Hypertension in a resource-limited setting: Poor Outcomes on Short-term Follow-up in an Urban Hospital in Maputo, Mozambique.

Mozambique has low levels of detection, treatment, and control of hypertension. However, data on target organ damage and clinical outcomes are lacking. The authors aimed at characterizing the clinical profile, pattern of target organ damage, and short-term outcomes of patients referred to a first referral urban hospital in a low-income setting in Africa. We conducted a prospective descriptive cohort study from February 2016 to May 2017 in Maputo, Mozambique. Adult patients with systolic and diastolic blood pressure ≥180 mm Hg and/or ≥110 mm Hg, respectively, or any systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg in the presence of target organ damage (with or without antihypertensive treatment) were submitted to detailed physical examination, funduscopy, laboratory profile, electrocardiography, and echocardiography. Six months after the occurrence of complications (stroke, heart failure, and renal failure), hospital admission and death were assessed. Overall, 116 hypertensive patients were recruited (mean age 57.5 ± 12.8 years old; 111[95.7%] black; 81[70%] female) of which 79 had severe hypertension. The baseline mean values recorded for systolic and diastolic blood pressure were 192.3 ± 23.6 and 104.2 ± 15.2 mm Hg, respectively. Most patients (93; 80.2%) were on antihypertensive treatment. Patients' risk profile revealed dyslipidemia, obesity, and diabetes in 59(54.1%), 48(42.5%), and 23(19.8%), respectively. Target organ damage was found in 111 patients. The commonest being left atrial enlargement 91(84.5%), left ventricular hypertrophy 57(50.4%), hypertensive retinopathy 30(26.3%), and chronic kidney disease 27(23.3%). Major events during 6-month follow-up were hospitalizations in 10.3% and death in 8.6% of the patients. Worsening of target organ damage occurred in 10 patients: four stroke, two heart failure, and four renal damage. Patients with severe hypertension and target organ damage were young with high-risk profile, low hypertension control, and high occurrence of complications during short-term follow-up. Efforts to improve high blood pressure control are needed to reduce premature mortality in this highly endemic poor setting.

Effectiveness of olmesartan-based treatment on home and clinic blood pressure in elderly patients with masked and white coat hypertension.

Few large-scale studies have evaluated the effectiveness of angiotensin receptor blockers in patients with masked hypertension (MH) and white coat hypertension (WCH) based on age using real-world blood pressure (BP) data. We used data from the Home BP measurement with Olmesartan Naive patients to Establish Standard Target BP (HONEST) study to investigate the effectiveness of olmesartan-based treatment by patient age (<65 years of age, n = 9817; 65-74 years of age, n = 6792; ⩾ 75 years of age, n = 4732), focusing on morning home BP (strongly associated with cardiovascular disease and useful for MH and WCH diagnosis). Sixteen weeks of treatment changed morning home BP (mean systolic/diastolic) by -18.1/-9.7, -15.9/-7.4 and -14.2/-6.4 mm Hg and clinic BP by -20.1/-11.3, -17.3/-8.7 and -15.4/-7.2 mm Hg, in these age groups, respectively (P < 0.0001). Pulse pressure decreased (-7.8 to -8.8 mm Hg, P < 0.0001). Patients aged ⩾ 80 years experienced similar BP and pulse pressure changes. In patients aged ⩾ 75 years, mean morning and clinic BP after 16 weeks was 137.5/74.8 and 129.7/70.4 mm Hg, respectively, in MH patients and 132.3/72.2 and 139.7/72.7 mm Hg, respectively, in WCH patients. Regardless of age, only elevated clinic or home BP values decreased to target ranges. The incidence of adverse effects associated with excessive BP lowering was low in all of the age groups. In conclusion, our study suggests that olmesartan-based treatment was safe and useful for managing MH, WCH and sustained hypertension in elderly patients. The lack of a placebo group was a limitation of the study.

Assessment of effect of irbesartan and nebivolol on the left atrium volume and deformation in the patients with mild-moderate hypertension.

