Correlation between epicardial fat thickness with intima-media thickness and ankle-brachial index in patients with metabolic syndrome.

Background An increase in epicardial fat thickness (EFT) has been associated with increased cardiovascular risk and the development of atherosclerosis. Transthoracic echo-cardiography provides a reliable measurement of EFT. We evaluated the relationship of EFT with carotid intima-media thickness (CIMT) and ankle-brachial index (ABI), in patients with metabolic syndrome. Methods We assessed 80 patients with metabolic syndrome who underwent echocardiography; EFT was measured by two cardiologists. The CIMT (B-mode colour imaging of extracranial carotid arteries using high-resolution ultrasound) was also measured by a certified ultrasonographer, and ABI was measured by the main researcher. Results We did not find any correlation between ABI with EFT (r=0.0103, p=0.93) or with CIMT (r=-0.1625, p=0.15). However, we found a significant correlation between EFT and CIMT (r=0.2718, r2=0.074, p=0.015). When we evaluated the risk for a CIMT >0.9 mm in patients with an EFT >3 mm, we found a statistically significant association (p=0.039). Interestingly, only 1 patient with an EFT <3 mm had a CIMT >0.9 mm. Conclusion We found that the EFT correlates with CIMT in patients with metabolic syndrome, which explains, at least in part, the higher risk of atherosclerosis in them. Measurement of EFT should be part of the cardiovascular risk evaluation in patients with metabolic syndrome.

Depression increases the risk for uncontrolled hypertension.

BACKGROUND: Because hypertension and depression share common pathways, it is possible that each disease has an impact on the natural history of the other. OBJECTIVE: To determinate whether depression influences blood pressure control in hypertensive patients. METHODS: Forty hypertensive patients undergoing antihypertensive treatment, excluding beta-blockers and central-acting agents, self-measured their blood pressure several times a day for three days using a validated, commercially available device. All patients also completed the Zung Self-rating Depression Scale survey for depression. Associations between the results of the blood pressure and depression tests were determined using the Spearman correlation coefficient; RR was also measured. RESULTS: Of the 40 patients, 23 were depressed, and 21 of these 23 had poor control of their blood pressure. The RR for uncontrolled hypertension in depressed patients was 15.5. A significant correlation between systolic (r=0.713) and diastolic (r=0.52) blood pressure values and depression was found. CONCLUSION: Depression is common in patients with uncontrolled hypertension and may interfere with blood pressure control. Screening for depression in hypertensive patients is a simple and cost-effective tool that may improve outcomes.

[Validation of diagnosis scales for differencing hemorrhagic from ischemic cerebral vascular disease]. / Escalas clínicas para diferenciar enfermedad vascular cerebral hemorrágica de isquémica.

BACKGROUND: differentiating hemorrhagic from ischemic cerebral vascular disease (CVD) is the starting point for the treatment. The aim was to compare the diagnostic accuracy of the scales that differentiate hemorrhagic from ischemic stroke. METHODS: we applied the scale of Siriraj Stroke Score (SSS) and Greek Stroke Score (GSS) to patients with stroke. The results were described as means and frequencies. For significant variables odds ratio was calculated. We calculated the validity of both scales compared to the head computed tomography. RESULTS: ninety one patients had ischemic stroke and 28 were hemorrhagic. The mean systolic blood pressure in ischemic stroke was 138.94 mmHg (SD ± 26.90) and hemorrhagic was 165.55 mmHg (SD ± 36.40) p = 0.0007. The atherogenic index (AT) in ischemic stroke was 4.52 (SD ± 1.52) and in hemorrhagic was 4.84 (SD ± 2.01) p = 0.87. The specificity of the SSS for hemorrhagic stroke is 85.5 % and 96.7 % for the GSS. CONCLUSIONS: the GSS has a high specificity for hemorrhagic stroke.

[Insulin, renin-angiotensin system, aldosterone and endothelial dysfunction]. / Insulina, sistema renina-angiotensina-aldosterona y disfunción endotelial.

Beyond its metabolic effects, insulin has several actions on the vasculature. Under normal conditions, insulin maintains normal endothelial function, but in the presence of insulin resistance, insulin leads to endothelial dysfunction. Insulin releases nitric oxide, which promotes an antiatherosclerotic, antiinflamatory and vasodilated state. However, in presence of high levels of angiotensin II, insulin activates pathways that lead to atherosclerosis, vasoconstriction and inflammation. We will review the actions of insulin on the vascular system, and its interactions with other vasoactive mediators, such as angiotensin II and endothelin-1.

[Ankle-brachial index and albuminuria correlation in diabetic patients with normal blood pressure]. / Índice brazo-tobillo y albuminuria en pacientes diabéticos normotensos.

