Marking Techniques for Targeted Axillary Dissection Among Patients With Node-Positive Breast Cancer Treated With Neoadjuvant Chemotherapy.

Invasive breast cancer with axillary lymph node (LN) invasion is a continuing problem worldwide. The morbidity associated with axillary LN dissection along with the high rate of nodal downstaging after neoadjuvant chemotherapy (NACT) made the standard treatment shift towards less invasive surgery. Sentinel lymph node biopsy (SLNB) after NACT is associated with high false-negative rates (13%-14%). To overcome this problem, it was concluded that the positive nodes should first be indicated with image-detectable markers and then removed together with SLNB: targeted axillary dissection (TAD). This review aims to describe and evaluate the different marking techniques for TAD in patients with node-positive breast cancer treated with NACT, namely: clip placement and guidewire localization; clip placement and 125I-labelled radioactive seed localization; clip placement and skin mark; clip placement and intraoperative ultrasound; tattooing with a sterile black carbon suspension; magnetic seeds; radar and infrared light technology localization. Targeted axillary dissection techniques have shown false-negative rates below 9% and identification rates above 95%. The most studied technique is guidewire localization, as it is also the oldest one. However, according to data gathered from this review, some newer techniques have shown to be very promising due to their statistical results and management factors.

Variable association of 24-h peripheral and central hemodynamics and stiffness with hypertension-mediated organ damage: the VASOTENS Registry.

OBJECTIVE: In this analysis of the telehealth-based Vascular health ASsessment Of The hypertENSive patients Registry, we checked how 24-h central and peripheral hemodynamics compare with hypertension-mediated organ damage (HMOD). METHODS: In 646 hypertensive patients (mean age 52 ±â€Š16 years, 54% males, 65% treated) we obtained ambulatory brachial and central SBP and pulse pressure (PP), SBP, and PP variability, pulse wave velocity and augmentation index with a validated cuff-based technology. HMOD was defined by an increased left ventricular mass index (cardiac damage, evaluated in 482 patients), an increased intima-media thickness (vascular damage, n = 368), or a decreased estimated glomerular filtration rate or increased urine albumin excretion (renal damage, n = 388). RESULTS: Ambulatory SBP and PPs were significantly associated with cardiac damage: the largest odds ratio was observed for 24-h central SBP [1.032 (1.012, 1.051), P = 0.001] and PP [1.042 (1.015, 1.069), P = 0.002], the weakest for brachial estimates. The association was less strong for vascular damage with a trend to the superiority of 24-h central [1.036 (0.997, 1.076), P = 0.070] over brachial PP [1.031 (1.000, 1.062), P = 0.052]. No statistically significant association was observed for renal damage. SBP and PP variabilities, pulse wave velocity and augmentation index were not associated with any form of HMOD. In the multivariate analysis, age was associated with any type of HMOD, whereas central SBP and PP were predictive of an increased risk of cardiac damage. CONCLUSION: In hypertensive patients a variable association exists between peripheral and central hemodynamics and various types of HMOD, with the most predictive power being observed for central SBP and PP for cardiac damage.

Ambulatory blood pressure and arterial stiffness web-based telemonitoring in patients at cardiovascular risk. First results of the VASOTENS (Vascular health ASsessment Of The hypertENSive patients) Registry.

The VASOTENS Registry is an international telehealth-based repository of 24-hour ambulatory blood pressure monitorings (ABPM) obtained through an oscillometric upper-arm BP monitor allowing combined estimation of some vascular biomarkers. The present paper reports the results obtained in 1200 participants according to different categories of CV risk. Individual readings were averaged for each recording and 24-hour mean of brachial and aortic systolic (SBP) and diastolic blood pressure (DBP), pulse wave velocity (PWV), and augmentation index (AIx) obtained. Peripheral and central BP, PWV and AIx values were increased in older participants (SBP only) and in case of hypertension (SBP and DBP). BP was lower and PWV and AIx higher in females. PWV was increased and BP unchanged in case of metabolic syndrome. Our results suggest that ambulatory pulse wave analysis in a daily life setting may help evaluate vascular health of individuals at risk for CV disease.

Carotid pulse wave analysis: left or right, does it matter?

