Increased Blood Pressure Variability Contributes to Worse Outcome After Intracerebral Hemorrhage.

Background and Purpose- Increased systolic blood pressure variability (BPV) is associated with worse outcome after acute ischemic stroke and may also have a negative impact after intracerebral hemorrhage. We sought to determine whether increased BPV was detrimental in the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage II) trial. Methods- The primary outcome of our study was a 3-month follow-up modified Rankin Scale of 3 to 6, and the secondary outcome was a utility-weighted modified Rankin Scale. We calculated blood pressure mean and variability using systolic blood pressure from the acute period (2-24 hours postrandomization) and subacute period (days 2, 3, and 7). Results- The acute period included 913 patients and the subacute included 877. For 5 different statistical measures of systolic BPV, there was a consistent association between increased BPV and worse neurological outcome in both the acute and subacute periods. This association was not found for systolic blood pressure mean. Conclusions- In this secondary analysis of ATACH-2, we show that increased systolic BPV is associated with worse long-term neurological outcome. Additional research is needed to find techniques that allow early identification of patients with an expected elevation of BPV and to study pharmacological or protocol-based approaches to minimize BPV.

Aortic elastic properties : effects of carvedilol versus nebivolol.

OBJECTIVES: The aim of this study was to compare the effects of the new generation ß-blocker anti-hypertensive drugs carvedilol and nebivolol on aortic elastic properties which are important indicators of hypertension-related morbidity and mortality. METHODS: A total of 50 patients who had been diagnosed with stage 1 hypertension according to the Joint National Committee (JNC) VII criteria and who had not received any anti-hypertensive treatment were enrolled in this study. Patients were randomized to receive either 25 mg/day carvedilol (n=25) or 5 mg/day nebivolol (n=25) for 3 months at the beginning of the study. Three patients (1 in the carvedilol group, 2 in the nebivolol group) who did not attend 3 month follow-up measurements were excluded from the study. The study was completed with 47 patients (25 women; mean age: 49 ± 9 years). The aortic elastic parameters such as aortic strain (AS), aortic distensibility (AD), and aortic stiffness index (ASI) were measured by echocardiography. RESULTS: Carvedilol and nebivolol provided a similar decline in both systolic and diastolic blood pressures (-12/-7 mmHg, p<0.0001 and -12/-7 mmHg, p=0.002, respectively). Both carvedilol and nebivolol induced a significant decrease in heart rate (-15 bpm, p<0.0001, -17 bpm, p<0.0001, respectively). Even though the heart rate at the end of the treatment was lower for the nebivolol group, the rate of decrease of heart rates between carvedilol and nebivolol groups was not statistically significant (p=0.074). Both groups demonstrated improvements in the diastolic functions of the left ventricle where certain values showed more improvement for the nebivolol group. Both groups showed improvements in AS and AD rates compared to basal rates; however, these improvements were not statistically significant. Although the improvement rates in AS, AD, and ASI were higher in the nebivolol group compared to the carvedilol group, the differences were not statistically significant (p=0.091, p=0.095, p=0.259, respectively). CONCLUSION: Both carvedilol and nebivolol induced a decrease in blood pressure and heart rate and showed an improvement in left ventricular diastolic functions. It was observed that both drugs did not cause deterioration in the aortic elastic properties but a slight improvement was seen. However, this improvement was not statistically significant. The improvement was more explicit in the nebivolol group. It may be concluded that nebivolol is slightly superior to carvedilol in reducing heart rate and improving left ventricular diastolic functions. However, further long-term studies with larger sample sizes should be performed in order to better define the effects of both drugs.

[Effects of heart rate variability and smoothness index on the reversal of hypertensive left ventricular hypertrophy].

