Identification of the hemodynamic modulators and hemodynamic status in uncontrolled hypertensive patients.

Only 20-30% out of the treated hypertensive patients in Europe are achieving blood pressure (BP) control. Among other recognized factors, these poor results could be attributable to the fact that for many doctors it is very difficult to detect which is the predominant hemodynamic cause of the hypertension (hypervolemia, hyperinotropy or vasoconstriction). The aim of the study was to use non-invasive thoracic electrical bioimpedance (TEB) to evaluate hemodynamic modulators and subsequent hemodynamic status in uncontrolled hypertensive patients, receiving at least two antihypertensive drugs. A number of 134 uncontrolled hypertensive patients with essential hypertension were evaluated in nine European Hypertension Excellence centers by means of TEB (the HOTMAN(®) System). Baseline office systolic and diastolic BP averaged 156/92 mmHg. Hemodynamic measurements show that almost all patients (98.5%) presented at least one altered hemodynamic modulator: intravascular hypervolemia (96.4%) and/or hypoinotropy (42.5%) and/or vasoconstriction (49.3%). Eleven combinations of hemodynamic modulators were present in the study population, the most common being concomitant hypervolemia, hypoinotropy and vasoconstriction in 51(38%) patients. Six different hemodynamic states (pairs of mean arterial pressure and stroke index) were found. Data suggest that there is a strong relation between hypertension and abnormal hemodynamic modulators. This method might be helpful for treatment individualization of hypertensive patients.

Nebivolol induces a hyperpolarizing effect on smooth muscle cells in the mouse renal artery by activation of beta-2-adrenoceptors.

Nebivolol is a highly selective beta(1)-adrenoceptor antagonist with vasodilator properties involving the vascular endothelium, but its effect on the smooth muscle cells (SMC) is still unclear. In this paper, we tested the effect of nebivolol on renal artery smooth muscle cells and investigated the cellular mechanism involved. To this purpose, the denuded renal arteries isolated from mice were studied in vitro using the myograph and the nitric oxide (NO) sensor techniques, while the SMC in culture were analyzed by the patch-clamp technique. The myograph technique was used to assay the vasodilator effect of nebivolol on the arterial muscular layer, and to establish the optimal dose of the drug to be tested on single SMC by the patch-clamp technique. Using both the myograph and the patch-clamp techniques, we examined the potential contribution of beta(2)-adrenoceptors and Ca(2+)-activated K(+) channels to the nebivolol-induced effects, by exposing the denuded arteries and SMC cultures to specific inhibitors such as butoxamine (100 micromol/l), tetraethylammonium (TEA, 1 mmol/l), and iberiotoxin (100 nmol/l). The direct measurement of NO using the NO sensor enabled us to evaluate if nebivolol induces/or not the release of NO in denuded renal arteries. The results of this study show that nebivolol exerts vasodilator effects on the SMC in the denuded renal arteries and the maximal response is achieved at a concentration of 50 micromol/l. Nebivolol effects involve binding to the beta(2)-adrenoceptors and the subsequent activation of Ca(2+)-activated K(+) channels in SMC, with no contribution of NO. Taken together, the study brings new insights into the mechanism underlying the nebivolol-induced arterial vasodilation.

WS/PIDS: standard interoperable PIDS in web services environments.

An electronic health record depends on the consistent handling of people's identities within and outside healthcare organizations. Currently, the Person Identification Service (PIDS), a CORBA specification, is the only well-researched standard that meets these needs. In this paper, we introduce WS/PIDS, a PIDS specification for Web Services (WS) that closely matches the original PIDS and improves on it by providing explicit support for medical multimedia attributes. WS/PIDS is currently supported by a test implementation, layered on top of a PIDS back-end, with Java- and NET-based, and Web clients. WS/PIDS is interoperable among platforms; it preserves PIDS semantics to a large extent, and it is intended to be fully compliant with established and emerging WS standards. The specification is open source and immediately usable in dynamic clinical systems participating in grid environments. WS/PIDS has been tested successfully with a comprehensive set of use cases, and it is being used in a clinical research setting.

[Thrombolysis: Bucarest registry]. / La thrombolyse. Registre roumain de Bucarest.