INTRODUCTION: Pulse wave analysis (PWA) over the carotid artery is one of the available methodological options to obtain central arterial pressures and other important hemodynamic parameters. However, limited data exist relating the PWA estimates of one carotid artery over the contralateral one as the majority of the available data rely on measures over the right carotid artery. OBJECTIVE: To evaluate the agreement of the PWA estimates between the right carotid artery and the left carotid artery. PATIENTS AND METHODS: A cross-sectional study of 38 patients, with a mean age of 28.85±1.70 years, was carried out. Brachial blood pressure was evaluated using a sphygmomanometer. Subsequently, PWA was obtained randomly over the left or the right carotid arteries with the Complior Analyse. All the evaluations were performed by the same experienced operator. RESULTS: The overall mean differences observed by comparing the obtained parameters in each carotid territory were -1.50±8.06 mmHg for central systolic blood pressure (SBP), -1.63±7.98 mmHg for central pulse pressure, -3.37±27.80% for the augmentation index, and 1.50±8.06 mmHg for the SBP amplification, and were not statistically significant for all the parameters. The Bland-Altman analysis showed distinct correlations and concordance levels for different parameters: central SBP and central pulse pressure showed a very strong agreement (intraclass correlation of 0.926 and 0.886, respectively). In contrast, the concordance for the augmentation index and the SBP amplification was moderate (intraclass correlations between 0.5 and 0.8). CONCLUSION: PWA provides similar measures of central blood pressure, whether measured over the right or the left carotid arteries, even though the morphological features of the pulse waves showed moderate agreement. The advantages of PWA over each arterial territory and the requirements that should mediate the choice of one of the both sides require further investigation.

Pulse wave analysis reproducibility with the Complior Analyse device: a methodological study.

INTRODUCTION: The aim of this study was to assess the interobserver and intraobserver reproducibility, as well as the temporal variability of the new Complior Analyse assessing central arterial hemodynamic parameters through carotid pulse wave analysis (PWA). PATIENTS AND METHODS: Eighty-seven (60% men) participants, with a mean age of 34.26±16.58 years, were enrolled in a cross-sectional study. All patients were subjected to sequential measures of carotid PWA by two experienced operators. In a group of 27 patients, PWA was also determined 1 month after the first evaluation to address the temporal stability of the PWA estimations with the device. RESULTS: The analysis of concordance revealed a very good agreement for paired PWA values, regarding both intraobserver variability and interobserver variability and also the temporal variability. Intraclass correlation coefficients above 0.9 were calculated for central systolic blood pressure, central pulse pressure, and the augmentation index, in all three conditions. Small mean differences for intraobserver, interobserver, and temporal reproducibility were also observed for the three major parameters: -0.5 mmHg [limits of agreement (LOA): 9.1;8.1], 0.1 mmHg (LOA: 6.6;6.8), and -0.3 mmHg (LOA: 10.2;9.6), respectively, for central systolic blood pressure; 0.4 mmHg (LOA: 6.2;6.9), 1.0 mmHg (LOA: 6.0;8.1), and -0.4 mmHg (LOA: 6.7;6.1), respectively, for central pulse pressure; and 0.8% (LOA: 14.0;15.5), 0.1% (LOA: 15.6;15.9), and -0.1% (LOA: 16.2;16.1), respectively, for the augmentation index. The observed correlations were independent of sex, age, arterial pressure, heart rate, and BMI. CONCLUSION: The data demonstrated an excellent reproducibility of the Complior Analyse for the assessment of central hemodynamic parameters, when used in ideal conditions and by experienced observers. The results demonstrates that this device is suitable for the inclusion in integrated clinical follow-up programs, particularly regarding central arterial pressure estimations.

Vascular Health Assessment of The Hypertensive Patients (VASOTENS) Registry: Study Protocol of an International, Web-Based Telemonitoring Registry for Ambulatory Blood Pressure and Arterial Stiffness.

BACKGROUND: Hypertension guidelines recommend ambulatory blood pressure (ABP), central aortic pressure (CAP), and pulse wave velocity (PWV) as parameters for estimating blood pressure (BP) control and vascular impairment. Recent advances in technology have enabled devices to combine non-invasive estimation of these parameters over the 24-hour ABP monitoring. However, currently there is limited evidence on the usefulness of such an approach for routine hypertension management. OBJECTIVE: We recently launched an investigator-initiated, international, multicenter, observational, prospective study, the Vascular health Assessment Of The Hypertensive patients (VASOTENS) Registry, aimed at (1) evaluating non-invasive 24-hour ABP and arterial stiffness estimates (through 24-hour pulse wave analysis, PWA) in hypertensive subjects undergoing ambulatory blood pressure monitoring (ABPM) for clinical reasons; (2) assessing the changes in estimates following treatment; (3) weighing the impact of 24-hour PWA on target organ damage and cardiovascular prognosis; (4) assessing the relationship between arterial stiffness, BP absolute mean level and variability, and prognosis; and (5) validating the use of a 24-hour PWA electronic health (e-health) solution for hypertension screening. METHODS: Approximately 2000 subjects, referred to 20 hypertension clinics for routine diagnostic evaluation and follow-up of hypertension of any severity or stage, will be recruited. Data collection will include ABPM, performed with a device allowing simultaneous non-invasive assessment of 24-hour CAP and arterial stiffness (BPLab), and clinical data (including cardiovascular outcomes). As recommended by current guidelines, each patient will be followed-up with visits occurring at regular intervals (ideally every 6 months, and not less than once a year depending on disease severity). A Web-based telemedicine platform (THOLOMEUS) will be used for data collection. The use of the telemedicine system will allow standardized and centralized data collection, data validation by experts and counseling to remote centers, setup and maintenance of the Registry, and prompt data analysis. RESULTS: First follow-up results are expected to be available in the next 2 years. CONCLUSIONS: The results of the VASOTENS Registry will help define the normalcy thresholds for current and future indices derived from 24-hour PWA, according to outcome data, and will also provide supporting evidence for the inclusion of this type of evaluation in hypertension management. TRIAL REGISTRATION: Clinicaltrials.gov NCT02577835; https://clinicaltrials.gov/ct2/show/NCT02577835 (Archived by WebCite at http://www.Webcitation.org/6hzZBKY2Q).

