A questionnaire-based, multicenter registry of resistant and pseudo-resistant arterial

Introduction: Hypertensive patients with poor blood pressure (BP) control are commonly referred to tertiary centers with a diagnosis of resistant hypertension (RH). The aim of the study was to identify the causes of insufficient BP control and to assess the incidence of true resistant hypertension. Material and Methods: We ran a questionnaire-based, multicenter study (10 high volume tertiary centers in Poland) of patients referred with an initial diagnosis of RH. Only patients with ABPM-confirmed uncontrolled hypertension (systolic ≥140 mmHg and/or diastolic ≥90mmHg despite maximal doses of ≥3 medications, including a diuretic) were included. We assessed the causes of non-optimal BP control, a proportion of patients with excluded secondary hypertension, and the burden of hypertension-related complications. Results: We analyzed 124 patients aged 41-88, with a history of hypertension of 17.5±9 years. 90% of them had developed systemic complications, the most common being LV hypertrophy (73.4%) and LV diastolic dysfunction (63.4%). In only 47% all major causes of secondary hypertension were excluded. In 90.3% of subjects, at least one factor affecting BP control was identified. The most frequent factors were medication noncompliance (52.4%), metabolic syndrome (43.6%) excessive sodium intake (66.1%) and chronic administration of non-steroid anti-inflammatory drugs (40%). The incidence of real resistant hypertension was only 4.8%. Conclusions: Among patients referred with uncontrolled hypertension, the incidence of real resistant hypertension is small. A majority of these patients have multiple factors potentially responsible for poor BP control, the most common being medication non-adherence, use of drugs increasing BP, excessive salt intake and metabolic syndrome.

Angio-computed tomography reveals differences in the anatomy of renal arteries in resistant hypertension patients qualified for renal denervation versus pseudo-resistant hypertensive subjects.

BACKGROUND: Renal denervation is a novel therapeutic option in resistant hypertension (RHT). The anatomy of renal arteries and the presence of additional renal arteries are important determinants of the effect of the procedure. The aim of this study was to assess the anatomy of renal arteries using angio- -computed tomography in patients with RHT, who were qualified for renal denervation. METHODS: We analyzed angio-computed tomography scans of the renal arteries of 72 patients qualified for renal denervation. We divided the study population into two groups: a resistant hypertension group (RHT) and a pseudo-resistant hypertension group (NRHT). The biochemical and endocrine diagnostic procedures were performed to rule out secondary hypertension. We analyzed the morphology, the diameters, and the number of additional renal arteries. RESULTS: In both groups, we found additional renal arteries (ARN). ARN were more frequent in RHT than in patients with non-resistant hypertension (48.4% vs. 24.3%; p < 0.05). They were present more often on the left side (18 left side vs. 7 right side). The ARNs were longer than main renal artery - left side 41.7 ± 12.1 mm vs. 51.1 ± 11.8 mm, right side 49.2 ± 14.5 mm vs. 60 ± ± 8.6 mm, respectively (p < 0.05). The diameters of ARN were similar in both groups. In the group of patients with RHT the number of ARN was significantly higher (p < 0.04). CONCLUSIONS: The ARNs occur more often in patients with RHT. It seems that there is no connection between the resistance of hypertension and the diameters of renal arteries.

Coronary artery calcium score assessed by a 64 multislice computed tomography and early indexes of functional and structural vascular remodeling in cardiac syndrome X patients.