The end-point of this retrospective study was to evaluate the standard of care in terms of in-hospital morbidity and mortality for patients with acute myocardial infarction (AMI) treated by thrombolysis within the first 12 hours from the start of the symptoms in five cardiology centers from Bucarest for a period of 5 years (2000-2004). This retrospective registry on a central database included 1814 patients (73.63% men, mean age 59.9 +/- 11.8 years), presented in an average time of 211.63 minutes from pain start. The most frequently used fibrinolitic was streptokinase (66.21%), administered most often in 30 minutes and for a subgroup in 20 minutes--accelerated regimen, with a good efficiency for the reperfusion of the culprit vessel evaluated non-invasively (clinical, electrical and biological methods). The global in-hospital mortality was 11.1%. The only predictors of in-hospital mortality were female gender and advanced age (>75 years) [p < 0.05]. The rate of haemorrhagic complications was not different from the one described by other clinical studies. The treatment by anticoagulants, antiaplatelets agents like aspirin, ACE inhibitors and statins were significant determinants of in-hospital survival. In the subgroup followed-up for 1 year (315 patients), the most frequent complication was the heart failure. In conclusion, in Bucarest, where availability of primary angioplasty in AMI was limited, thrombolysis with streptokinase was still very much used, with acceptable low in-hospital mortality and relatively high rate of artery reperfusion appreciated by non-invasive methods.

Prognostic value of ventricular arrhythmias in systemic hypertension.

OBJECTIVE: Hypertensive left ventricular hypertrophy is associated with an increased risk of arrhythmias and mortality. However, no clinical study has demonstrated a significant relationship between ventricular arrhythmias and mortality in systemic hypertension. DESIGN AND METHODS: To evaluate the prognostic value of arrhythmogenic markers, we included, prospectively, 214 hypertensive patients aged (mean+/-SD) 59.1+/-12.8 years, without symptomatic coronary disease, myocardial infarction, systolic dysfunction or electrolyte disturbances. At inclusion, a 12-lead electrocardiogram (ECG) with QT dispersion calculation, a 24 h Holter ECG (204 patients) with Lown classification of ventricular arrhythmias, echocardiography (reliable in 187 patients) and a signal-averaged ECG (125 patients) with ventricular late potentials were recorded. RESULTS: At baseline, echocardiographic left ventricular hypertrophy was found in 63 patients (33.7%). Non-sustained ventricular tachycardia (Lown class IVb) was recorded in 33 patients (16.2%) and late potentials in 27 patients (21.6%). After a mean follow-up of 42.4+/-26.8 months, all-cause mortality was 11.2% (24 patients); 17 patients died of cardiac causes (7.9%); of these, nine (4.2%) died suddenly. In univariate analysis, age, Lown class IVb and a QT dispersion > 80 ms were significantly related to global, cardiac and sudden death (P < 0.01). The left ventricular mass index was related to cardiac mortality (P= 0.002). In multivariate analysis, only Lown class IVb was an independent predictor of global and cardiac mortality, increasing the risk of global death 2.6-fold (95% confidence interval 1.2-6.0) and cardiac death 3.5-fold (95% confidence interval 1.2-9.7). CONCLUSION: In hypertensive patients the presence of non-sustained ventricular tachycardia has prognostic value.

[Calcium channel inhibitors and ventricular filling]. / Inhibiteurs calciques et remplissage ventriculaire.

Abnormalities of ventricular relaxation and compliance often precede changes in systolic function in ischemic and hypertrophic or hypertensive heart disease. Several studies using non-invasive methods have confirmed the beneficial effects of calcium channel blockers on left ventricular diastolic function in ischemic and primary hypertrophic cardiomyopathies. Their usefulness remains controversial in secondary cardiac hypertrophy such as in hypertensive heart disease. Improved left ventricular isovolumic relaxation and filling results more from the coronary and peripheral vasodilatory effects of calcium channel blockers than from a direct action on the cardiac muscle.

[Correlation between QT interval dispersion and ventricular arrhythmia in hypertension]. / Corrélation entre la dispersion de l'intervalle QT et les arythmies ventriculaires dans l'hypertension artérielle.