BACKGROUND: We aimed to assess the effects of irbesartan and nebivolol on the left atrium (LA) volume and deformation in the patients with mild-moderate hypertension. PATIENTS AND METHODS: The study comprised of 160 patients (mean age: 55.6±9.6 years), who had Stage 1 or 2 hypertension according to the European Society of Cardiology (ESC) and have not been receiving antihypertensive therapy. The patients were assigned to treatment groups; irbesartan (n=80) and nebivolol (n=80). The patients were clinically and echocardiographically reevaluated on the 6th and 12th months after the onset of treatment. RESULTS: There was no difference between the two treatment groups in terms of baseline demographic, clinical and echocardiographic characteristics. Moreover, no difference was observed between the treatment groups on the 6th and 12th months. Intragroup analyses revealed that systolic blood pressure (SBP) and diastolic blood pressure (DBP) significantly decreased in time and diastolic function parameters were improved. However, whilst significant increase was observed in conduit volume, decrease was observed in other volumes of the LA in the irbesartan and nebivolol groups. This significant change was observed on the 6th month in both treatment groups. LA global peak systolic strain (LAGLSs), LA global peak systolic strain rate (LAGLSRs), LA global peak strain rate during early ventricular diastole (LAGLSRe) and LA global peak strain rate (LAGLSRa) during late ventricular diastole (LAGLSRa) values began to be significantly increased after 6 months of treatment in both treatment groups. CONCLUSIONS: We found that nebivolol, which is a new generation beta blocker, is effective as irbesartan with proven efficacy in improving LA volume and LA myocardial performance in patients with mild-moderate hypertension. Moreover, we determined that strain and strain rate, which are the new echocardiographic parameters, are effective as LA volumes in assessing LA functions.

Impact of sex on the heart's metabolic and functional responses to diabetic therapies.

Increased myocardial lipid delivery is a determinant of myocardial substrate metabolism and function in animal models of type 2 diabetes (T2DM). Sex also has major effects on myocardial metabolism in the human heart. Our aims were to determine whether 1) sex affects the myocardial metabolic response to lipid lowering in T2DM, 2) altering lipid [fatty acid (FA) or triglyceride] delivery to the heart would lower the elevated myocardial lipid metabolism associated with T2DM, and 3) decreasing lipid delivery improves diastolic dysfunction in T2DM. To this end, we studied 78 T2DM patients (43 women) with positron emission tomography, echocardiography, and whole body tracer studies before and 3 mo after randomization to metformin (MET), metformin + rosiglitazone (ROSI), or metformin + Lovaza (LOV). No treatment main effects were found for myocardial substrate metabolism, partly because men and women often had different responses to a given treatment. In men, MET decreased FA clearance, which was linked to increased plasma FA levels, myocardial FA utilization and oxidation, and lower myocardial glucose utilization. In women, ROSI increased FA clearance, thereby decreasing plasma FA levels and myocardial FA utilization. Although LOV did not change triglyceride levels, it improved diastolic function, particularly in men. Group and sex also interacted in determining myocardial glucose uptake. Thus, in T2DM, different therapeutic regimens impact myocardial metabolism and diastolic function in a sex-specific manner. This suggests that sex should be taken into account when designing a patient's diabetes treatment.

Assessment of left ventricular systolic and diastolic function with conventional and tissue Doppler echocardiography imaging techniques in patients administered tyrosine kinase inhibitor.

OBJECTIVES: The aim of this study was to use echocardiographic techniques to determine the possible cardiotoxic effects of low molecular weight tyrosine-kinase inhibitors (TKI) in patients receiving the therapy for the first time. STUDY DESIGN: Thirty patients (17 females; 13 males; mean age 49±16; range 22 to 76 years) who met the exclusion criteria and were diagnosed as having malignancy were enrolled. All patients underwent conventional echocardiography and tissue Doppler imaging (TDI) prior to the treatment. The conventional echocardiogram was repeated 2 months later as the patients were concurrently receiving therapy. Myocardial Performance Index was obtained by conventional echocardiography and by TDI techniques to evaluate left ventricular systolic and diastolic function. RESULTS: Statistically significant increase occurred in mean left ventricle (LV) end-systolic volume. However, there was significant decrease in both mean LV ejection fraction and LV stroke volume values (64±3, 62±4, p=0.000 and 67±13, 61±13, p=0.000, respectively). Anterior wall Em/Am ratio measured by using the TDI technique was significantly decreased at the end of two months (0.99±0.49, 0.90±0.41, p=0.03). In addition, decreases were determined in Sm values obtained from all of four LV walls and also in mean Sm value, but this decrease was significant only for the lateral wall Sm measurement (12.8±2.9, 11.6±2.3, p=0.004). CONCLUSION: Tyrosine-kinase inhibitors therapy can be administered safely to patients without predisposing factors for cardiotoxicity in short treatment intervals, and low molecular TKIs may cause subtle or clinically significant cardiotoxicity following the treatment period even in patients without predisposing factors for cardiotoxicity, so clinicians should consider this possibility.