BACKGROUND: Regardless of normal coronary angiograms, coronary artery calcium (CAC) can be found in cardiac syndrome X (CSX) patients. According to some data, a relationship between the CAC score and markers of early atherosclerosis in CSX has been observed. Our aim was to assess whether the extent of the CAC score assessed by multislice computed tomography (MSCT) with a 64-slice system in CSX patients is related to brachial artery reactivity, intima-media thickness (IMT), and arterial compliance indexes. METHODS AND RESULTS: High-resolution ultrasound was used to measure flow-mediated dilatation (FMD) and nitroglycerin-mediated vasodilatation, as well as the following parameters of arterial structural changes: IMT, pulse wave velocity, total arterial compliance, and stiffness index. MSCT was used to assess the presence and the quantity of CAC. The study group consisted of 46 CSX patients (mean age, 56.3 +/- 9 years), whereas the control group comprised 21 healthy subjects (mean age, 54.9 +/- 7 years). The assessment of the vascular parameters showed significantly decreased FMD and increased IMT in the CSX subjects (9.06% +/- 3.2% and 0.67 +/- 0.1 mm, respectively) in comparison to the control subjects (17.42% +/- 8.4% [P = .008] and 0.57 +/- 0.2 mm [P = .021], respectively). CAC was detectable in 19 CSX patients (41%) (CAC range according to Agatston score, 2-500; mean, 101.6; median, 26.5) and in 1 control subject (4.8%) (CAC value, 13). CSX patients with detectable CAC were characterized by a significantly higher age (P = .001), lower body mass index (P = .017), and increased stiffness index (P = .020); there were no differences in FMD and IMT values. In a multivariate logistic and linear regression analysis, age was the only risk factor independently associated with the presence of CAC (P = .001) and the log(CAC + 1) value (P = .01). In the subgroup of women, log(CAC + 1) significantly correlated with age (r = 0.587, P = .002) and stiffness index (r = 0.427, P = .024), and in a borderline significant manner, it correlated with weight (r = -0.329, P = .07) and waist-hip ratio (r = 0.315, P = .07). There were no significant correlations in the male subgroup. CONCLUSIONS: Low ranges of CAC are frequently detectable in CSX patients, and the results are age-related and independent of impaired early indexes of functional and structural vascular remodeling.

Long-term follow-up after radio-frequency catheter-based denervation in patients with resistant hypertension.

UNLABELLED: The aim of this single-center study was to asses the long-term clinical data of patients with resistant hypertension who underwent radiofrequency renal denervation (RND). METHODS: Out of 86 patients with resistant-hypertension, 15 pts fulfilled the study criteria for performing RND using Simplicity system by Medtronic. RESULTS: Baseline office systolic BP was 204±32.7 and diastolic BP 107.7±15.1mmHg. Baseline 24h ambulatory systolic BP was 151.8±13.9 and diastolic BP 86.8±13.8mmHg. Patients were treated with an average of 5 antihypertensive agents in maximally tolerated doses (including diuretic) during the whole trial and were followed up at 1,6,24month after RND. At every appointment an echocardiography, blood test, and blood pressure (office and ABMP) measurements were performed. The mean reduction in office systolic (SBP) and diastolic (DBP) blood pressure were the following: There were no procedural complications. All denervations were performed by experienced operator. CONCLUSIONS: We regard RND as a safe and effective procedure in resistant hypertension, although more studies and trials are needed to find the most adequate model of a patient that would be a good responder to RND.

Quality of life in patients with paroxysmal atrial fibrillation after circumferential pulmonary vein ablation.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia and is associated with a deterioration of quality of life (QoL). Catheter ablation is a therapeutic strategy for some patients with AF. The effectiveness of pulmonary vein isolation is still under assessment. AIM: To assess the long-term influence of circumferential pulmonary vein ablation (CPVA) on QoL in patients with AF. METHODS: The study population consisted of 33 patients (26 males, age 54.2 ± 9 years) with highly symptomatic (EHRA II-III) drug refractory paroxysmal AF, who underwent CPVA. A clinical examination, electrocardiogram (ECG), and Holter ECG were performed before and during a one-year follow-up. The SF-36 Medical Outcomes Survey Short-Form QoL questionnaire, scored on a 0-100 scale for each of eight domains: bodily pain (BP), general health (GH), mental health (MH), physical functioning (PF), role-emotional (RE), role-physical (RP), social functioning (SF), and vitality (V), was collected before and one year after CPVA. RESULTS: In the one-year follow-up 27 (82%) patients were free of AF. EHRA symptoms were improved one-year after CPVA regardless of CPVA efficacy. After the follow-up the SF-36 questionnaire results improved significantly in all of the subscales in patients without a recurrence of AF after CPVA. In subjects with a recurrence of AF, all of the subscales did not indicate any statistically significant differences. There was an association between the CPVA and the following QoL domains: GH (p = 0.018), PF (p = 0.042), and V (p = 0.041). The highest values of the GH and V domains were found in the non-recurrence patients one year after CPVA. CONCLUSIONS: CPVA results in the clinical improvement of patients with symptomatic AF regardless of the final arrhythmia termination. Patients after successful CPVA experienced a significant improvement in all of the subscales of the QoL.

Long-term follow-up of renal arteries after radio-frequency catheter-based denervation using optical coherence tomography and angiography.