BACKGROUND: both, the ankle-brachial index < 0.9, and microalbuminuria are considered markers of endothelial dysfunction. Our objective was to evaluate if there is a correlation between the ankle-brachial index (ABI) and the degree of albuminuria in diabetic normotensive patients. METHODS: we included 32 diabetic normotensive patients and measured their ABI, and their 24-h urinary albumin excretion by nephelometry; the ABI and albuminuria were correlated with the Spearman correlation coefficient. RESULTS: we did not find overall correlation between the ABI and albuminuria (r = 0.21, 95 % CI = -0.14-0.52, p = 0.12); However, when we measured the correlation of an ABI < 0.9 with any degree of albuminuria, we found a significant correlation (r = -0.32 ± 0.11, 95 % CI = 0.027 to -0.6, p = 0.03); and when the correlation of ABI with albuminuria > 300 mg, we also found a significant correlation (r = -0.45 ± 0.11, 95 % CI = -0.015 to -0.76, p = 0.3). CONCLUSIONS: our results suggest that ABI < 0.9 is a useful marker to estimate microalbuminuria in diabetic normotensive patients.

Correlation between the levels of circulating adhesion molecules and atherosclerosis in hypertensive type-2 diabetic patients.

Endothelial dysfunction is a common feature in type-2 diabetic patients and in hypertension, and is associated with inflammation, increased levels of circulating soluble adhesion molecules, and atherosclerosis. The aim of this study was to evaluate the relationship between the levels of circulating soluble adhesion molecules and the degree of atherosclerosis in hypertensive type-2 diabetic patients. We studied 30 hypertensive type-2 diabetic patients in whom VCAM-1, ICAM-1, and E-selectin were measured by ELISA. Additionally, the intimal-medial thickness of both the common and internal carotid arteries was measured (B-mode ultrasound). The levels of circulating adhesion molecules and maximal carotid artery intimal-medial thicknesses were correlated using the Spearman correlation coefficient test. Statistical analysis was performed with ANOVA. We found significant correlations between ICAM-1 (r = 0.5) levels and maximal carotid artery intimal-medial thickness these patients. No correlation was observed with E-selectin and VCAM-1. Our results suggest that ICAM-1 is associated and correlated with the degree of atherosclerosis in type-2 diabetic hypertensive patients.

Correlation between circulating adhesion molecule levels and albuminuria in type-2 diabetic hypertensive patients.

BACKGROUND/AIMS: Endothelial dysfunction, a common feature among hypertensive and type-2 diabetic patients, is associated with inflammation, increased levels of circulating soluble adhesion molecules (SAM), and urinary albumin excretion. The aim of this study was to evaluate the role of circulating SAM levels in the development of albuminuria in hypertensive type-2 diabetic patients. METHODS: We studied 30 hypertensive type-2 diabetic patients and 30 non-diabetic normotensive subjects, and measured their VCAM-1, ICAM-1 and E-selectin levels by ELISA, and their 24-hour urinary albumin excretion by nephelometry; the levels of circulating adhesion molecules and albuminuria were correlated with the Spearman correlation coefficient. RESULTS: We found that the diabetic patients had significantly (p < 0.001) higher levels of circulating SAM than control subjects. When levels of circulating SAM were correlated with albuminuria, we found a significant correlation between VCAM-1 levels and 24-hour urinary albumin excretion (r = 0.4, p < 0.02). CONCLUSION: Our results suggest that VCAM-1 may be a marker of nephropathy in hypertensive type-2 diabetic patients.

Triglycerides and waist to height ratio are more accurate than visceral adiposity and body adiposity index to predict impaired fasting glucose.

AIMS: To evaluate the clinical accuracy of novel indices visceral adiposity index (VAI) and body adiposity index (BAI) to identify patients with impaired fasting glucose (IFG) and compare with its individual components and other obesity indicators. METHODS: A cross-sectional study was conducted in Mexican population. Body mass index (BMI), waist circumference, hip circumference, triglycerides (TG), High density lipoprotein cholesterol (HDL-C), VAI, BAI, waist to hip ratio (WHR) and waist to height ratio (WHtR) were determined. We plotted a receiver operating characteristic curves to assess the abilities to discriminate subjects with IFG from those with normal glucose tolerance (NGT) of the measurements. A binary logistic regression analysis was performed to determine the strength of association with IFG. RESULTS: A total of 280 individuals were included, from which 144 (51.3%) have IFG; the mean age was 47.14 years and 164 (55.5%) were females. Compared with NGT subjects, the participants with IFG had significantly higher levels of BMI, WHtR, VAI, BAI and TG. The measurements with highest area under the curve were TG, (0.631, 95% confidence interval [CI] 0.566-0.697) VAI (0.628, 95% CI 0.563-0.693) and WHtR (0.622, 95% CI 0.557-0.688) and in the adjusted binary logistic regression model, were found to be independently associated with IFG, Odds Ratio of 2.665, (95% CI 1.567-4.533) 2.567 (95% CI 1.527-4.317) and 2.171 (95% CI 1.102-4.276) respectively. CONCLUSIONS: Our data provide evidence that TG, VAI and WHtR could be considered potential tools for the risk assessment of type 2 diabetes mellitus (T2DM) in this population.