Invasive validation of the Complior Analyse in the assessment of central artery pressure curves: a methodological study.

INTRODUCTION: Arteries are the target, the place, and the common denominator of cardiovascular diseases; hence, study of arterial function is of greatest importance in clinical practice. The aim of this study was to evaluate the accuracy of carotid pulse wave analysis using the new version of the Complior device--the Complior Analyse. METHODS AND RESULTS: This was a cross-sectional study that included 15 patients (seven women), mean age 62.07±10.59 years, referenced for cardiac catheterization. Pressure curves were obtained simultaneously in the ascending aorta (invasively) and in the right common carotid artery (using the Complior Analyse). Mean central arterial pressures, augmentation indexes, and wave morphology obtained using both methods were compared. A good concordance between methods was obtained for all the parameters measured, with intraclass correlation coefficients above 0.9. Bland-Altman analysis also indicated a good accuracy profile of the Complior device, with small mean differences observed for all parameters and most values confined within 2 SD of the mean difference. This was further confirmed by the strong Pearson correlation coefficients, with r² coefficients above 0.92 for all the variables studied. The correlations observed were independent of sex, age, arterial pressure, and BMI. CONCLUSION: The results presented and available research clearly indicate that the Complior Analyse device measures carotid pressure waves accurately; therefore, it is a simple and reliable noninvasive alternative for pressure wave analysis.

Efficacy and safety of a lercanidipine/enalapril fixed-dose combination in hypertensive patients in Portugal.

BACKGROUND: Fixed-dose combinations of hypertensive drugs have been advocated as a suitable option for hypertensive patients who require two or more drugs to achieve blood pressure (BP) targets. OBJECTIVES: Our objective was to assess the efficacy and safety of lercanidipine/enalapril in clinical practice. METHODS: This observational study collected data for patients with hypertension treated by 46 specialists at clinics across Portugal with lercanidipine/enalapril (10/20 mg). The primary outcome measure was the reduction from baseline in systolic BP (SBP) and diastolic BP (DBP). RESULTS: The registry enrolled 315 patients (59.1 % females; mean age 64.84 ± 12.18 years). Baseline SBP and DBP were 159.11 ± 16.93 and 88.32 ± 12.35 mmHg, respectively. At a mean 2.88 ± 1.75 months after starting lercanidipine/enalapril, the mean change from baseline in SBP and DBP were -18.08 ± 15.91 and -10.10 ± 11.46 mmHg, respectively (both p < 0.001). This corresponded to reductions of 11.4 and 11.3 % in SBP and DBP, respectively. SBP was reduced independently of sex and age, and DBP was reduced independently of sex. The BP control (<140/90 mmHg) rate significantly increased from 10.2 % at baseline to 51.0 % after a mean of 2.88 months of treatment with lercanidipine/enalapril (p < 0.001). Adverse effects were seen in only one patient (0.3 %), who developed a persistent dry cough. CONCLUSIONS: Treatment with the fixed-dose combination lercanidipine/enalapril was associated with significant reductions in SBP and DBP, and a significant increase in the BP control rate. This fixed-dose combination has been shown to effectively reduce BP, generally independently of age and sex, and with an excellent safety profile.

Reproducibility of aortic pulse wave velocity as assessed with the new Complior Analyse.

INTRODUCTION: The aim of this study was to assess the interobserver and intraobserver reproducibility, as well as the temporal variability of the new Complior Analyse assessing aortic pulse wave velocity (PWV). METHODS: Eighty-seven participants (60% men), mean age 34.26 ± 16.58 years, were enrolled in a cross-sectional study. All patients were subjected to sequential measures of aortic PWV by two experienced operators. In a group of 27 participants, PWV was also determined 1 month after the first moment evaluation to assess the temporal stability of the PWV estimations with the device. RESULTS: The analysis of concordance showed a very good agreement for paired PWV values in terms of both the intraobserver and the interobserver variability and also the temporal variability. The intraclass correlation coefficients were above 0.98 for the three conditions (P<0.0001), indicating an excellent strength of agreement. Further evidences in favor of a good overall performance of the device were determined from the Bland-Altman analysis, with small mean differences for intrareproducibility, interreproducibility, and temporal reproducibility (respectively, 0.02 ± 0.38, 0.10 ± 0.45, and 0.07 ± 0.51 m/s), and with differences mainly between 2 SDs of the mean difference. The correlations observed were independent of sex, age, arterial pressure, heart rate, and BMI. CONCLUSION: The data showed an excellent reproducibility of the Complior Analyse for the assessment of aortic PWV when used in ideal conditions and by experienced observers. The technical profile presented shows that this device meets the requirements of quality for its inclusion in integrated clinical follow-up programs.

