Morning blood pressure surge is associated with death in hypertensive patients.

BACKGROUND: Morning blood pressure surge (MS), defined as the difference between the mean blood pressure (BP) 2 h after waking up and the mean of the three lowest BP values during sleep, has been correlated with increased cardiovascular risk. We sought to evaluate its association with cardiovascular events and death. METHODS: We retrospectively analyzed data from 632 hypertensive patients [median age 58 years (50-67 years), 37% men] who underwent ambulatory BP monitoring between January 2005 and December 2006. Patients were divided into two groups according to MS (≥41 mmHg and <41 mmHg), and mortality from any cause was retrieved after a median time of 50 months (46-54 months). RESULTS: Patients with MS of 41 mmHg or higher were older, had a higher daytime systolic BP, as well as a higher systolic and diastolic dipping, and a lower night-time diastolic BP. During follow-up, there were 19 deaths and MS of 41 mmHg or higher was associated with a higher hazard for death in the crude model [hazard ratio: 3.47 (95% confidence interval: 1.25-9.65)], as well as after adjustments for age and the presence of diabetes [hazard ratio: 3.35 (95% confidence interval: 1.18-9.49)]. CONCLUSION: An increased BP surge is associated with higher hazard for death. Future studies specifically designed to evaluate the real impact of MS on outcomes, as well as to define its optimal cutoff value, are required.

Clinical determinants and prognostic significance of the electrocardiographic strain pattern in chronic kidney disease patients.

The electrocardiographic (ECG) strain pattern (Strain) is a marker of left ventricular hypertrophy (LVH) severity that provides additional prognostic information beyond echocardiography (ECHO) in the community level. We sought to evaluate its clinical determinants and prognostic usefulness in chronic kidney disease (CKD) patients. We evaluated 284 non-dialysis-dependent patients with CKD stages 3 to 5 (mean age, 61 years [interquartile range, 53-67 years]; 62% men). Patients were followed for 23 months (range, 13-32 months) for cardiovascular (CV) events and/or death. Strain patients (n = 37; 13%) were using more antihypertensive drugs, had higher prevalence of peripheral vascular disease and smoking, and higher levels of C-reactive protein, cardiac troponin, and brain natriuretic peptide (BNP). The independent predictors of Strain were: left ventricular mass index (LVMI), BNP, and smoking. During follow-up, there were 44 cardiovascular events (fatal and non-fatal) and 22 non-CV deaths; and Strain was associated with a worse prognosis independently of LVMI. Adding Strain to a prognostic model of LVMI improved in 15% the risk discrimination for the composite endpoint and in 12% for the CV events. Strain associates with CV risk factors and adds prognostic information over and above that of ECHO-assessed LVMI. Its routine screening may allow early identification of high risk CKD patients.

Reliability of electrocardiographic surrogates of left ventricular mass in patients with chronic kidney disease.

OBJECTIVE: Left ventricular hypertrophy (LVH) is a prevalent condition in chronic kidney disease (CKD) very often underdiagnosed and misdiagnosed. Electrocardiography (ECG) is an easily accessible LVH diagnostic tool. We evaluated the usefulness of commonly applied ECG criteria for LVH diagnosis in CKD patients. METHODS: Cross-sectional evaluation of 253 nondialysis-dependent CKD stages 3-5 patients (61 [53-67] years; 65% men). Left ventricular mass (LVM) was assessed by echocardiography (ECHO). ECG was performed to assess Cornell voltage and Sokolow-Lyon voltage and their products (Cornell product and Sokolow-Lyon product, respectively). RESULTS: The prevalence of LVH ranged from 72 to 89% depending on ECHO criteria used. Cornell product showed the best correlation with ECHO-estimated LVM (ρ = 0.41; P <0.001). Across sex-specific tertiles of ECHO-LVM, ECG criteria increased and patients were more often hypertensive, obese, fluid overloaded, inflamed, and with higher albuminuria. Cornell product showed the strongest association with ECHO-LVM in crude and adjusted regression models, and the higher predictive performance for all the ECHO-based LVH definitions. However, when applying literature-based ECG cut-offs for LVH diagnosis, Sokolow-Lyon product showed a higher specificity. The agreement between ECG criteria cut-offs and ECHO-based definitions of LVH was in general poor, and the number of patients reclassified correctly by ECHO ranged from 77 to 94%. CONCLUSION: Our data suggest that ECG alone is a weak indicator of LVH, and do not support its routine use as a unique tool in the screening of LVH in CKD patients. Further studies are needed to confirm these results and to try establishing adequate cut-offs for LVH diagnosis in this population.