The effect of trandolapril and its fixed-dose combination with verapamil on circulating adhesion molecules levels in hypertensive patients with type 2 diabetes.

BACKGROUND AND AIM: Endothelial dysfunction in hypertensive type-2 diabetic patients is associated with increased levels of circulating soluble adhesion molecules (SAM). SAM participate in the development of diabetic macroangiopathy and microangiopathy. The aim of this study was to compare the effect of trandolapril (T) and its fixed-dose combination with verapamil (FDTV) on SAM levels in hypertensive type-2 diabetic patients. METHODS: Forty type-2 diabetic patients with never-treated hypertension were randomly assigned to two groups. One group (FDTV) received 2/180 mg once a day; the other group received T 2 mg once a day. Study drugs were administered for three months in both groups. VCAM-1, ICAM, and E-selectin were measured by ELISA at the beginning and end of the study. Patients were evaluated monthly for blood pressure, fasting serum glucose, and adverse events. Statistical analysis was performed with ANOVA. RESULTS: Both therapeutics regimens reduced significantly the levels of the SAM tested. When both groups were compared, we did not find a significant difference in ICAM and E-selectin reduction. However, VCAM-1 presented a significantly greater reduction (p = 0.022) in the trandolapril-verapamil group. No patient suffered adverse events. CONCLUSION: Our results show that FDTV produces a greater reduction of VCAM-1 circulating levels than trandolapril alone. This may explain some of the beneficial effects of this fixed dosed combination that are non-related to its antihypertensive effects.

[Levels of soluble adhesion molecules among normal and hypertensive type 2 diabetic patients]. / Niveles de moléculas de adhesión solubles en pacientes diabéticos tipo 2 normotensos e hipertensos.

BACKGROUND: Hypertension and type-2 diabetes affect endothelial function, which in turn increases the expression of soluble adhesion molecules and lead to the development of vascular damage. The aim of this study was to assess soluble adhesion molecule levels among normotensive and hypertensive diabetic patients. MATERIAL AND METHODS: Serum levels of soluble VCAM1, ICAM1 and e-selectin were measured in 80 type-2 diabetic patients, (40 normotensive and 40 hypertensive), and in 40 normotensive non-diabetic subjects by ELISA (RyDSystems Minneapolis). Statistical analysis was performed with ANOVA. RESULTS: Among diabetic patients, levels of all three soluble adhesion molecules were significantly increased when compared with non-diabetic patients (p < 0.001 for all three molecules), In diabetic hypertensive patients, higher levels of ICAM1 were detected in comparison to normotensive diabetic patients (316 vs. 295 ng/ml p < 0.01), VCAM1 and e-selectin levels were not different between diabetic patients with and without hypertension. CONCLUSIONS: Diabetes is associated with increased levels of soluble adhesion molecules, suggesting a role of these molecules may play in endothelial damage. ICAM1 is further increased when hypertension and diabetes are present. The latter may explain why diabetic-hypertensive patients displayed more complications than normotensive patients.

Combination therapy in the treatment of hypertension.

Hypertension is a major preventable risk factor for atherosclerosis and ischemic heart disease. Although modern and effective antihypertensive drugs are available, most patients remain with a suboptimal blood pressure control. Most hypertensive patients will need a combination of antihypertensive agents to achieve the therapeutic goals - recent guidelines recommend initiating treatment with two drugs in those patients with a systolic blood pressure >20 mmHg and/or a diastolic blood pressure >10 mmHg above the goals, and in those patients with high cardiovascular risk. In addition, approximately 25% of patients will require three antihypertensive agents to achieve the therapeutic targets. In this review, we analyse the latest information available regarding the treatment of hypertension with combination therapy.

¿Debemos manejar la hiperuricemia asintomática para proteger al riñón?