Assessment of endothelial function by means of flow-mediated changes using pulse wave velocity.

Endothelial dysfunction is a leading cause of early development of cardiovascular diseases. Endothelial function can be assessed using ultrasound methods to watch the arterial flow-mediated dilation. It is also possible to find changes in pulse wave velocity (PWV) after induced ischemia related to the vessel diameter changes. Pre- and post-induced ischemia carotid-radial PWV was recorded in 226 hypertensive patients (150 women [63.5+/-12.4 years old] and 76 men [63.2+/-11.8 years old] and 55 healthy patients (38 women [63.1+/-12.6 years old] and 17 men [54.8+/-12.8 years old]). The authors considered normal endothelial function a PWV reduction of 5% from baseline. To assess nondependent endothelial dilation the authors performed carotid-radial PWV after sublingual administration of 5 mg of isosorbide dinitrate in a group of patients with abnormal flow-mediated dilation. A significant PWV reduction of 9.8% in normal patients and only 1.2% among hypertensive patients (P<.0005) was found. After sublingual isosorbide dinitrate intake the authors observed a greater fall in PWV (14%) than that observed in healthy people after induced ischemia. Carotid-radial PWV after induced ischemia decreased significantly in normal participants. No significant changes were observed in hypertensive patients. These results may offer a reliable tool to assess endothelial function in medium-size arteries.

Effect of Shenmai Injection on ventricular diastolic function in patients with chronic heart failure: An assessment by tissue Doppler imaging.

OBJECTIVE: To assess the effect of Shenmai Injection (SMI) on left ventricular diastolic function (LVDF) in patients with chronic heart failure (CHF) by tissue Doppler imaging (TDI). METHODS: Sixty-four CHF patients were randomly assigned to two groups, the observation group and the control group. Basic treatment including polarized liquid therapy was given to all the patients. In addition, SMI was given to patients of the observation group. The treatment duration was 14 days. TDI was performed in all the patients 3 days prior to the initiation of the treatment and one week after the medication to measure the average movement velocity of the mitral ring of the left ventricle at the early systolic stage and late diastolic stage (Ea and Aa); the outcomes were compared with the corresponding parameters obtained from blood flow Doppler echocardiography, namely, the velocity of the E-wave (E) and A-wave (A). RESULTS: After treatment, Ea and Ea/Aa increased and Aa decreased significantly in the observation group (P<0.05). In the control group, although some improvement was seen, there was no statistically significant change (P>0.05). No statistical significance was shown between groups in these parameters after treatment. CONCLUSION: TDI assessment shows that SMI could effectively improve the LVDF in CHF patients.

Assessment of regional systolic and diastolic functions affected by atorvastatin in coronary artery disease using tissue Doppler imaging.

BACKGROUND: Several studies have shown regional left ventricular (LV) systolic and diastolic changes associated with coronary artery disease (CAD). Statins may have beneficial pleiotropic effects in addition to their lipid-lowering properties. HYPOTHESIS: We hypothesized that atorvastatin can improve regional LV systolic and diastolic functions in CAD patients using tissue Doppler imaging (TDI). METHODS: A total of 63 patients with hyperlipemia and CAD were studied. Forty-three patients were given 10 mg daily of atorvastatin and 20 patients were assigned only a low-fat diet. Tissue Doppler imaging was applied to evaluate LV peak systolic velocity (VS), early diastolic velocity (VE), and late diastolic velocity (VA) in 18 segments. The mean value of LV peak systolic velocity (VS(')), the mean value of early diastolic velocity (VE(')), and the mean value of late diastolic velocity (VA(')), in 18 segments were calculated. RESULTS: Compared with the baseline, VS('), and VE('), increased significantly after the therapy in the atorvastatin group (p < 0.05), while there was no change in the control group (p > 0.05). At 6 mo of therapy, a significant reduction in total cholesterol, triglyceride, and low-density lipoprotein (LDL) cholesterol was observed in the 2 groups (p < 0.05). CONCLUSIONS: These findings demonstrate that atorvastatin can improve regional LV systolic and diastolic functions in CAD patients independent of its lipid-lowering properties.

Assessment of left ventricular dysfunction in children undergoing chemotherapy.