OBJECTIVE: To evaluate the correlation between QT interval dispersion (QTd) and ventricular arrhythmias in hypertensive patients (pts) with or without left ventricular hypertrophy (LVH). A secondary aim was to investigate correlations of QTd with other markers of arrythmogenic propensity: ventricular late potentials (LP) and heart rate variability (HRV). METHODS: We retrospectively measured the QTd on the 12 standard surface ECG leads in 230 hypertensive pts (94F, 136M; 59.6 +/- 12.7 years old). A 24 hours ECG Holter recording was performed in 218 pts and ventricular arrhythmias were appreciated using the Lown classification. Left ventricular mass was determined by echocardiography (LVM-Devereux formula) and left ventricular mass index (LVMI) were determined in 202 subjects. LP (122 pts) and HRV (55 pts) were investigated. RESULTS: The QTd varied between 20 and 160 msec (57.8 +/- 32.7 msec). The distribution of pts classified using Lown criteria was: 29 pts (13.3%) class O; 106 pts (48.6%) class I; 8 pts (3.6%) class II; 13 pts (6%) class III; 29 pts (13.3%) class IVa; 33 pts (15.1%) class IVb; 116 pts (69.5%) had LVH determined by echocardiography. The QTd was strongly correlated with the Lown classes (p < 0.0001). The QTd was significantly broader in Lown classes III, IVa and IVb compared to classes O, I and II cumulated (p < 0.002); there was no difference concerning QTd between Lown classes III, IVa and IVb. The QTd was also correlated with the absolute number of premature ventricular depolarizations/24 hours (p = 0.02; r = 0.16). The 75 pts with an increased LVMI had significantly elevated QTd compared to pts without it (p < 0.0001). Qtd was correlated with LVMI (r = 0.37; p < 0.0001). There was no correlation between QTd and the existence of LP (which were correlated with the Lown classes; p < 0.03) and HRV parameters. CONCLUSION: Elevated QT interval dispersion is associated with more severe ventricular arrhythmias in hypertensive subjects with LVH. The mechanism of an increased inhomogeneity of repolarisation is probably related to the anatomic modifications induced by LVH. No significant correlation between QTd, LP and HRV was observed.

[Prognostic value of ventricular arrhythmia in hypertensive patients]. / Valeur pronostique des arythmies ventriculaires chez l'hypertendu.

OBJECTIVE: Hypertensive left ventricular hypertrophy (LVH) is associated with increased risk of arrhythmias and mortality. However, no clinical study demonstrated a significant relation between ventricular arrhythmias and mortality in systemic hypertension. DESIGN AND METHODS: To evaluate the prognostic value of arrhythmogenic markers in systemic hypertension, we included between 1987 and 1993. 214 hypertensive patients, 59.1 +/- 12.8 years old, without symptomatic coronary disease, myocardial infarction, systolic dysfunction, electrolyte disturbances or antiarrhythmic therapy. At inclusion, an ECG, a 24 h Holter ECG (204 patients) with Lown classification of ventricular arrhythmias, an echocardiography (reliable in 187 patients) with left ventricular mass index and ejection fraction calculation, a SAECG (125 patients, enrolled after 1988) with ventricular late potentials (LP) were recorded. QT interval dispersion (QTd) was calculated on 12 leads standard ECG and LVH was appreciated. RESULTS: At baseline echocardiographic LVH was recorded in 63 patients (33.7%) with normal ejection fraction (75 +/- 7.4%). Non-sustained ventricular tachycardia (Lown IVb) was found in 33 pts (16.2%) and LP in 27 patients (21.6%). After a mean follow up of 42.4 +/- 26.8 months, all-cause mortality was 11.2% (24 patients); 17 patients died of cardiac causes (7.9%); of these 9 patients (4.2%) died suddenly. In univariate analysis, age, strain pattern of LVH, advanced Lown classes and abnormal QT dispersion (> 80 ms) were significantly related to global, cardiac and sudden death (p < or = 0.01). Left ventricular mass index was closely related to cardiac mortality (p = 0.002). LP failed to predict mortality. In multivariate analysis, only Lown class IVb was an independent predictor of global and cardiac mortality, increasing the risk of global death 2.6 fold [1.2-6.0] (CI 95%) and the risk of cardiac death 3.5 fold [1.2-9.7] (CI 95%). CONCLUSIONS: In hypertensive patients the presence of non-sustained ventricular tachycardia on 24 h Holter has a prognostic value.