Optical coherence tomography (OCT) imaging at the time of renal denervation (RDN) showed that procedure might cause spasm, intimal injury or thrombus formation. In the present study, we assessed the healing of renal arteries after RDN using OCT and renal angiography in long-term follow-up. OCT and renal angiography were performed in 12 patients (22 arteries) 18.41 ± 5.83 months after RNS. There were no adverse events or complications during the long-term follow-up. In ten patients (83 %), significant reductions of blood pressure was achieved without a change of the antihypertensive medications. We demonstrated the presence of 26 areas of focal intimal thickening identified by OCT in 10 (83 %) patients and in 14 (63 %) arteries. The mean area of focal intimal thickening was 0.054 ± 0.033 mm(2). No vessel dissection, thrombus, intimal tear or acute vasospasm were observed during the OCT analysis. Also, the quantitative angiography analysis revealed a significant reduction of the minimal and proximal lumen diameters at follow-up as compared to measurements obtained before RDN. Renal arteries have a favorable "long-term" vessel healing response after RDN. Focal intimal thickening and a modest reduction of the minimal lumen diameter may be observed after RF denervation. Further studies are needed to determine whether intravascular imaging may be helpful in evaluating the vessel healing of RF RDN.

[Results of treating myocardial infarction patients with ST segment elevation in Górnoslaskim Osrodku Kardiologii in Katowice]. / Wyniki leczenia chorych z zawalem serca z uniesieniem odcinka ST w Górnoslaskim Osrodku Kardiologii w Katowicach.

BACKGROUND: Reperfusion therapy reduces mortality rate in patients with acute myocardial infarction with ST-segment elevation (STEMI). AIM: The aim of the study was to access the early outcome of patiens (pts) with STEMI admitted to Upper Silesian Cardiology Centre in 2002. METHODS: 957 pts with AMI were enrolled into the study. The influence of several factors on in-hospital mortality was analised. RESULTS: Out of 957 pts 51 died during hospitalization (5,3%). Coronary angiography was performed in 98,0% of pts. Primary PTCA was performed in 94,5% of pts. Stents were implanted in 85,9% of patients who underwent PTCA. The following factors significantly contributed to increased mortality among pts with acute myocardial infarction: female sex (p<0,02), multivessel disease (p<0,05), age above 65 yrs (p<0,001), time from the onset of chest pain above 6 hours (p<0,01) and 12 hours (p<0,001). The use of GP IIB/IIIA inhibitors significantly reduced the mortality rate (p<0,05). Cardiogenic shock was the only independent factor of the increased risk of mortality in multivariate regression analysis (p<0,0001) with relative risk of death (RR 33,5). The mortality rate in pts with shock was 40,2%: 70,8% in case of conservative treatment, 70% in the group of failed PTCA and only 17,2% in the group of successful PTCA. Among pts who underwent primary PTCA the failure to restore coronary blood flow of the infarct related artery contributed to increased relative risk of death (RR 14,5) (p<0,001). Stents improved the survival rate (p<0,01). In PTCA group cardiogenic shock and failed PTCA were independent risk factors in multivariate regression analysis. CONCLUSIONS: The results of our study show low rate of in-hospital mortality in pts without cardiogenic shock (1,2%). PTCA is highly successful method of treatment of pts with shock with mortality rate 17,2% in pts who underwent successful procedure.

Oligonucleotide microarray analysis of genes regulating apoptosis in chronically ischemic and postinfarction myocardium.

The pathology of cardiomyocyte death during and after myocardial infarction involves both necrosis and apoptosis. Although both mechanisms lead to cell death, participation of apoptosis in this process carries the potential of developing therapies influencing at least part of the population of dying cells. Therefore the aim of this study was to determine (using oligonucleotide microarrays) expression profiles of apoptosis-regulating genes in postinfarction myocardium, comparing chronically ischemic and healthy heart muscle. Tissue samples were obtained during elective surgery from the right cardiac auricles of three patients. The expression of 141 genes involved in fibrosis was assessed using the Affymetrix HG_U133A microarray. The patients' transcriptomes were compared using hierarchical clusterization. Differentiating genes were determined using regression analysis and Bland-Altman graph analysis. Hierarchical clusterization demonstrated that the profile of gene expression in postinfarction myocardium was different from that in the remaining specimens. Further statistical analysis showed two important differentiating genes: FOXO3A (underexpressed in post-MI sample) and CFLAR (overexpressed in post-MI sample). The expression of apoptosis-regulating genes is significantly different in post-MI myocardium from chronically ischemic and a nonischemic myocardium. Our results suggest that CFLAR is important in the induction of apoptosis in postinfarction cardiac tissue.