BACKGROUND: In Taiwan, children with malignancies are treated under the protocols of the Taiwan Pediatric Oncology Group (TPOG). The purpose of this study was to determine the change in left ventricular (LV) function in pediatric patients undergoing chemotherapy. METHODS: A total of 19 pediatric patients (mean age, 12.5 +/- 4.6 years; 11 males, 8 females) were enrolled. We divided the patients into 2 groups: (1) osteogenic sarcoma (OGS) group (n = 12; Group I); and (2) non-osteogenic sarcoma (non-OGS) group (n = 7; Group II). The accumulated dosages of anthracycline in Group I and II patients were 144.3 +/- 56.4 mg/M2 and 131.7 +/- 105.5 mg/M2 (p = 0.735), respectively. The children received echocardiography to investigate the parameters of LV systolic function, LV diastolic function, and myocardial performance index (MPI) after the entire chemotherapy course. RESULTS: Higher E/A ratio (1.71 +/- 0.37), shorter isovolumic relaxation time (IRT, 42 +/- 19.14 ms), and shorter deceleration time (DT, 140.3 +/- 40.6 ms) were demonstrated in these patients. There was no statistically significant difference in the E/A ratio and DT between the 2 groups. Group I children were older (14.4 +/- 3.7 vs. 9.3 +/- 4.5 years; p = 0.015) and had lower MPI (0.20 +/- 0.02 vs. 0.28 +/- 0.07; p = 0.031) than Group II children. CONCLUSION: The children treated with chemotherapy using the TPOG protocol had a shorter IRT, higher E/A ratio and shorter DT. No significant evidence of anthracycline-related cardiotoxicity was found in any of the children in this study undergoing chemotherapy with the TPOG protocol.

Global diastolic strain rate for the assessment of left ventricular relaxation and filling pressures.

BACKGROUND: Diastolic strain rate (SR) measurements that comprise all left ventricular (LV) segments are advantageous over myocardial velocity for assessment of diastolic function. Mitral early diastolic velocity (E)/SR ratio during the isovolumetric relaxation (IVR) period can be used to estimate LV filling pressures. METHODS AND RESULTS: Simultaneous echocardiographic imaging and LV pressure measurements (7F catheters) were performed in 7 adult dogs. Loading conditions were altered by saline infusion and caval occlusion, and lusitropic state was changed by dobutamine and esmolol infusion. A curve depicting global SR was derived from each of the 3 apical views, and SR was measured during IVR (SR(IVR)) and early LV filling (SR(E)). SR(IVR) had a strong correlation with time constant of LV pressure decay during the IVR period (tau) (r=-0.83, P<0.001), whereas SR(E) was significantly related to LV end-diastolic pressure (r=0.52, P=0.005) in the experimental stages where tau was <40 ms. In 50 patients with simultaneous right heart catheterization and echocardiographic imaging, mitral E/SR(IVR) ratio had the best correlation with mean wedge pressure (r=0.79, P<0.001), as well as in 24 prospective patients (r=0.84, P=0.001). E/SR(IVR) was most useful in patients with ratio of E to mitral annulus early diastolic velocity (E/Ea ratio) 8 to 15 and was more accurate than E/Ea in patients with normal ejection fraction and regional dysfunction (both P<0.01). CONCLUSIONS: Global SR(IVR) by 2-dimensional speckle tracking is strongly dependent on LV relaxation. E/SR(IVR) can predict LV filling pressures with reasonable accuracy, particularly in patients with normal ejection fraction and in those with regional dysfunction.

Results of a comparative, phase III, 12-week, multicenter, prospective, randomized, double-blind assessment of the efficacy and tolerability of a fixed-dose combination of telmisartan and amlodipine versus amlodipine monotherapy in Indian adults with stage II hypertension.