OBJECTIVE: To investigate the relationship of reversal of hypertensive left ventricular hypertrophy (LVH) with heart rate variability (HRV) and smoothness index (SI). METHODS: A total of 127 patients with untreated essential hypertension associated with LVH were enrolled to receive a 20-week treatment. The drugs included losartan potassium & hydrochlorothiazide (1 tablet/day) and metoprolol (12.5 mg - 50 mg twice daily). The sitting systolic and diastolic blood pressures (SBP & DBP), M-mode and pulsed Doppler echocardiography, 24-hour ambulatory blood pressure monitoring (ABPM) and 24-hour ambulatory ECG (Holter) were performed at pre- and post-treatment. The changes in various parameters such as echocardiography left ventricular end-systolic dimension (LVDs), left ventricular end-diastolic dimension (LVDd) and the thickness of interventricular septum (IVST) and posterior wall (PWT) were measured. And left ventricular mass index (LVMI) and smoothness index (SI) were also examined. The evaluated parameters of ABPM were average 24-hour, daytime and nighttime SBP & DBP. As to 24-hour ambulatory ECG (Holter), the parameters were standard deviation of normal to normal intervals (SDNN), rate mean square of the differences of successive RR intervals (RMSSD), percentage of RR intervals differing > 50 ms (PNN50), high frequency (HF) and low frequency (LF). RESULTS: After a 20-week treatment, the levels of sitting blood pressure (SBP 158.72 ± 12.11 mm Hg vs 132.21 ± 14.03 mm Hg; DBP 97.20 ± 7.71 vs 86.36 ± 6.48 mm Hg, P < 0.001), parameters of 24-hour ABPM (24-hour mean SBP 146.20 ± 10.11 mm Hg vs 129.68 ± 6.12 mm Hg, P < 0.001; 24-hour mean DBP 93.45 ± 5.46 mm Hg vs 81.77 ± 6.71 mm Hg, P < 0.01; daytime mean SBP 149.53 ± 8.67 mm Hg vs 133.60 ± 6.27 mm Hg, P < 0.001; daytime mean DBP 94.68 ± 4.96 mm Hg vs 83.55 ± 7.03 mm Hg, P < 0.001; nighttime mean SBP 137.21 ± 8.73 mm Hg vs 122.74 ± 7.58 mm Hg, P < 0.001; nighttime mean DBP 86.75 ± 6.22 mm Hg vs 72.81 ± 5.47 mm Hg, P < 0.001) and LVMI significantly decreased (128.90 ± 32.35 g/m(2) vs 118.39 ± 31.10 g/m(2), P < 0.01) while the indicators of HRV changes such as SDNN, RMSSD, PNN50 and HF significantly increased (SDNN 97.28 ± 16.67 ms vs 152.27 ± 34.23 ms, P < 0.01; RMSSD 21.32 ± 8.70 ms vs 41.91 ± 10.38 ms, P < 0.001; PNN50 3.17 ± 1.23 vs 5.89 ± 2.18, P < 0.01; HF 239.82 ± 98.26 ms(2)/Hz vs 367.32 ± 188.37 ms(2)/Hz, P < 0.01)accompanied by the decreases in LF and LF/HF (LF 485.22 ± 217.34 ms(2)/Hz vs 287.94 ± 128.61 ms(2)/Hz, P < 0.01; LF/HF 2.03 ± 0.56 vs 0.79 ± 0.38, P < 0.001). The post-treatment SIs of SBP and DBP were 1.35 and 1.2 respectively. CONCLUSION: The combination treatment of angiotensin II receptor blocker (ARB), diuretics and ß1-receptor blockers can lower the blood pressures stably, improve heart rate variability and lead to a reversal of hypertensive LVH.

Telmisartan improves morphologic and functional changes in both left ventricular myocardium and carotid arterial wall in patients with hypertension: assessment by tissue Doppler imaging and carotid ultrasonography.

