreased to 120 mg 2 times a day. There were no significant differences in blood pressure between this group and patients given 120 mg 3 times a day. It is concluded that verapamil is an effective and safe antihypertensive agent in mildly to moderately hypertensive patients. Because a dosage of 120 mg 2 times a day was as effective as 120 mg 3 times a day, the former should be recommended, as it may improve patient compliance.

Left ventricular mass is better correlated with arising blood pressure than with office or occasional blood pressure.

The peak incidence of cardiovascular complications in the morning points to a possible role of the abrupt increase in blood pressure on arising. However, there is as yet no firm evidence linking the extent of the elevation in blood pressure on arising and the risk of cardiovascular complications. We sought a correlation between blood pressure on arising and left ventricular mass in a population of 181 previously untreated hypertensive patients. Ambulatory blood pressure was measured over a 24-h period, and each patient was requested to trigger a blood pressure determination immediately after standing on arising in the morning. Left ventricular mass was measured with M-mode echocardiography and indexed for height, height(2.7), and body surface area. The systolic blood pressure on arising was significantly (P <.01) better correlated than office blood pressure with left ventricular mass index and wall thickness. On multivariate analysis, the values of systolic blood pressure on arising and mean 24-h systolic blood pressure contributed significantly and independently to the correlation with left ventricular mass and wall thickness. These observations point to the significance of the arising blood pressure. A marked abrupt daily elevation in blood pressure on arising, then maintained for a certain time, could contribute to the development of left ventricular hypertrophy and may constitute a trigger for cardiovascular complications.

Assessment of arterial distensibility by monitoring the timing of Korotkoff sounds.

The timing of Korotkoff sounds, blood pressure, and heart rate can now be monitored in the ambulatory patient: the QKD interval is the time between the onset of the depolarization on the electrocardiogram (Q) and detection of the last Korotkoff sound (K) at the level of brachial artery during cuff deflation, corresponding to diastolic blood pressure (D). Because this interval is inversely related to pulse wave velocity, this recently developed device enables evaluation of the influence of blood pressure on arterial rigidity, providing valuable information on the properties of the arteries. In this study, we examined the influence of hypertension and age on the above parameters and their correlations to left ventricular mass. QKD interval, blood pressure, and heart rate were monitored over a period of 24 h (four measurements/hour) in 33 normotensive and 70 untreated essential hypertensive patients. The slopes of the plots of QKD interval versus systolic and pulse pressure during the 24 h were calculated for each patient. The influence of age and hypertension on these slopes was tested by comparison of matched groups and multivariate analysis. Moreover the relationships between these parameters and echocardiographically assessed left ventricular mass were studied in 37 patients. We found a reduction in mean QKD interval with age and hypertension, reflecting the recognized higher pulse wave velocity in these patients. The slopes of the plots of QKD interval versus blood pressure were also lower in these patients, indicating the smaller influence of a change in blood pressure on pulse wave velocity in patients with stiffer arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

High night blood pressure in treated hypertensive patients: not harmless.

UNLABELLED: The left ventricular mass index (LVMI) is better related to activity than resting systolic blood pressure (BP) in treated hypertensive patients. Many recommend ambulatory BP monitoring only during the day. However, 24-hour BP monitoring may be useful in treated patients to check adequate control of BP during the entire 24-hour period. We tested the influence of night BP on LVMI in treated versus nontreated patients. We compared two groups of hypertensive patients: A: 40 patients who had discontinued therapy at least 8 days prior to the study; B: 24 patients treated for more than 3 months with the same drugs (beta-blockers in 14 cases). Ambulatory BP was recorded every 30 minutes during night and every 15 minutes during day (Spacelabs 5200). The LVMI was calculated from M mode echo blind reading (Devereux's formula). Correlation coefficients between LVMI and casual, systolic BP were calculated for both day (7:00 AM to 10:59 PM) and night time (11:00 PM to 6:59 AM). Day systolic BP is better related to LVMI than casual and night systolic BP in group A. In contrast, a significantly higher correlation existed between night BP and LVMI in B, though average night BP level was lower. CONCLUSION: 24-hour BP monitoring may be useful in treated hypertensive patients. Inadequate lowering of night BP may partially account for persistent LVH in treated hypertensive patients.

Daytime and nighttime ambulatory blood pressures should be calculated over the true sleep/waking cycle and not over arbitrary periods.

The present study was done to compare the values of mean daytime and nighttime blood pressure (BP) calculated over arbitrary periods to those calculated over the true retiring and rising times of the individual patients. A total of 88 individuals, including 55 untreated hypertensives (office BP > 140/90 mm Hg) and 33 normotensives, were recruited. Ambulatory BP was monitored over 24 h during the normal routine of the patient. The patient was requested to trigger a recording on going to bed and on rising in the morning to clearly identify these periods. The mean daytime and nighttime values were calculated over arbitrarily defined periods (6 AM to 10PM daytime and 10 PM to 6 AM nighttime) and as a function of the true retiring and rising times of the individual patients. The true daytime BP was significantly higher than the value calculated over the arbitrary period and the true nighttime BP was significantly lower than the value calculated between 10 PM and 6 AM (paired t test, P < .05). Employing a cutoff value of 135/85 mm Hg for daytime BP, a significant proportion of patients classified as normotensive when daytime BP was calculated over arbitrary periods were in fact classified as hypertensive from the values calculated over true retiring and rising times.

Prognostic value of ambulatory measurement of the timing of Korotkoff sounds in elderly hypertensives: a pilot study.

Alteration in the physical properties of the large arteries is probably an important contributory factor in morbidity and mortality in the elderly as well as in patients with hypertension or diabetes. We have developed a simple method based on the ambulatory measurement of the timing of Korotkoff sounds (QKD interval), together with blood pressure, to assess these properties. We report its prognostic value in a retrospective survey of elderly hypertensives. We included in this study 134 hypertensive patients over 45 years of age with no cardiovascular complications, either receiving placebo or prior to treatment with antihypertensive medication and seen between January 1992 and July 1993. In June 1995, a survey was carried out to determine outcome by contacting the patients themselves and their family physicians. Data on outcome were obtained for 111 patients with a mean follow-up period of 30 +/- 8 months. At least one cardiovascular complication was recorded during the follow-up period in 14 patients. From the Cox model, data obtained from QKD monitoring, namely the QKD(100-60), was the best predictor of complications and remained significant (P < .01) even after introduction of age, mean 24 h SBP, gender, and smoking into the model. A QKD(100-60) below 187 msec was accompanied by a relative hazard of cardiovascular complications adjusted for age and mean 24 h BP of 7.3 (95% confidence interval: 2.9 to 11.7). The indices provided by the ambulatory measurement of QKD interval are significant predictors of cardiovascular complications independently of age and BP. This new method seems to add useful information to classic ambulatory blood pressure monitoring. However this will require confirmation in a large prospective study.