OBJECTIVE: The aim of this study was to evaluate the efficacy and tolerability of a new fixed-dose combination (FDC) of telmisartan 40 mg + amlodipine 5 mg (T+A) compared with amlodipine 5-mg monotherapy (A) in adult Indian patients with stage II hypertension. METHODS: This comparative, Phase III, 12-week, multicenter, prospective, randomized, double-blind study was conducted in Indian patients aged 18 to 65 years with established stage II hypertension. Patients were treated with oral FDC of T+A or A QD before breakfast for 12 weeks; blood pressure (BP) and heart rate were measured in the sitting position. Primary efficacy end points were reduction in clinical systolic BP (SBP)/ diastolic BP (DBP) from baseline to study end and number of responders (ie, patients who achieved target SBP/ DBP <130/<80 mm Hg) at end of study. Tolerability was assessed by treatment-emergent adverse events, identified using physical examination, laboratory analysis, and electrocardiography. RESULTS: A total of 210 patients were enrolled in the study; 203 patients (143 men, 60 women) completed the study while 7 were lost to follow-up (4 patients in the T+A group and 3 in the A group) and considered with-drawn. At study end, statistically significant percentage reductions from baseline within groups and between groups were observed in SBP (T+A [-27.4%]; A [-16.6%]) and DBP (T+A [-20.1%]; A [-13.3%]) (all, P < 0.05). Response rates were 87.3% (89/102) in the T+A group and 69.3% (70/101) in the A group (P < 0.05). The prevalences of adverse events were not significantly different between the 2 treatment groups (T+A, 16.0% [17/106]; A, 15.4% [16/104]). Peripheral edema was reported in 8.5% patients (9/106) in the T+A group compared with 13.5% (14/104) in the A group, and cough was reported in 3.8% patients (4/106) in the T+A group and 1.0% (1/104) patients in the A group; these differences did not reach statistical significance. The incidences of headache, dizziness, and diarrhea were similar between the 2 groups. CONCLUSIONS: Among these Indian patients with stage II hypertension, the FDC of T+A was found to be significantly more effective, with regard to BP reductions, than A, and both treatments were well tolerated.

Effects of anesthesia on echocardiographic assessment of left ventricular structure and function in rats.

Echocardiography is an essential diagnostic tool for accurate noninvasive assessment of cardiac structure and function in vivo. However, the use of anesthetic agents during echocardiographic studies is associated with alterations in cardiac anatomical and functional parameters. We sought to systematically compare the effects of three commonly used anesthetic agents on echocardiographic measurements of left ventricular (LV) systolic and diastolic function, LV dimensions, and LV mass in rats. Adult male Fischer 344 rats underwent echocardiographic studies under pentobarbital (PB, 25 mg/kg i.p.) (group I, n = 25), inhaled isoflurane (ISF, 1.5%) (group II, n = 25),or ketamine/xylazine (K/X, 37 mg/kg ketamine and 7 mg/kg xylazine i.p.) (group III, n = 25) anesthesia in a cross-over design. Echocardiography was also performed in an additional group of unanesthetized conscious rats (group IV, n = 5). Postmortem studies were performed to validate echocardiographic assessment of LV dimension and mass. Rats in group I exhibited significantly higher LV ejection fraction, fractional shortening, fractional area change, velocity of circumferential fiber shortening corrected for heart rate, and heart rate as compared with groups II and III. LV end-diastolic volume, end-diastolic diameter, and cross-sectional area in diastole were significantly smaller in group I compared with groups II and III. Cardiac output was significantly lower in group III compared with groups I and II. Postmortem LV mass measurements correlated well with echocardiographic estimation of LV mass for all anesthetic agents, and the correlation was best with PB anesthesia. Limited echocardiographic data obtained in conscious rats were similar to those obtained under PB anesthesia. We conclude that compared with ISF and K/X anesthesia, PB anesthesia at a lower dose yields echocardiographic LV structural and functional data similar to those obtained in conscious rats. In addition, PB anesthesia also facilitates more accurate estimation of LV mass.

The Swedish National Programme for Quality Control of Secondary Prevention of Coronary Artery Disease--results after one year.

BACKGROUND: Guidelines for the prevention of coronary artery disease (CAD) have been developed both in Europe and in the USA. However, several surveys have shown that these guidelines are poorly implemented in clinical practice. DESIGN/METHODS: The Swedish Quality Control Programme on Secondary Prevention of CAD includes patients after myocardial infarction, or having undergone coronary artery surgery or percutaneous coronary intervention. Fifty of Sweden's 79 hospital districts are currently participating. Patients are asked to send report-cards regarding risk factor management to a central registry after discharge from hospital, at a 3-6 month visit and then yearly for 5 years. RESULTS: Results based on data from 1 year after the index event show that a majority of patients reach targets for serum cholesterol (70%), and low-density lipoprotein (LDL)-cholesterol (71%). Mean value for total cholesterol is 4.6 (+/-SD 0.9) mmol/l, LDL-cholesterol 2.7 (+/-SD 0.8) mmol/l. Blood pressure targets are less often achieved, with 58% reaching the European Society of Cardiology target for systolic (<140 mmHg) and 81% for diastolic (<90 mmHg) blood pressure. A large proportion of patients are prescribed preventive drugs: aspirin (96%), beta-blockers (78%) and lipid-lowering drugs (83%). CONCLUSIONS: The Swedish Quality Control Programme is one of the first attempts to assess implementation of guidelines on a national level based on patient participation. It is hoped that shared care programmes and increased patient involvement with feedback on achieved treatment goals in relation to guidelines will improve outcomes in patients with CAD.