OBJECTIVE: The aim of the present study was to clarify the beneficial effects of telmisartan on the morphologic and functional changes in left ventricular (LV) myocardium and carotid arterial wall in patients with hypertension (HT) using tissue Doppler imaging and carotid ultrasonography. METHODS: Telmisartan (20-40 mg daily) was administered to 35 previously untreated patients with HT. Conventional and pulsed tissue Doppler echocardiography were performed after medication had been continued for 1-2 months with normal values for blood pressure (BP) (phase I) and for 12 months (phase II). Subclinical atherosclerosis also was determined by measuring the intima-media thickness (IMT) and stiffness ß of the left and right common carotid arteries using B- and M-mode ultrasonography. RESULTS: In the phase II, the LV mass index and isovolumic relaxation time were lower, the peak systolic and early diastolic mitral annular motion velocities were greater compared to the phase I. The stiffness ß and mean IMT were lower in the phase II than in the phase I. On multivariate regression analyses, age, BP, and LV diastolic variables emerged as stronger predictors of carotid arterial IMT and stiffness ß. CONCLUSIONS: The 1-year use of telmisartan improved LV hypertrophy, regional LV myocardial contraction and relaxation, and carotid atherosclerosis in patients with HT. Our results support cardio- and arterioprotective benefits from continuous long-term telmisartan monotherapy, and combined analysis of tissue Doppler imaging and carotid ultrasonography may be a useful tool for understanding ventriculoarterial coupling in patients with HT.

Renal artery aneurysm in a hypertensive child treated by percutaneous coil embolization.

A 16-year-old boy was admitted to our hospital with uncontrolled hypertension. A left renal artery aneurysm was detected on colour Doppler US and CT. Renal arteriography demonstrated the aneurysm and focal renal parenchymal areas of decreased perfusion. The renal artery aneurysm was successfully treated by transcatheter coil embolization.

Impact of amlodipine or ramipril treatment on left ventricular mass and carotid intima-media thickness in nondiabetic hemodialysis patients.

OBJECTIVE: Left ventricular hypertrophy (LVH) and atherosclerosis are frequently observed in uremic patients and they have appeared as an independent predictor of cardiovascular morbidity and mortality. The aim of this study was to compare the effects of ramipril and amlodipine on left ventricular mass index (LVMI) and carotid intima-media thickness (CIMT) in nondiabetic hypertensive hemodialysis patients. METHODS: A total of 112 hemodialysis (HD) patients were included in this study. Patients were randomly allocated to receive ramipril or amlodipine for 1 year. Blood pressure (BP) measurements, LVMI, and CIMT were assessed at baseline and 6-month intervals. Biochemical parameters and inflammatory markers were also determined at the initiation and during the study period. RESULTS: Similar BP decrease was observed in treatment groups. During follow-up, LVMI and CIMT progressed likewise in both treatment groups despite BP control. However, subgrouping analyses due to the pattern of left ventricular geometry showed that LVMI in patients with eccentric LVH increased, whereas LVMI decreased in subjects with concentric LVH under antihypertensive treatment. DISCUSSION: BP control with ramipril or amlodipine could not provide adequate protection for development or progression of atherosclerosis and eccentric type of LVH in nondiabetic HD patients.

[Chronic Debakey I aortic dissection in Marfan syndrome and hypertensive patients with modified stented elephant trunk surgery: a post-operative CT assessment].

OBJECTIVE: To assess the outcome of stented elephant trunk surgery for chronic DebakeyIaortic dissection in Marfan syndrome and hypertension patients by CT. METHODS: Between 2003 and 2008, 54 patients underwent the modified stented elephant trunk procedure and total arch replacement for chronic DebakeyIaortic dissection. Twenty-two patients were made a diagnosis of Marfan syndrome and the other 32 patients of hypertension. Aortic evolvement was evaluated with CT angiography by calculating the diameter ratios between the stent graft/true lumen and the aorta at the same level. RESULTS: CT study one year after discharge showed no difference in the diameter ratios of the stent and aorta at the carina level between groups (0.84 +/- 0.16 vs 0.80 +/- 0.23, P = 0.472), but had significant difference before and after surgery (0.29 +/- 0.16 vs 0.72 +/- 0.21, P < or = 0.001). And significant difference occurred at the different periods after discharge (0.72 +/- 0.21 vs 0.81 +/- 0.20, 0.81 +/- 0.20 vs 0.77 +/- 0.20, P < or = 0.001). The residual false lumen in the proximal descending aorta reached complete thrombosis in 59% of Marfan and 78% of hypertension. CONCLUSION: The modified stented elephant trunk technique is effective for closing the false lumen in the proximal descending aorta of chronic DebakeyIaortic dissection in Marfan syndrome and hypertension patients.