[Ventricular arrhythmias and arterial hypertension]. / Arythmies ventriculaires et hypertension artérielle.

Hypertension has two major consequences on the heart: left ventricular hypertrophy and morphological and functional alterations of the coronary macro- and microvessels. These two cardiac modifications are responsible for three types of complications: myocardial ischaemia, left ventricular dysfunction and electrical instability which are involved in the pathogenesis of ventricular arrhythmias in hypertensive patients. The mechanisms of ventricular arrhythmias in hypertension, their incidence and severity, and their therapeutic and clinical implications will be discussed in this review article.

Right ventricular septal pacing- clinical and electrical predictors for LV contraction asynchrony.

PURPOSE: Prolonged pacing from the right ventricular apex (RV) is associated with the LV dyssynchrony leading to progressive left ventricular dysfunction and increased morbidity and mortality. Alternate RV pacing sites-in particular the mid- RV septum and the RV outflow tract (RVOT) septum were considered, but no clear benefit was proven till now for this pacing sites. This may be due to the heterogeneity of the RV septal positions and to the significant number of leads placed on the RV free wall. The aim of this study is to find a reliable method of septal lead placement and to identify those pacing sites which provide better LV electrical activation Methods: 50 consecutive patients referred for pacemaker implants due to AV block were included. Patients with history of heart failure or LVEF < 50% at the implant were excluded. All patients had RV leads placed in septal position. This was achieved with a double curved stilet with the distal curve aimed posteriorly. RV septum and RVOT were mapped during implant aiming for a narrow paced QRS with an axis as close to normal as possible. Pacing lead position was evaluated during the implant using fluoroscopy (AP and LAO 40 °) and than by 12 lead ECG and echo. IntraLV dyssynchrony was evaluated during pacing using SPWMD in short axis parasternal view and the TDI septal to lateral ∆ t. Paced QRS duration and axis were also recorded. The correlation was sought between lead position evaluated by Rx and by echo and between paced QRS duration and axis and LV dyssynchrony. RESULTS: 92%(46) of the patients had the lead in septal position RV (32 in the mid-septal RV and 14 in RVOT), while 8% (4 pts) had the lead on the RVOT RV free wall as shown by echo. An anterior-oriented lead in the left anterior oblique fluoroscopic projection was specific for free wall position while positive QRS in DI in RVOT position was suggestive for free wall position on the ECG. No correlation was made between paced QRS axis and LV dyssynchrony while the QRS duration of > 160 ms was associated with significant LV dyssynchrony (SPWMD > 130 ms and to lateral septal ∆ t > 70 ms). CONCLUSIONS: RV lead placement on the RV septum can be reliably achieved using a specially curved stilet and the LAO projection for confirmation. The wide paced QRS is correlated with significant intra LV dyssynchrony and therefore the RV pacing site with the narrowest QRS should be sought.

Prevalence, Awareness, Treatment, and Control of Hypertension in Romania: Results of the SEPHAR Study.

East European countries have reported high prevalence of Arterial Hypertension (AHT). In order to investigate the data for Romania, we firstly performed a national survey-the Study for the Evaluation of Prevalence of Hypertension and Cardiovascular Risk in Adult Population in Romania (SEPHAR). A representative population was selected using stratified proportional sampling, including 2017 adult subjects, ≥18 years old. The general prevalence of AHT was 44,92%, higher in men (50,17%) than in women (41,11%) (P < .0001) and predominant in rural areas (49,47%) in comparison to the urban ones (41,58%) (P < .02). AHT awareness attended 44,26%, rising with age, significantly lower in men (34,58%) than in women (52,8%) (P < .0006). We have found a 38,85% proportion of treated hypertensive persons, worse for men (30,11%) then for women (46,56%) (P < .003). The rate of AHT control was 19,88%, with no significant differences between gender. In conclusion, we estimated for Romania a high prevalence of AHT, a level of awareness and treatment lower than in many European countries and a rate of treatment control at the inferior limit of the European average. Males, characterized by a higher prevalence of AHT, were also less aware and less treated than women.