Barriers to management of cardiovascular risk in a low-resource setting using hypertension as an entry point.

OBJECTIVE: Assess capacity of health-care facilities in a low-resource setting to implement the absolute risk approach for assessment of cardiovascular risk in hypertensive patients and effective management of hypertension. DESIGN AND SETTING: A descriptive cross-sectional study in Egbeda and Oluyole local government areas of Oyo State in Nigeria in 56 randomly selected primary- (n = 42) and secondary-level (n = 2) health-care and private health-care (n = 12) facilities. PARTICIPANTS: One thousand consecutive, known hypertensives attending the selected facilities for follow-up, and health-care providers working in the above randomly selected facilities, were interviewed. RESULTS: About two-thirds of hypertensives utilized primary-care centers both for diagnosis and for follow-up. Laboratory and other investigations to exclude secondary hypertension or to assess target organ damage were not available in the majority of facilities, particularly in primary care. A considerable knowledge and awareness gap related to hypertension and its complications was found, both among patients and health-care providers. Blood pressure control rates were poor (28% with systolic blood pressure (SBP) < 140 mmHg and diastolic blood pressure (DBP) < 90 mmHg] and drug prescription patterns were not evidence based and cost effective. The majority of patients (73%) in this low socio-economic group (mean monthly income 73 US dollars) had to pay fully, out of their own pocket, for consultations and medications. CONCLUSIONS: If the absolute risk approach for assessment of risk and effective management of hypertension is to be implemented in low-resource settings, appropriate policy measures need to be taken to improve the competency of health-care providers, to provide basic laboratory facilities and to develop affordable financing mechanisms.

Noninvasive assessment of left and right internal mammary artery graft patency using transthoracic color Doppler echocardiography.

BACKGROUND: The aim of this study was to evaluate the patency of left and right internal mammary artery grafts respectively on the left anterior descending and right coronary artery by noninvasive transthoracic color Doppler echocardiography. METHODS: Thirty eight patients (34 males, 4 females, mean age 59 +/- 2 years), with a history of coronary artery bypass grafting for a total of 42 mammary artery grafts, were studied by means of color Doppler echocardiography at baseline and after vasodilation with dipyridamole infusion (0.56 mg/kg i.v. over 4 min). The evaluated echocardiographic parameters included: systolic (SPV) and diastolic peak velocities (DPV), systolic (SVI) and diastolic velocity-time integrals (DVI), and the DPV/SPV and DVI/SVI ratios. We also calculated the dipyridamole infusion to baseline ratio of the diastolic peak velocities (DPVdip/DPVbaseline), the index of internal mammary artery graft blood flow reserve and the percent DPV increment as an index of graft stenosis. RESULTS: On the basis of coronary angiography, two groups were selected: group A (36 mammary grafts) with patent grafts and group B (6 mammary grafts) with moderate or severe stenosis of the grafts. Group A had a predominant diastolic pattern with a DPV of 0.24 +/- 0.13 m/s, whereas group B had a predominant systolic pattern with a reduced DPV of 0.12 +/- 0.03 m/s (p < 0.01). Dipyridamole induced an increase in the DPV respectively of 86.8 +/- 64.4% in group A and 13.8 +/- 15.9% in group B (p < 0.001). Statistical analysis (Mann-Whitney test) revealed a significant difference between the two groups for the baseline DPV (p < 0.01), DVI (p < 0.05), DPV/SPV ratio (p < 0.005), DVI/SVI ratio (p < 0.05), and for the after dipyridamole infusion values: DPV (p < 0.0001), DVI (p < 0.005), DPV/SPV ratio (p < 0.001), and DVI/SVI ratio (p < 0.05). Multivariate analysis showed that the percent DPV increment, the DPVdip/DPVbaseline ratio and the baseline DPV were independent determinants of the stenosis as evaluated at angiography (beta = -0.38, p < 0.01; beta = -0.37, p < 0.01, and beta = -0.33, p < 0.05, respectively; cumulative r2 = 0.25, standard error 0.30 m/s, p < 0.005). CONCLUSIONS: The echocardiographic evaluation of the mammary grafts is a simple, noninvasive method for the assessment of the graft patency and of the functional status of the vessel. The percent DPV increment and baseline DPV were independent determinants of mammary graft stenosis.