Pure sensory stroke due to bilateral basal ganglion hemorrhage: a case report.

Bilateral simultaneous hypertensive intracerebral hemorrhages are extremely rare. The predisposing factors and pathophysiological mechanisms leading to the development of this picture are not well known. Possible mechanisms of simultaneous multiple hemorrhages include concomitant primary hemorrhages in two or more regions, or development of a second hemorrhage in another region shortly after the primary hemorrhage. The etiology of the cases presenting with bilateral simultaneous basal ganglion hemorrhage include migraine, lightning stroke, hyperglycemic hyperosmolar coma, hypertension and diabetic ketoacidosis coma. Bilateral simultaneous hemorrhage has a poor prognosis. The case of bilateral simultaneous intracerebral hemorrhage presented here had a good clinical course similar to a pure sensorial stroke.

Posterior Reversible Encephalopathy Syndrome Caused by Induced Hypertension to Treat Cerebral Vasospasm Secondary to Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: The aim of the present study was to describe the case of a patient who had presented to a university hospital with induced-hypertension (IH) posterior reversible encephalopathy syndrome (PRES). We also reviewed all other reports of such patients. METHODS: We have described the clinical course of a patient who had presented to the university hospital neurosurgical department. We also performed a systematic review of studies related to the incidence of PRES caused by the use of IH in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. RESULTS: The patient had presented with an acute-onset headache and found to have a subarachnoid hemorrhage due to anterior communicating artery aneurysm rupture. She underwent coiling the next day. During the subsequent days, she demonstrated fluctuating clinical examination findings, aphasia, and decreased levels of arousal. Digital subtraction angiography was performed, and the findings were concerning for mild vasospasm of the anterior and middle cerebral arteries. The systolic blood pressure goal was increased to 180-220 mm Hg for an IH trial, which had initially resulted in some transient clinical improvements in her level of arousal. However, the improvement was not sustained. During the next 36 hours, the patient worsened, and she developed left middle cerebral artery syndrome. Given the concern for a possible ischemic event, magnetic resonance imaging was performed, which demonstrated interval development of multiple areas of cortical-based fluid-attenuated inversion recovery hyperintensity consistent with PRES. The systolic blood pressure goal was relaxed to normotension, and ~48 hours later, the patient's clinical status had significantly improved. CONCLUSION: IH-PRES is a rare complication that should be remembered in the differential diagnosis for at-risk patients.

Case Report: The Importance of Novel Coronavirus Disease (COVID-19) and Coinfection with Other Respiratory Pathogens in the Current Pandemic.

The early shortage of novel coronavirus disease (COVID-19) tests in the United States led many hospitals to first screen for common respiratory pathogens, and only if this screen was negative to proceed with COVID-19 testing. We report a case of a 56-year-old woman with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) coinfection with group A Streptococcus. The initial testing strategy resulted in delays in both diagnosis and implementation of appropriate precautions. Underlined is the importance of testing for both SARS-CoV-2 and other common respiratory pathogens during the current pandemic.

Favourable effects of nilvadipine on cognitive function and regional cerebral blood flow on SPECT in hypertensive patients with mild cognitive impairment.

OBJECTIVE: We compared the effects of nilvadipine and amlodipine on the cognitive function and regional cerebral blood flow (rCBF) in patients with mild cognitive impairment (MCI) and hypertension. METHODS: Twelve patients with MCI and hypertension were randomly assigned to receive nilvadipine or amlodipine for 12-16 weeks. Before and after treatment all patients underwent neuropsychological evaluation and single photon emission computed tomography (SPECT) studies with N-isopropyl-p-[123I]iodoamphetamine. RESULTS: Both nilvadipine (n=6) and amlodipine (n=6) groups had similar significant reduction in systolic and diastolic blood pressure after treatment. The Logical Memory subscore of the Wechsler Memory Scale-Revised increased significantly in the nilvadipine group, but not in the amlodipine group after treatment. Although SPECT demonstrated no significant differences in rCBF deficits at baseline between the two groups, the nilvadipine group showed an improvement of rCBF in the left frontal lobe, while the amlodipine group showed a decrease of rCBF in the left temporal lobe. CONCLUSION: Our results suggest that nilvadipine, a highly lipophilic agent that easily penetrates the central nervous system, may have additional benefits and be potentially useful for the treatment of patients with MCI and hypertension.