Aortic pulse wave velocity improves cardiovascular event prediction: an individual participant meta-analysis of prospective observational data from 17,635 subjects.

OBJECTIVES: The goal of this study was to determine whether aortic pulse wave velocity (aPWV) improves prediction of cardiovascular disease (CVD) events beyond conventional risk factors. BACKGROUND: Several studies have shown that aPWV may be a useful risk factor for predicting CVD, but they have been underpowered to examine whether this is true for different subgroups. METHODS: We undertook a systematic review and obtained individual participant data from 16 studies. Study-specific associations of aPWV with CVD outcomes were determined using Cox proportional hazard models and random effect models to estimate pooled effects. RESULTS: Of 17,635 participants, a total of 1,785 (10%) had a CVD event. The pooled age- and sex-adjusted hazard ratios (HRs) per 1-SD change in loge aPWV were 1.35 (95% confidence interval [CI]: 1.22 to 1.50; p < 0.001) for coronary heart disease, 1.54 (95% CI: 1.34 to 1.78; p < 0.001) for stroke, and 1.45 (95% CI: 1.30 to 1.61; p < 0.001) for CVD. Associations stratified according to sex, diabetes, and hypertension were similar but decreased with age (1.89, 1.77, 1.36, and 1.23 for age ≤50, 51 to 60, 61 to 70, and >70 years, respectively; pinteraction <0.001). After adjusting for conventional risk factors, aPWV remained a predictor of coronary heart disease (HR: 1.23 [95% CI: 1.11 to 1.35]; p < 0.001), stroke (HR: 1.28 [95% CI: 1.16 to 1.42]; p < 0.001), and CVD events (HR: 1.30 [95% CI: 1.18 to 1.43]; p < 0.001). Reclassification indices showed that the addition of aPWV improved risk prediction (13% for 10-year CVD risk for intermediate risk) for some subgroups. CONCLUSIONS: Consideration of aPWV improves model fit and reclassifies risk for future CVD events in models that include standard risk factors. aPWV may enable better identification of high-risk populations that might benefit from more aggressive CVD risk factor management.

A distensibilidade da aorta prediz o acidente vascular cerebral em pacientes hipertensos / Aortic stiffness is an independent predictor of stroke in hypertensive patients

FUNDAMENTO: A doença cardiovascular continua a ser principal causa de morte nos países desenvolvidos e não é inteiramente prevista por fatores de risco clássicos. O aumento da rigidez arterial constitui um importante determinante de morbidade e mortalidade cardiovascular. OBJETIVO: Avaliar se a velocidade da onda de pulso prediz a ocorrência de acidente vascular cerebral (AVC) em pacientes hipertensos. MÉTODOS: Estudo de coorte, observacional, prospetivo, multicêntrico, incluindo 1.133 pacientes hipertensos (586 homens), com uma média de idade de 51,05 ± 12,64 anos. Todos os pacientes foram submetidos à avaliação da VOP pelo método Complior, a uma avaliação clínica pormenorizada e à medição da pressão arterial. RESULTADOS: A incidência cumulativa de risco de AVC nos hipertensos com VOP aumentada foi de 3,25% (IC: 1,97%-5,25%), em comparação com 0,78% (IC: 0,28% - 1,87%) nos hipertensos com VOP normal (risco relativo (RR) = 4,15; IC: 1,53 - 11,26). Numa análise multivariável, ajustando o modelo aos fatores de risco cardiovasculares clássicos, a VOP foi um preditor independente de AVC, com um hazard ratio (HR) = 1,40 (IC: 1,13 - 1,73, p < 0,002), indicando um incremento de 40% no risco de AVC por cada incremento de 1 m/seg na VOP. A adição da VOP a um modelo composto pelos fatores de risco cardiovascular convencionais melhorou significativamente a sua capacidade discriminativa para o risco de AVC (C de Harrel aumentou de 0,68 para 0,71 após inclusão da VOP; p <0,01). CONCLUSÃO: A distensibilidade arterial aferida pela VOP aórtica é um fator de risco independente de AVC em pacientes hipertensos, sendo recomendável a sua integração em programas de follow-up de situações em que o risco cardiovascular é manifesto.