Assessment of left ventricular diastolic function by radionuclide ventriculography at rest and exercise in subclinical hypothyroidism, and its response to L-thyroxine therapy.

Hypothyroidism is associated with intrinsic myocardial changes reflected by alterations in contractility and relaxation. Diastolic function, however, rather than systolic cardiac function, seems to be mostly impaired by thyroid hormone deprivation. Our aim was to evaluate diastolic function at rest and during maximal exercise by means of radionuclide ventriculography in subclinical hypothyroidism before and after restoration of euthyroidism. Ten subclinical hypothyroid patients (50 +/- 8.7 years) (thyroid-stimulating hormone 11 +/- 4.2 microUI/ml) without cardiac disease were studied before and 6 months after levothyroxine (L-T(4)) replacement (thyroid-stimulating hormone 1.9 +/- 1.1 microUI/ml). We compared the basal and post-therapy cardiac parameters with a control group of 14 euthyroid patients (52.5 +/- 10 years) (thyroid-stimulating hormone 2.5 +/- 1.2 microUI/ml). Multigated equilibrium radionuclide ventriculography was performed to assess systolic and diastolic ventricular function. Student's t and paired Student's t tests were applied for statistical analysis. We found a significant difference between the time to peak filling rate (TPFR) at rest before (0.241 +/- 0.002 ms) and after (0.190 +/- 0.012 ms) treatment with L-T(4). A significant difference that disappeared after restoration of euthyroidism was also observed between the basal TPFR values of the subclinical hypothyroid patients and the control group (0.189 +/- 0.01 ms). The same pattern was observed at maximal exercise. Thus, TPFR, a parameter of left ventricular (LV) diastolic function measured by radionuclide ventriculography, is impaired in subclinical hypothyroid patients both at rest and during exercise and returns to normal values after L-T(4) therapy.

Shifting trends in the pharmacologic treatment of hypertension in a Nigerian tertiary hospital: a real-world evaluation of the efficacy, safety, rationality and pharmaco-economics of old and newer antihypertensive drugs.

The current prescription patterns for essential hypertension and the efficacy, safety, tolerability and cost-effectiveness of the newer antihypertensive drugs were evaluated in Nigerian patients. The findings were compared with that of a previous study conducted in the same tertiary hospital 10 years earlier. A cross-sectional evaluation of blood pressure (BP) control in a hypertension clinic was undertaken among 150 Nigerian patients aged 61 +/- 12 years (55% females), with a duration of treatment on a particular drug class or combination of 9 +/- 3 months. The initial blood pressure was 176 +/- 20/108 +/- 11 mmHg and 22% of the patient had concurrent diabetes mellitus. Thiazide diuretics (D) alone or in combination remained the most commonly prescribed drugs in 56% of all patients. There were significant increases in the prescriptions of calcium channel blockers (CCBs) (51%), P < 0.0001, and ACE-inhibitors (ACEIs) (24%), P < 0.0001, but a slight reduction in the use of methyldopa, and fixed drug combinations (P < 0.01) compared to the previous study. The fall in systolic blood pressure on D (r = 0.65, P < 0.001) or CCB (r = 0.48, P < 0.02) was significantly correlated with the initial systolic blood pressure, but not age. More patients achieved normotension BP < 140/90 mmHg on CCB monotherapy (71%), than D monotherapy (56%). Combination therapy with ACEIs + D or methyldopa+thiazides normalized BP in 63 and 68%, respectively. Pulse pressure, a surrogate marker for cardiovascular complications and mortality in essential hypertension, was significantly reduced (P < 0.01) equally by all treatments, with 95% confidence intervals ranging from -28 to -1 mmHg. However, hypertensive-diabetic (HT-DM) patients (n = 33) exhibited no significant change in pulse pressure in response to treatment. Adverse drug reactions that occurred in 11% were impotence or postural dizziness with D, headache and pitting oedema with CCB, and dry cough with ACEI. Pharmaco-economic comparison of the drug classes revealed that for every US dollar (dollar) spent per month, the percentage of treated patients attaining normotension was 18.6 for D, 4.73 for CCB, 3.5 for ACEI + D and 13.6 for methyldopa + thiazides. A combination of ACEI + CCB or D was the preferred treatment for hypertensive-diabetic Nigerians, but only 24% attained a BP < 130/85 mmHg. These results demonstrate a shift in trend to a more rational and efficacious treatment of hypertension over a 10 year period. This may be associated, at least in part, with the intensive and continuous education of the prescribers in rational drug use and the introduction of a hospital formulary. Methyldopa is still a highly efficacious and cost-effective drug in this population. Black HT-DM Africans still constitute a subgroup who not only require more and costlier antihypertensive drugs, but whose BP control is suboptimal, and exhibit a poor therapeutic response to other risk factors (pulse pressure) that constitute a continuing risk for cardiovascular mortality.