Clinical determinants and prognostic significance of the electrocardiographic strain pattern in chronic kidney disease patients

The electrocardiographic (ECG) strain pattern (Strain) is a marker of left ventricular hypertrophy (LVH) severity that providesadditional prognostic information beyond echocardiography (ECHO) in the community level. We sought to evaluateits clinical determinants and prognostic usefulness in chronic kidney disease (CKD) patients. We evaluated 284 nondialysis-dependent patients with CKD stages 3 to 5 (mean age, 61 years [interquartile range, 53–67 years]; 62% men).Patients were followed for 23 months (range, 13–32 months) for cardiovascular (CV) events and/or death. Strain patients(n » 37; 13%) were using more antihypertensive drugs, had higher prevalence of peripheral vascular disease and smoking,and higher levels of C-reactive protein, cardiac troponin, and brain natriuretic peptide (BNP). The independent predictors ofStrain were: left ventricular mass index (LVMI), BNP, and smoking. During follow-up, there were 44 cardiovascular events(fatal and non-fatal) and 22 non-CV deaths; and Strain was associated with a worse prognosis independently of LVMI.Adding Strain to a prognostic model of LVMI improved in 15% the risk discrimination for the composite endpoint and in12% for the CV events. Strain associates with CV risk factors and adds prognostic information over and above that ofECHO-assessed LVMI. Its routine screening may allow early identification of high risk CKD patients.

Morning blood pressure surge is associated with death in hypertensive patients

Background Morning blood pressure surge (MS), definedas the difference between the mean blood pressure (BP) 2 hafter waking up and the mean of the three lowest BP valuesduring sleep, has been correlated with increasedcardiovascular risk. We sought to evaluate its associationwith cardiovascular events and death.Methods We retrospectively analyzed data from 632hypertensive patients [median age 58 years (50–67 years),37% men] who underwent ambulatory BP monitoringbetween January 2005 and December 2006. Patients weredivided into two groups according to MS (≥41 mmHg and<41 mmHg), and mortality from any cause was retrievedafter a median time of 50 months (46–54 months).Results Patients with MS of 41 mmHg or higher were older,had a higher daytime systolic BP, as well as a highersystolic and diastolic dipping, and a lower night-timediastolic BP. During follow-up, there were 19 deaths and MSof 41 mmHg or higher was associated with a higher hazardfor death in the crude model [hazard ratio: 3.47 (95%confidence interval: 1.25–9.65)], as well as afteradjustments for age and the presence of diabetes [hazardratio: 3.35 (95% confidence interval: 1.18–9.49)].Conclusion An increased BP surge is associated withhigher hazard for death. Future studies specificallydesigned to evaluate the real impact of MS on outcomes, aswell as to define its optimal cutoff value, are required.

Reliability of electrocardiographic surrogates of left ventricular mass in patients with chronic kidney disease

Objective: Left ventricular hypertrophy (LVH) is a prevalentcondition in chronic kidney disease (CKD) very oftenunderdiagnosed and misdiagnosed. Electrocardiography(ECG) is an easily accessible LVH diagnostic tool. Weevaluated the usefulness of commonly applied ECG criteriafor LVH diagnosis in CKD patients.Methods: Cross-sectional evaluation of 253 nondialysisdependentCKD stages 3–5 patients (61 [53–67] years;65% men). Left ventricular mass (LVM) was assessed byechocardiography (ECHO). ECG was performed to assessCornell voltage and Sokolow–Lyon voltage and theirproducts (Cornell product and Sokolow–Lyon product,respectively).Results: The prevalence of LVH ranged from 72 to 89%depending on ECHO criteria used. Cornell product showedthe best correlation with ECHO-estimated LVM (r»0.41;P<0.001). Across sex-specific tertiles of ECHO-LVM, ECGcriteria increased and patients were more oftenhypertensive, obese, fluid overloaded, inflamed, and withhigher albuminuria. Cornell product showed the strongestassociation with ECHO-LVM in crude and adjustedregression models, and the higher predictive performancefor all the ECHO-based LVH definitions. However, whenapplying literature-based ECG cut-offs for LVH diagnosis,Sokolow–Lyon product showed a higher specificity. Theagreement between ECG criteria cut-offs and ECHO-baseddefinitions of LVH was in general poor, and the number ofpatients reclassified correctly by ECHO ranged from 77 to94%.Conclusion: Our data suggest that ECG alone is a weakindicator of LVH, and do not support its routine use as aunique tool in the screening of LVH in CKD patients.Further studies are needed to confirm these results and totry establishing adequate cut-offs for LVH diagnosis in thispopulation.