Contexto: el ácido úrico es el producto final de la degradación de las purinas en los primates, en condiciones normales es un agente antioxidante endógeno y participa en varias vías fisiológicas, sin embargo, cuando los niveles séricos de urato se incrementan, estos participan en el desarrollo de diversas enfermedades. Desde el siglo XIX se conoce de la asociación entre hiperuricemia y daño renal, aunque ninguna guía de manejo recomienda el uso de fármacos hipouricemiantes en pacientes asintomáticos, en algunos casos especiales, el manejo farmacológico beneficiará a pacientes con hiperuricemia, brindando protección al riñón y disminuyendo el riesgo de desarrollar enfermedad renal terminal. Objetivo: describir la relación entre hiperuricemia y daño renal, y analizar los casos en los que el manejo de esta condición con medicamentos resultará en un beneficio para el riñón de los pacientes. Metodología: revisión de la literatura sobre la participación de la hiperuricemia en el daño renal y análisis de los artículos revisados. Resultados: el manejo de la hiperuricemia asintomática puede proteger el riñón en algunas situaciones específicas. Conclusiones: hay situaciones específicas para la disminución de los niveles séricos de ácido úrico.

Background: Uric acid is the end product of purine degradation in primates, under normal conditions it is an endogenous antioxidant agent and participates in several physiological pathways. However, when serum urate levels are increased, they participate in the development of various diseases. Since the nineteenth century, the association between hyperuricemia and kidney damage has been known. Although no management guideline recommends the use of hypouricemic drugs in asymptomatic patients, in some special cases pharmacological management will benefit patients with hyperuricemia, providing protection to the kidney and decreasing the risk of developing end-stage renal disease. Purpose: To describe the relationship between hyperuricemia and kidney damage, and to analyze the cases in which the management of this condition with medications will result in a benefit for the kidney of patients. Methodology: Review of the literature on the involvement of hyperuricemia in kidney damage, analysis of the reviewed articles. Results: Management of asymptomatic hyperuricemia may protect the kidney in some specific situations. Conclusions: There are specific situations for the decrease of serum uric acid levels.

Correlation between epicardial fat thickness and biochemical markers of metabolic risk. / Correlación entre el grosor de la grasa epicárdica y los marcadores bioquímicos de riesgo metabólico.

INTRODUCTION AND OBJECTIVE: Epicardial fat has been associated with increased cardiovascular risk and the development of atherosclerosis. Transthoracic echocardiography provides a reliable measurement of epicardial fat thickness (EFT). The aim of this study is to evaluate the relationship between EFT and biochemical parameters of metabolic risk. MATERIAL AND METHOD: We assessed 211 patients who underwent echocardiography; EFT was measured by two cardiologists. In addition, patients' glycaemia, lipid profile and serum uric acid were measured. Statistical analysis was performed with the Pearson coefficient test and Odds ratio. RESULTS: A positive correlation between EFT with glycaemia (r=.064), total serum cholesterol (r=.0056), high density lipoproteins (r=-.038), or with triglycerides (r=.118) was not observed. However, we did find a significant positive correlation between EFT and serum uric acid (r=.415, P<.00001). The odds ratio for EFT>3mm in patients with hyperuricemia was 6.26 (IC 95 2.79-14, P<.0001). CONCLUSION: Hyperuricemia is strongly associated with EFT in Mexican patients; EFT is a useful tool for global cardiovascular risk calculation.

Echocardiographic measurements of epicardial adipose tissue and comparative ability to predict adverse cardiovascular outcomes in patients with coronary artery disease.

The present study aimed to compare echocardiography measurements of epicardial adipose tissue (EAT) thickness and other risk factors regarding their ability to predict adverse cardiovascular outcomes in patients with coronary artery disease (CAD). Outcomes of 107 patients (86 males, 21 females, mean age 63.6 years old) submitted to diagnostic echocardiography and coronary angiography were prospectively analyzed. EAT (measures over the right ventricle, interventricular groove and complete bulk of EAT) and left ventricle ejection fraction (LVEF) were performed by echocardiography. Coronary complexity was evaluated by Syntax score. Primary endpoints were major adverse cardiovascular events (MACE's), composite of cardiovascular death, myocardial infarction, unstable angina, intra-stent re-stenosis and episodes of decompensate heart failure requiring hospital attention during a mean follow up of 15.94 ± 3.6 months. Mean EAT thickness was 4.6 ± 1.9 mm; and correlated with Syntax score and body mass index; negatively correlated with LVEF. Twenty-three cases of MACE's were recorded during follow up, who showed higher EAT. Diagnostic ability of EAT to discriminate MACE's was comparable to LVEF (AUROC > 0.5); but higher than Syntax score. Quartile comparison of EAT revealed that measurement of the complete bulk of EAT provided a better discrimination range for MACE's, and higher, more significant adjusted risk (cutoff 4.6 mm, RR = 3.91; 95% CI 1.01-15.08; p = 0.04) than the other risk factors. We concluded that echocardiographic measurement of EAT showed higher predicting ability for MACE's than the other markers tested, in patients with CAD. Whether location for echocardiographic measurement of EAT impacts the diagnostic performance of this method deserves further study.