Left ventricular diastolic function assessment by tissue Doppler echocardiography in relation to hormonal replacement therapy in postmenopausal women with diastolic dysfunction.

The objective of this study was to evaluate the effect of hormone replacement therapy (HRT) regimens on left ventricular diastolic function by using mitral pulsed wave Doppler (MPWD) and tissue Doppler velocities (TDE). Seventy-eight postmenopausal women with normotensive and impaired diastolic left ventricular filling were included in the study. All the patients began a six-cycle HRT course. This formulation consisted of E2 valerate plus Medroxy progesterone acetate (MPA). Left ventricular diastolic function at rest was evaluated by M-mode, two-dimensional, MPWD and TDE in 78 postmenopausal women with normal blood pressure before the treatment for 6 months of HRT. The M-mode, two-dimensional, and MPWD parameters assessed were heart rate, systolic blood pressure, diastolic blood pressure, left ventricular mass index, ejection fraction of the left ventricle (EF), septal (IVS) and posterior wall (PW) thickness, left ventricular end-systolic (LVESD) and end-diastolic (LVEDD) diameter, left atrial diameter, peak early diastolic velocity (E), peak atrial velocity (A), E/A ratio, E acceleration time, E deceleration time, diastolic filling period, and isovolumic relaxation time (IVRT). The TDE parameters assessed were peak early diastolic velocity (E'), peak late diastolic velocity (A'), peak systolic velocity, E'/A' ratio, E' acceleration time, E' deceleration time, IVRT', and E/E' ratio. Quantitative data were analyzed using Student t test. Among the MPWD parameters, peak A velocity, E deceleration time, and IVRT significantly decreased, while peak E velocity and E/A ratio increased after a 6-month treatment. From the point of TDE parameters, E' velocity and E'/A' ratio increased, while A' velocity, E' deceleration time, E/E' ratio and IVRT' decreased. Some MPWD and TDE parameters were partially reversed after HRT. TDE velocities and especially E/E' ratio may provide better and true information of the diastolic function. TDE parameters were independent from the preload and did not produce pseudonormal pattern. HRT may cause increase in the blood volume and produce pseudonormal pattern in transmitral flow. In that case, TDE may be a beneficial method for evaluation of diastolic function.

Calcium supplementation in patients with essential hypertension: assessment by office, home and ambulatory blood pressure.

OBJECTIVE: To study the effects of a high calcium intake in hypertensive patients by blood pressure monitoring. DESIGN: In a randomized crossover study, patients were assigned to an 8-week calcium supplementation period and an 8-week control period. The subjects were given 25 mmol/day (1 g/day) of calcium as calcium carbonate during the intervention period. SETTING: A hypertension clinic in a tertiary teaching hospital. PATIENTS: Sixty untreated or treated hypertensive patients (35 men and 25 women, mean age 58 years) with office systolic/diastolic blood pressure > or = 140/90 mmHg. MAIN OUTCOME MEASURES: Office blood pressure, home blood pressure (last 7 days), and ambulatory 24 h blood pressure (every 30 min using TM-2421). RESULTS: The serum calcium concentration and urinary calcium excretion increased significantly with calcium supplementation. Office, home and 24 h blood pressure were lower in the calcium period than in the control period, although the differences were small (mean +/- SEM office blood pressure: 1.2+/-1.2/1.1+/-0.7 mmHg; home blood pressure: 1.9+/-0.7/1.3+/-0.6 mmHg; 24 h blood pressure: 1.2+/-0.8/0.9+/-0.5 mmHg,), and significant only for home systolic and diastolic blood pressures. The difference in home systolic blood pressure was inversely correlated with the level of home blood pressure in the control period and with the difference in urinary calcium. The difference in 24 h systolic blood pressure was positively correlated with the control level of urinary calcium. Age, sex, antihypertensive medication, drinking habit, sodium intake or order of treatment did not significantly influence the effects of calcium supplementation. CONCLUSIONS: An increase in calcium intake tends to lower office, home and ambulatory blood pressure in hypertensive patients. However, the antihypertensive effect is too small to support the general application of a high calcium intake in the treatment of hypertension.