BACKGROUND: Cardiovascular disease remains the leading cause of death in developed countries and is not entirely predicted by classic risk factors. Increased arterial stiffness is an important determinant of cardiovascular morbidity and mortality. OBJECTIVE: To assess whether Aortic Pulse Wave Velocity (PWV) predicts the occurrence of stroke in hypertensive patients METHODS: A cohort, observational and prospective study, including 1133 hypertensive patients (586 men), with a mean age 51.05 ± 12.64 years, was designed. PWV with the Complior method was performed in all patients, as well as a detailed clinical evaluation and blood pressure measurement. RESULTS: The cumulative incidence of stroke in hypertensive patients with increased PWV was 3.25% (CI: 1.97% -5.25%), compared with 0.78% (CI: 0.28% -1.87%) in hypertensive patients with normal PWV (Risk Ratio (RR) =4.15; CI:1.53-11.26). In a multivariate analysis, adjusting the model to classical cardiovascular risk factors, PWV was an independent predictor of stroke, with a Hazard Ratio (HR) = 1.40 (CI:1.13-1.73, p<0.001), indicating a 40% increase in the risk of stroke per 1m/s increment in PWV. The addition of PWV to a model consisting of conventional cardiovascular risk factors significantly improved the discriminative capacity for stroke (Harrell's C increased from 0.68 to 0.71 after the inclusion of the PWV; p<0.01). CONCLUSION: Aortic PWV is a risk factor for stroke in hypertensive patients, and its integration into clinical follow-up programs in patients whose cardiovascular risk is manifest is strongly recommended.

Aortic stiffness is an independent predictor of stroke in hypertensive patients.

BACKGROUND: Cardiovascular disease remains the leading cause of death in developed countries and is not entirely predicted by classic risk factors. Increased arterial stiffness is an important determinant of cardiovascular morbidity and mortality. OBJECTIVE: To assess whether Aortic Pulse Wave Velocity (PWV) predicts the occurrence of stroke in hypertensive patients METHODS: A cohort, observational and prospective study, including 1133 hypertensive patients (586 men), with a mean age 51.05 ± 12.64 years, was designed. PWV with the Complior method was performed in all patients, as well as a detailed clinical evaluation and blood pressure measurement. RESULTS: The cumulative incidence of stroke in hypertensive patients with increased PWV was 3.25% (CI: 1.97% -5.25%), compared with 0.78% (CI: 0.28% -1.87%) in hypertensive patients with normal PWV (Risk Ratio (RR) =4.15; CI:1.53-11.26). In a multivariate analysis, adjusting the model to classical cardiovascular risk factors, PWV was an independent predictor of stroke, with a Hazard Ratio (HR) = 1.40 (CI:1.13-1.73, p<0.001), indicating a 40% increase in the risk of stroke per 1m/s increment in PWV. The addition of PWV to a model consisting of conventional cardiovascular risk factors significantly improved the discriminative capacity for stroke (Harrell's C increased from 0.68 to 0.71 after the inclusion of the PWV; p<0.01). CONCLUSION: Aortic PWV is a risk factor for stroke in hypertensive patients, and its integration into clinical follow-up programs in patients whose cardiovascular risk is manifest is strongly recommended.

Peripheral artery disease and kidney function in hypertensive patients.

BACKGROUND: Patients with peripheral arterial disease (PAD) have a high risk of developing cardiovascular events. There is a high prevalence of PAD in individuals with kidney disease and both are important risk factors for cardiovascular events. OBJECTIVE: The aim of this study was to investigate the association between PAD and renal function in hypertensive patients. METHODS: The sample consisted of 909 individuals with arterial hypertension. The presence of PAD was evaluated using the ankle-brachial index (ABI) method and renal function was assessed based on the estimated glomerular filtration rate (eGFR). The subjects were divided into groups, according to abnormal (ABI < 0.9) and normal ABI (ABI 0.9-1.4). RESULTS: The percentage of subjects with abnormal ABI was 8%. In the group of individuals with abnormal ABI, prevalence of CKD was 23.4%, compared to a prevalence of 11.2% in patients with normal ABI. Multivariable logistic regression analysis, after adjusting the model to the conventional cardiovascular risk factors, identified a statistically significant and independent effect of eGFR on the likelihood of developing PAD, with an OR of 0.987 (CI: 0.97-1.00). CONCLUSION: An independent association between PAD and chronic kidney disease was observed in the present study. Therefore, the combination of an accurate diagnosis of kidney disease and routine ABI evaluation could constitute a more efficient means to identify subclinical PAD, allowing individuals to benefit from early interventions, aiming at reducing cardiovascular risk.