Pheochromocytoma underlying hypertension, stroke, and dilated cardiomyopathy.

We report the case of a 65-year-old man with a 6-year history of hypertension who presented with dilated cardiomyopathy, a transient cerebrovascular event, paroxysmal sweating, and intractable hypertension. Coronary angiography revealed no abnormality, but diagnostic testing was pursued because of the severe sweating and hypertension. Two-dimensional echocardiography showed 4-chamber dilatation with decreased left ventricular contractility. Further investigation, including a computed tomographic scan of the abdomen, led to a diagnosis of pheochromocytoma. Surgical resection of a left adrenal pheochromocytoma quickly resolved the patient's hypertension and resulted in substantially improved cardiac function after 4 months. Although pheochromocytoma has rarely been reported in the presence of both dilated cardiomyopathy and cerebrovascular events, it should be included in the differential diagnosis when patients present with dilated cardiomyopathy and a cerebrovascular event that have no obvious cause.

Effects of monotherapy and combination therapy on blood pressure control and target organ damage: a randomized prospective intervention study in a large population of hypertensive patients.

This prospective, randomized trial evaluated the effect of monotherapy and different combination therapies on cardiovascular target organ damage and metabolic profile in 520 hypertensive patients. Patients were allocated to a single agent: carvedilol 25 mg, amlodipine 10 mg, enalapril 20 mg, or losartan 50 mg (groups C, A, E, and L, respectively). After 2 months (level 2), nonresponders received a low-dose thiazide diuretic, and after 4 months (level 3), amlodipine (groups E, C, and L) and carvedilol (group A). Twenty-four-hour blood pressure was significantly lowered in all treatment groups. Blood pressure control was more pronounced in patients receiving two or three drugs. At the end of the study, the carotid intima-media thickness decreased in group L (P<.01), left ventricular mass index in groups E and L (P<.05 and P<.001, respectively), with a concomitant reduction in cholesterol in group L (P<.03). Diastolic function improved significantly in group L (P<.05). This study describes the need to control blood pressure with two or more drugs in most hypertensive patients and illustrates good clinical outcomes, independent of blood pressure lowering, using combination therapy with losartan, low-dose thiazide, and amlodipine.

Assessment of Primary Care Physicians' Use of a Pocket Ultrasound Device to Measure Left Ventricular Mass in Patients with Hypertension.

PURPOSE: Left ventricular hypertrophy (LVH) is common in primary care and is associated with increased morbidity and mortality. Treatment of underlying hypertension can reverse LVH and eliminate the associated risks. Electrocardiography is widely available and commonly used to screen hypertensive patients for LVH, but it is limited by low sensitivity. Limited echocardiographic measurement of the left ventricle is a method for screening with improved sensitivity; however, it is not currently widely used in the primary care setting. This study attempts to test the accuracy of primary care physicians' (PCPs) measurements of the left ventricle using a pocket-sized ultrasound (pUS) device after a brief training session. METHODS: This study was performed in an outpatient cardiology clinic by 3 family medicine residents and 1 family medicine faculty member after a 4-hour training session. Measurements of the left ventricle were made by PCPs using a pUS device; these measurements were compared with cardiologists' measurements from images obtained by echocardiography technicians. Left ventricular mass index (LVMI) was calculated based on these measurements and then compared between groups. RESULTS: There was no statistically significant difference between the mean LVMI calculations in the 2 groups. The agreement in measurements between the groups, however, showed high variability. This was manifested by the low sensitivity (70%) and specificity (76%) of PCPs in the detection of LVH. CONCLUSIONS: This study showed that limited echocardiography for the detection of LVH performed by PCPs at the point of care was feasible. Future studies are needed to determine the ideal training and experience necessary to yield competency.