[The etiological spectrum of mitral insufficiency: a 10-year retrospective study]. / Spectrul etiologic al insuficientei mitrale: studiu retrospectiv pe 10 ani.

The incidence, etiology and data on the severity and therapeutic implications of the mitral insufficiency were investigated in the patients admitted in the clinic during 10 years. The diagnosis was based mainly on clinical and echocardiography mode M data. 595 patients suffering from mitral insufficiency (below 2% of the total of the patients admitted) were recorded. In 65% of the cases mitral insufficiency had a rheumatic etiology (the majority associated polyvalvulopathies), in 14.8% an ischaemic origin, and in 10.9% an organic-functional one (the left ventricle was dilated). The primary prolapse of the mitral valve appeared in 6.9% of the cases (the low incidence was explained by the severe criteria applied in positive diagnosis). 4 cases of rupture of the subvalvular apparatus are described in the patients suffering from prolapse. All of them had a sudden onset, by severe cardiac insufficiency without a clear cause, appeared under conditions of seemingly complete health. Intense therapy followed by valvular prosthesis, resulted in a spectacular recovery of the heart function.

Prognostic value of arrhythmogenic markers in systemic hypertension.

OBJECTIVE: To evaluate the prognostic value of arrhythmogenic markers in hypertensive patients. DESIGN: Two hundred and fourteen hypertensive patients without symptomatic coronary disease, systolic dysfunction, electrolyte disturbances or anti-arrhythmic therapy were included. Recordings were made of 12-lead standard ECGs with calculations of QT interval dispersion, 24 h Holter ECGs (204 patients), echocardiography (187 patients) and signal-averaged ECGs (125 patients). BASELINE DATA: echocardiographic left ventricular hypertrophy was found in 63 patients (33.7%), non-sustained ventricular tachycardia (Lown class IV b) in 33 patients (16.2%), ventricular late potentials in 27 patients (21.6%). Mortality: after a mean follow-up of 42.4 +/- 26.8 months, global mortality was 11.2% (24 patients), cardiac mortality 7.9% (17 patients), sudden death 4.2% (nine patients). Univariate analysis: predictors of global, cardiac and sudden death were age > or = 65 years, ECG strain pattern, Lown class IV b and QT interval dispersion > 80 ms (P < or = 0.01). Left ventricular mass index was closely related to cardiac mortality (P = 0.002). Multivariate analysis: only Lown class IV b was an independent predictor of global (RR 2.6, 95% CI 1.2-6.0) and cardiac mortality (RR 3.5, 95% CI 1.2-9.7). CONCLUSION: In hypertensive patients, non-sustained ventricular tachycardia has a prognostic value.

[Sudden death in acute myocardial infarct in hospitalized patients: a clinical and anatomicopathological study over a 10.5-year period]. / Moartea subita în faza acuta a infarctului de miocard la bolnavi spitalizati: studiu clinic si anatomopatologic pe o perioada de 10.5 ani.

The paper reports on the study of 1457 patients with acute myocardial infarct (Ami) admitted in the word of the cardiac intensive care of the clinic for 10.5 years. The general mortality was of 21.2% and the sudden death (defined as such when appeared suddenly within less than 1 hour from the onset of the acute symptoms, but after 24 hours from the onset of AMI in a patient apparently equilibrated) appeared in 114 patients who were examined postmortem (43.3% of the total of the deaths). The main causes of the SD was rupture of the myocardium (28.8% of the general mortality), primary ventricular fibrillation (22.0%) and thromboembolic phenomena (17.8%). The sudden death by rupture of the myocardium appeared in a first AMI, usually large and was not helped by the anticoagulant treatment or by other therapy. Primary ventricular fibrillation appeared during the first week from the onset and was favoured by the ventricular hyperexcitability and active myocardial ischemia (which were not specific). Xyline (only more than 2 mg/min) and amiodarone gave a good protection. The sudden death by systemic thromboembolization appeared almost only in the antero-lateral myocardial infarcts, 5-8 days after the onset. The appearance of a small flow syndrome "sine materia" with or without association of some recurrent arrhythmias was suggested. Efficient anticoagulation prevented systemic thromboembolization and, to a smaller extent to pulmonary thromboembolization.