Doença arterial periférica e função renal na hipertensão arterial / Peripheral artery disease and kidney function in hypertensive patients

FUNDAMENTO: Pacientes com Doença Arterial Periférica (DAP) possuem um risco elevado de eventos cardiovasculares existindo uma elevada prevalência dessa patologia em pacientes com doença renal crônica. OBJETIVO: O objetivo deste estudo consiste em verificar se existe uma associação entre a DAP e a função renal em pacientes hipertensos. MÉTODOS: A amostra deste estudo foi constituída por um total de 909 pacientes com hipertensão arterial. Foi avaliada a presença de DAP, com recurso ao índice tornozelo-braço (ITB), e a determinação da função renal com base no cálculo da taxa de filtração glomerular. Os indivíduos foram divididos em grupos de acordo com o ITB anormal (< 0,9) e normal (0,9-1,4). RESULTADOS: A porcentagem de pacientes com um ITB anormal foi de 8%. No grupo de pacientes com ITB anormal a prevalência de doença renal crônica foi de 23,4%, comparativamente a uma prevalência de 11,2% no grupo com ITB normal. Por meio da análise de regressão logística multivariável, ajustando o modelo aos factores de risco cardiovasculares convencionais, identificou-se um efeito estatisticamente significativo e independente da eTFG sobre a probabilidade de desenvolvimento de DAP, com um OR de 0,987 (IC: 0,97-1,00). CONCLUSÃO: Demonstrou-se uma associação independente entre a DAP e a doença renal crônica. Dessa forma, a combinação de um diagnóstico preciso da doença renal e a medida de rotina do ITB poderá constituir um meio mais eficiente de identificação de DAP subclínica, permitindo aos indivíduos se beneficiarem de intervenções precoces com o intuito da diminuição do risco cardiovascular.

BACKGROUND: Patients with peripheral arterial disease (PAD) have a high risk of developing cardiovascular events. There is a high prevalence of PAD in individuals with kidney disease and both are important risk factors for cardiovascular events. OBJECTIVE: The aim of this study was to investigate the association between PAD and renal function in hypertensive patients. METHODS: The sample consisted of 909 individuals with arterial hypertension. The presence of PAD was evaluated using the ankle-brachial index (ABI) method and renal function was assessed based on the estimated glomerular filtration rate (eGFR). The subjects were divided into groups, according to abnormal (ABI < 0.9) and normal ABI (ABI 0.9-1.4). RESULTS: The percentage of subjects with abnormal ABI was 8%. In the group of individuals with abnormal ABI, prevalence of CKD was 23.4%, compared to a prevalence of 11.2% in patients with normal ABI. Multivariable logistic regression analysis, after adjusting the model to the conventional cardiovascular risk factors, identified a statistically significant and independent effect of eGFR on the likelihood of developing PAD, with an OR of 0.987 (CI: 0.97-1.00). CONCLUSION: An independent association between PAD and chronic kidney disease was observed in the present study. Therefore, the combination of an accurate diagnosis of kidney disease and routine ABI evaluation could constitute a more efficient means to identify subclinical PAD, allowing individuals to benefit from early interventions, aiming at reducing cardiovascular risk.

[A statistical definition of aortic pulse wave velocity normality in a Portuguese population: a subanalysis of the EDIVA project]. / Definição de valores de referência da velocidade da onda de pulso arterial numa população portuguesa: Uma sub-análise do projecto EDIVA.

INTRODUCTION: Aortic pulse wave velocity (PWV) has been associated with cardiovascular risk in different clinical subsets. This subanalysis of the EDIVA project aimed to establish criteria for normality of PWV based on a statistical definition that considers the fundamental physiological role of aging in arterial stiffness. METHODS: A sample of 668 healthy subjects (412 male) enrolled in the EDIVA Project (a prospective, multicenter, observational study) were studied. Mean age was 40.00 ± 13.42 years, body mass index was 25.90 ± 4.21kg/m(2), and systolic and diastolic blood pressure were respectively 125.47 ± 11.18 and 75.75 ± 9.27mmHg. PWV was determined annually using a Complior device, and mean follow-up was 23.3 ± 3.34 months. Personal and family history, physical examination, electrocardiogram and biochemical analysis were used to determine individual health. RESULTS: In the overall population PWV was 8.8 ± 1.4m/sec, 8.7 ± 1.6m/sec in men and 8.9 ± 1.5m/sec in women (p=NS). Normal PWV was defined as the 95th percentile adjusted for age and gender, above which PWV was considered abnormal. Serial evaluation of PWV also enabled the annual age-dependent increase in PWV to be estimated at 5%, values above this cut-off being defined as abnormal vascular deterioration. CONCLUSION: This study establishes criteria for normality based on a statistical definition that takes into account the fundamental physiological role of aging in arterial stiffness. Additionally, it provides a cut-off for the clinical interpretation of serial PWV measurements.

Arterial stiffness predicts cardiovascular outcome in a low-to-moderate cardiovascular risk population: the EDIVA (Estudo de DIstensibilidade VAscular) project.