Circulating tissue inhibitor of matrix metalloproteinase-1 is associated with aldosterone-induced diastolic dysfunction.

OBJECTIVE: To test if collagen markers are associated with aldosterone-induced diastolic dysfunction. BACKGROUND: Although primary aldosteronism is associated with more prominent cardiac remodeling and diastolic dysfunction, the reversibility of diastolic function is unclear. In addition, there is no known biomarker associated with aldosterone-induced diastolic dysfunction. METHODS: We enrolled 27 patients with aldosterone-producing adenoma (APA) preparing for adrenalectomy, and 27 patients with essential hypertension prospectively from October 2006 to March 2010 at a tertiary referral center. Plasma matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) were measured, and echocardiography including tissue Doppler images was performed in both groups and 1 year after receiving adrenalectomy in the APA group. RESULTS: The baseline plasma TIMP-1 level (88.4 ±â€Š38.7 vs. 63.6 ±â€Š32.5 ng/ml; P = 0.014), left ventricular mass index (LVMI), and E/E' ratio (11.5 ±â€Š2.9 vs. 9.0 ±â€Š2.1; P < 0.001) were significantly higher in the APA group. The baseline plasma TIMP-1 level significantly correlated with the E/E' ratio, LVMI, interventricular septum, and left atrial diameter. The plasma MMP-2 level did not correlate with the left ventricular structure parameters, except for interventricular septum thickness. After adrenalectomy, LVMI and E/E' ratio improved significantly. The postadrenalectomy plasma TIMP-1 levels, but not MMP-2 levels, also decreased. The change of plasma TIMP-1 levels was negatively associated with the postadrenalectomy E/E' ratio after adjustment for age, sex, BMI, and mean blood pressure (ß-coefficient = - 3.6, P = 0.004). CONCLUSION: Excess of aldosterone induces cardiac diastolic dysfunction, which is reversible by adrenalectomy. TIMP-1 is associated with the aldosterone-induced diastolic dysfunction.

Guidelines for arterial hypertension: the echocardiography controversy.

While the recent evolution of guidelines for arterial hypertension also includes the need to evaluate coexistent cardiovascular risk factors and target organ damage in the base work-up for arterial hypertension, it does not include echocardiography systematically, because there is no evidence that information on LV geometry and function can modify management strategy in every circumstance, and there is concern about the technical variability of repeated echocardiographic examinations in the individual patient. The present issue of the Journal publishes a paper showing that adherence to the 1993 World Health Organization - International Society of Hypertension recommendations leaves untreated a proportion of patients with 'mild hypertension' who instead would have been treated if decision was also based on echocardiographic information on LV geometry. These findings challenge the most recent positions of national Societies, reserving the indication for echocardiography to patients with high risk (the vast majority). The present study appears indeed to reinforce the notion that echocardiographic examination might be very important in patients in whom, based on guidelines adherence, no pharmacological treatment would be required, whereas, based on the present evidence, echocardiographic information might be less important and perhaps superfluous for decision making in patients assigned to a high risk score, for whom aggressive treatment has been already scheduled.

Effects of losartan and its combination with quinapril on the cardiac sympathetic nervous system and neurohormonal status in essential hypertension.