Flow-mediated dilation and gender in patients with coronary artery disease: arterial size influences gender differences in flow-mediated dilation.

BACKGROUND: The risk of atherosclerosis and its complications differs between male and female subjects. This is probably associated with gender differences in endothelial function as reflected by endothelium-dependent vasodilation. The aim of the study was to compare flow-mediated dilatation (FMD) in males and females with coronary artery disease (CAD), and to determine factors that might potentially influence FMD. METHODS: Ninety-six patients with stable CAD (CCS II-III): 76 males (mean age: 57.7 +/- 10 years) and 20 postmenopausal females (mean age: 60.1 +/- 10 years) were included into the study. Clinical data, pharmacotherapy, concomitant diseases, and FMD were all assessed. FMD was measured with high-resolution ultrasound as the percent change of brachial artery diameter (BAd) after a 3-minute occlusion (%FMD), and following the administration of 0.4 mg sublingual nitroglycerin (%NTG-MD). RESULTS: The percentage of FMD was significantly decreased (P < 0.05), and BAd was significantly larger (P < 0.001) in males as compared to females. Clinical data, pharmacotherapy, and concomitant diseases were comparable in the study groups. In all subjects examined, %FMD was related to BAd (r =-0.415, P < 0.001) and the percentage of ejection fraction (EF%) (r = 0.325, P < 0.01) in the univariate analysis, and to BAd only (r =-0.343, P < 0.01) in the multivariate analysis. The percentage of nitroglycerine-mediated vasodilatation (NTG-MD) correlated negatively with BAd (r =-0.430, P < 0.001), and positively with EF% (r = 0.334, P < 0.01) in the univariate analysis, and with BAd (r =-0.288, P < 0.05) in the multivariate analysis. Index %FMD x BAd was comparable for male and female subjects. CONCLUSIONS: Males and postmenopausal females with CAD show differences in endothelium-dependent vasodilatation that seem to secondarily result from differences in the BAd. Objective comparison of %FMD is only possible between patients with the same brachial artery size.

[Combinated clinical picture of hypertrophic cardiomyopathy in 53-year-old male]. / Zlozony obraz kardiomiopatii przerostowej u 53-letniego mezczyzny.

We present and discuss a case of hypertrophic obstructive cardiomyopathy (HOCM), which until the proper interpretation of echocardiography image had been diagnosed and treated as a combinated mitro-aortic valve disease. Due to years of maltreatment the disease has reached an advanced stage. Available healing procedures, with thoroughly proved efficacy in reducing the sub-valvular pressure gradient, include: implantation of cardio-stimulator, alcohol ablation and surgical treatment. In the presented case the co-existing diseases have made the choice of optimal treatment difficult.

Influence of coronary artery bypass grafting on QT dispersion.

BACKGROUND: Abnormal dispersion of the QT interval (QTd), measured as the interlead variability of QT, reflects an inhomogeneity of ventricular action potentials. In this study we observed both short- and long-term influences of coronary artery bypass grafting (CABG) on rest and exercise QTd in 64 male patients, having a mean age of 54+/-10 years, with coronary heart disease. MATERIAL/METHODS: QTd was measured as the difference between QT maximum and minimum from 12 leads on an averaged ECG (25 mm/s). QTd and QTdc were measured at rest and at peak exercise during symptom-limited treadmill exercise (ET), which was performed before, 6 months after, and 2 years after CABG. RESULTS: There was a significant reduction in rest QTd from before CABG to 6 months and 2 years after (60+/-20 ms vs. 43+/-14 ms and 45+/-13 ms, respectively; p<0.001). Similarly, there was a significant reduction in peak QTd from before CABG to 6 months and 2 years after (66+/-22 ms vs. 38+/-11 ms and 36+/-11 ms, respectively; p<0.001). Two years after CABG, 17 patients had a recurrence of angina and ET provoked chest pain and/or >2 mm ST depression. The resting values did not distinguish patients with ischemia from nonischemic ones. In patients with ischemia, ET provoked an increase in QTdc. CONCLUSIONS: Rest and exercise QTd is significantly reduced after CABG. It seems that the measurement of QT dispersion during ET can be helpful in distinguishing patients with a recurrence of ischemia.