BACKGROUND: Pulse wave velocity (PWV) is a recognized marker of arterial stiffness, although little knowledge exists of their relationship to long-term cardiovascular risk in general populations. METHODS AND RESULTS: A prospective, multicenter, observational study included 2200 Portuguese nationals (1290 men), aged between 18 and 91 years (mean 46.33±13.76 years). They underwent clinical assessment and annual PWV measurement using a Complior device, and major adverse cardiovascular events (MACEs)--death, stroke, myocardial infarction, unstable angina, peripheral arterial disease, revascularization, or renal failure--were recorded. During a mean follow-up of 21.42±10.76 months, there were 47 nonfatal MACEs (2.1% of the sample). PWV was significantly higher in individuals with events than in those without events (11.76±2.13 vs. 10.01±2.01 m/s, respectively, P<0.001). The study population was divided into two groups by PWV, classified as normal (PWV<95th percentile) or high (PWV>95th percentile), according to predefined criteria for normality. Cumulative event-free survival at 2 years was 99.3% in the normal PWV group and 95% in the high PWV group. The hazard ratio for MACE in the high PWV group was 9.901 [95% confidence interval (CI) 5.00-19.59, P<0.001], and 4.832 (95% CI 2.35-9.94, P<0.001) when adjusted for other risk factors. For absolute PWV, the adjusted hazard ratio (per 1 m/s change) was 1.316 (95% CI 1.13-1.53, P<0.001). CONCLUSION: The results of the initial analysis of this study highlight the clinical relevance of PWV as a cardiovascular risk marker and demonstrate that PWV measurement can make an important contribution to assessment of cardiovascular prognosis.

An approach of hypertension prevalence in a sample of 5381 Portuguese children and adolescents. The AVELEIRA registry. "Hypertension in children".

INTRODUCTION: The distribution of blood pressure (BP) in children and adolescents remains relatively unknown. Thus, it is imperative to ascertain BP distribution at a young age, which constitutes the main objective of this registry. METHODS: Cross-sectional assessment of BP in 5381 Portuguese children and adolescents, mean age 12.50±3.23 years (4-18 years), body mass index (BMI) 19.65±4.00 kg/m(2) (9.37-60.30 kg/m(2)), mostly male (4519), mean age 12.70±3.16 years, and with 862 females, mean age 11.44±3.34 years. BP and heart rate were measured three times after a 10-min resting period, with a validated automatic blood pressure monitor (OMRON 705IT) and an appropriately sized cuff over the brachial artery. About 30% of the youngsters were amateur registered athletes and 70% were beginning their sportive activity at the time of evaluation. RESULTS: BP distribution was 12.8% stage 1 hypertension, 21.6% high-normal, and 65.6% normal (similar between genders). Registered athletes and subjects beginning their sports activity revealed different hypertension prevalence (9.8% vs 14.3%, respectively; p < 0.0001). Overweight was found in 7.8%. Hypertension and high-normal BP increased with increasing BMI. Body weight classification was independently associated with hypertension and high-normal BP. Registered sportive practice was independently associated with a reduction in hypertension prevalence. CONCLUSIONS: The proportion of children with BP above the 90th percentile was high, with an overall prevalence of hypertension of 12.8%, independent of gender and related to overweight. The implications of these observations are even more important when we consider the epidemiology of hypertension in Portugal and its link with stroke as the leading cause of death and disability.

Comparative study of two generations of the Complior device for aortic pulse wave velocity measurements.

INTRODUCTION: The purpose of this study was to evaluate intraobserver and interobserver reproducibility of carotid-femoral pulse wave velocity (PWV) with the Complior method, by comparing two generations of the device and the manual method. METHODS: We studied 31 participants (9 women) with a mean age of 47.67±12.55 years, who were submitted to sequential measures of carotid-femoral PWV by two experienced operators. The evaluations were made by randomly switching between the manual method, the Complior first generation, and the Complior SP (third generation). RESULTS: The analysis of concordance of measurements of PWV showed strong intraobserver and interobserver correlations. The intraobserver correlation coefficients were 0.984, 0.977, and 0.966, respectively, for manual evaluation, the Complior first generation, and the Complior SP (P<0.0001). In the case of interobserver reproducibility, we found correlations of 0.940, 0.979, and 0.974, respectively, for manual evaluation, the Complior first generation, and Complior SP (P<0.0001). Good indicators of reproducibility were also a withdrawal of the Bland-Altman analysis, with most values within 2 standard deviations. The mean difference±SD for intraobserver and interobserver agreement was -0.006±0.05 and -0.06±0.09 for manual determination; -0.02±0.06 and -0.04±0.06 for Complior first generation; and 0.16±0.09 and 0.15±0.07 for the Complior SP. CONCLUSION: The data showed a high reproducibility of the Complior method, documented by excellent correlations and low mean differences in measurements within and between observers. These data showed unequivocally that this method met the quality requirements for its inclusion in integrated clinical follow-up programs.