OBJECTIVE: Sympathetic nervous and renin-angiotensin systems play important roles in essential hypertension. This study was aimed at assessing the effects of losartan or its combination with quinapril on the cardiac nervous system and neurohormonal status in essential hypertension. DESIGN AND METHODS: Randomized, comparative study of 105 patients with mild essential hypertension, carried out at Shizuoka General Hospital. In phase 1, 40 hypertensives were allocated randomly into the losartan (50 mg) group or the quinapril (10 mg) group. In phase 2, 65 hypertensives, after 3 months 10 mg quinapril monotherapy, were allocated randomly into groups with 50 mg losartan (n = 32) or 5 mg amlodipine (n = 33) added to quinapril, and were treated for a further 3 months. All patients underwent [(123)I]metaiodobenzylguanidine (MIBG) imaging and neurohormonal measurements before and 3 months after treatment. RESULTS: Both monotherapies significantly increased renin activity, while losartan monotherapy also increased angiotensin II (AII) concentration. In both the losartan and quinapril groups, the washout rate was significantly decreased (18.1 +/- 11.4 versus 13.9 +/- 11.0%, P < 0.0002 and 13.3 +/- 9.3 versus 12.3 +/- 9.1%, P < 00001, respectively) without changes in the heart to mediastinum ratio (H/M ratio). Both combined therapies lowered blood pressure to similar levels. A combination therapy with losartan and quinapril significantly increased the H/M ratio (1.93 +/- 0.29 and 2.02 +/- 0.29, P < 0.01) and decreased the washout rate (17.6 +/- 11.0 and 15.3 +/- 9.2%, P < 0.02) without affecting AII concentration, whereas a combination therapy with amlodipine and quinapril therapy did not affect the scintigraphic parameters with an increase in the AII concentration. CONCLUSIONS: With a usual antihypertensive dose, both losartan and quinapril had a little suppressive effect on the cardiac sympathetic activity in essential hypertension. In contrast, the combination therapy with losartan and quinapril, which results in a higher degree of inhibition of the renin-angiotensin system, could suppress the cardiac sympathetic activity effectively.

Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases.

The indications for surgery in hypertensive intracerebral hematoma are still controversial. The reason for this may be: 1) lack of adequate and comparable data in conservative and surgical therapy from the same institution; 2) lack of adequate close follow-up monitoring over an extended period of time; or 3) lack of proper classification of hematomas for comparison of results from different institutions. The authors have treated 459 cases of hypertensive intracerebral hematoma between October, 1975, and July, 1983. The hematomas have been classified according to their mode of extension on computerized tomography. The long-term outcome was assessed on the basis of activity of daily living. Putaminal hematomas were classified as mild, moderate, severe, and very severe. In general, there was no significant difference in outcome between the surgical and nonsurgical cases; however, the outcome in the moderate and severe hematomas was found to be a little better for the surgical cases in some restricted areas. Thalamic and pontine hemorrhages were classified as mild, moderate, or severe. If the hematoma is localized to the thalamus or pons, and if it extends to the midbrain, there is no indication for surgery; however, in patients with moderate hematomas, the prognosis showed a variable outcome, and the indications for surgery were questionable. In cerebellar hematomas, the authors propose that even a hematoma with a diameter greater than 3 cm might show a good outcome with nonsurgical therapy.

Hematoma growth and outcomes in intracerebral hemorrhage: the INTERACT1 study.

OBJECTIVE: Uncertainty exists over the size of potential beneficial effects of medical treatments targeting hematoma growth in intracerebral hemorrhage (ICH). We report associations of hematoma growth parameters on clinical outcomes in the pilot phase, Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT1) (ClinicalTrials.gov NCT00226096). METHODS: In randomized patients with both baseline and 24-hour brain CT (n = 335), associations between measures of absolute and relative hematoma growth and 90-day poor outcomes of death and dependency (modified Rankin Scale score 3-5) were assessed in logistic regression models, with data reported as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: A total of 10.7 mL (1 SD) increase in hematoma volume over 24 hours was strongly associated with poor outcome (adjusted OR 1.72, 95% CI 1.19-2.49; p = 0.004). An association was also evident for relative growth (adjusted OR 1.67, 95% 1.22-2.27; p = 0.001 for 1 SD increase). The analyses were adjusted for age, sex, achieved systolic blood pressure, elevated NIH Stroke Scale score (≥ 14), hematoma location, baseline hematoma volume, intraventricular extension, antithrombotic therapy, baseline glucose, time from ICH to baseline CT scan, and time from baseline to repeat CT scan. A 1 mL increase in hematoma growth was associated with a 5% (95% CI 2%-9%) higher risk of death or dependency. CONCLUSION: Medical treatments, such as rapid intensive blood pressure lowering, could achieve ∼2-4 mL absolute attenuation of hematoma growth. There is hope that this could translate into modest but still clinically worthwhile (∼10%-20% better chance) outcome from ICH.