Self-measurement of blood pressure in arterial hypertension--preliminary results from the AMPA study.

INTRODUCTION: The clinical usefulness of home blood pressure monitoring (HBPM) is still uncertain, and is currently a major topic of scientific debate. Some studies have stressed its potential role in the clinical decision-making process, but there have been few prospective studies addressing this subject. The AMPA study is intended to contribute to this debate, exploring the potential usefulness of this methodology in the clinical setting of arterial hypertension using a prospective, observational and multicenter design. METHODS: The study included 685 hypertensive patients (346 female), with a mean age of 54.2 +/- 11.1 years (range: 17-86 years). All patients were being followed in primary care centers by their family doctors, and were being treated for arterial hypertension and other comorbidities. Forty-seven patients were smokers (6%), 90 (13%) had a personal history of cardiovascular disease, 42 (6%) were diabetic, 255 (37%) had dyslipidemia, and 31 (5%) were both diabetic and dyslipidemic. Blood pressure (BP) was measured in the brachial artery with a validated automatic blood pressure measurement device (Colson MAM BP 3AA1-2; Colson, Paris). This device has solid state memory (sufficient for 60 measurements) and an adaptable printer. A cuff appropriate for the arm size of each patient was used. All patients were instructed on how to operate the device correctly and how to perform the measurements in compliance with the study protocol. BP was always measured after a 5-minute resting period in a seated position. The protocol consisted of an HBP program over a period of five working days. Each day the patient performed six BP measurements in two different periods: three in the morning (between 6 and 10 am) and three in the evening (between 6 and 10 pm). Other clinical and anthropometric data were also collected. The HBP reference values adopted were 135 mmHg for systolic and 85 mmHg for diastolic BP. RESULTS: Analysis of BP behavior over time demonstrated a significant white-coat effect, with regression to the mean of BP levels after the first day of the HBP program. As a consequence, the first day values were excluded in determining mean HBP. This behavior was independent of gender, and was more pronounced in diabetic patients. Analysis of diagnostic concordance between office BP and HBP showed discrepancies in 27.4% of the patients. This prompted a change in diagnosis based on HBP values, with 133 patients (19.4%) presenting uncontrolled office BP levels but normal HBP values, while 55 patients (8%) had elevated HBP in contrast to normal office BP. CONCLUSIONS: These first results of the AMPA study illustrate the superiority of HBP compared with office BP in the evaluation of hypertensive patients. HBP provides a better characterization of each patient's BP profile, and hence may help improve therapeutic and clinical decisions. Confirmation of the potential of HBP monitoring will be addressed in a prospective analysis (6-year follow-up) of the AMPA study in the near future.

Blood pressure distribution of a sample of healthy Portuguese children and adolescents: the AVELEIRA registry.

INTRODUCTION: The distribution of blood pressure in Portuguese children and adolescents remains relatively unknown. Given the prevalence of hypertension in Portugal and the epidemiological trends for most cardiovascular diseases, it is important to ascertain blood pressure distribution at young ages, which constitutes the main objective of this registry. METHODS: A sample of 1618 children and adolescents from the Central region of Portugal was included in this survey. The sample's mean age was 12.98 +/- 3.12 years (range: 5-18 years), body mass index 19.85 +/- 3.55 (range: 12.71-38.46); 1438 were male, mean age 12.39 +/- 3.35 years, and 180 female, mean age 13.05 +/- 3.07 years. Blood pressure and heart rate were measured three times after a 10-minute resting period. The measurements were performed with a validated automatic blood pressure monitor (Colson MAM BP 3AA1-2; Colson, Paris) and with an appropriately sized cuff over the brachial artery. All subjects were involved in amateur sports, with 80% of the sample beginning their activity at the time of evaluation. RESULTS: The overall prevalence of hypertension was 9.8%, and high-normal blood pressure was found in 18.2%. Hypertension prevalence was higher in females (15.0% vs. 9.1% in males; p < 0.05). Comparison between registered athletes and subjects beginning their sports activity revealed similar hypertension prevalence (9.1% vs. 9.9% respectively; p = NS). Obesity was found in 5.3%, 3.9% in females and 5.5% in males. The prevalence of hypertension was greater in obese subjects (23%) than in overweight (14%) and normal weight (8%) subjects, clearly suggesting a relation between weight profile and blood pressure levels. CONCLUSIONS: Our results reveal that a significant proportion of the children studied have blood pressure levels above the 90th percentile, with an overall prevalence of hypertension of 9.8%, more pronounced in females and related to overweight. The implications of these observations are even more important when we consider the epidemiology of hypertension in Portugal and its link with stroke as the leading cause of death and disability.