[Morbidity and mortality by ischemic heart disease and stroke in Mexico. 2005]. / Morbilidad y mortalidad de la enfermedad isquémica del corazón y cerebrovascular en México, 2005.

Cardiovascular diseases are the main cause of death and disability in México. 25% of deaths under 60 years of age are related to chronic degenerative diseases. These disorders are more common in developing countries and are caused by an excessive intake of fatty acids, sodium, alcohol, tobacco consumption and decrease in physical activity. The prevalence of risk factors is increasing not only in adult population but also in youth and children. Data from the Department of Epidemiology from the Mexican Ministry of Health in the period between 1998 and 2000 showed that the death caused by coronary artery disease was more frequent in men (55%) than women (45%) and acute coronary syndrome was responsible for deaths in 83.5% of men and 76.8% in women. Primary Prevention Programs are necessary to decrease the impact of cardiovascular diseases.

Efficacy of a fixed-dose combination of trandolapril-verapamil in patients with stage 2 hypertension inadequately controlled by monotherapy.

BACKGROUND AND OBJECTIVE: About 70% of hypertensive patients need more than one drug to control their blood pressure (BP). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends a two-drug combination as initial drug therapy for patients with stage 2 hypertension. The aim of this study was to determine if a fixed-dose combination of trandolapril-verapamil is effective and safe in the treatment of stage 2 (moderate to severe) hypertension in hypertensive Mexican patients not controlled by monotherapy. METHODS: Forty hypertensive patients with BP >160/100mm Hg despite >6 months of drug treatment were given the fixed-dose combination of trandolapril-verapamil (2mg/180mg) for 12 weeks. Before taking the drug, they measured their own blood pressure (self-measured BP [SMBP]) several times a day for 3 days using a validated Omrom HEM 713C BP measuring device. At the end of the 12-week treatment period, the patients performed a second series of SMBPs in the same way as before treatment. A washout period was not included because the patients did not have an adequate response to previous antihypertensive treatment. Antihypertensive control during the 3-day SMBP period was evaluated. RESULTS: Patients experienced a significant reduction in mean BP (from 180/100mm Hg to 135/78mm Hg; p < 0.001). Seventy-five percent of patients reached their therapeutic goals (BP <140/90mm Hg). The SMBP records showed that BP values were maintained throughout the entire 3 days. One patient experienced headache and one had constipation; no patients discontinued the treatment. CONCLUSION: A fixed-dose combination of trandolapril-verapamil seems to be an effective and safe option for the management of stage 2 hypertension in Mexican patients uncontrolled by monotherapy.

The effect of trandolapril and its fixed-dose combination with verapamil on proteinuria in normotensive adults with type 2 diabetes.

OBJECTIVE: To compare the effect of fixed-dose trandolapril-verapamil (FDTV) with that of trandolapril on proteinuria in normotensive, type 2 diabetic patients. RESEARCH DESIGN AND METHODS: A total of 60 normotensive, type 2 diabetic patients with 24-h proteinuria >300 mg were randomly assigned to two groups for open-label treatment. One group received 2 mg trandolapril/180 mg verapamil FDTV once daily; the other group received 2 mg trandolapril once daily. Study drugs were administered for 6 months in both groups. Creatinine clearance and 24-h urinary protein excretion were measured at the beginning and the end of the study. Patients were evaluated monthly for blood pressure, fasting blood glucose level, heart rate, and adverse events. Statistical analysis was performed using ANOVA. RESULTS: Both groups experienced a statistically significant (P < 0.005) mean decrease in mean proteinuria from baseline: FDTV ([mean +/- SD] 1200 +/- 200 to 540 +/- 79 mg; P < 0.001) and trandolapril (1,105 +/- 212 to 750.9 +/- 134 mg; P < 0.005). A significantly greater reduction from baseline in proteinuria was observed in the FDTV group compared with the trandolapril group. Patients who received trandolapril experienced a statistically significant (P < 0.05) decrease in mean creatinine clearance (91.1 +/- 3.4 to 75.3 +/- 3 ml/min; P < 0.05) compared with patients who received FDTV (88.3 +/- 3.6 to 82.9 +/- 3.5 ml/min; P > 0.05). Final fasting blood glucose was significantly lower in the FDTV group (139 +/- 19) compared with the trandolapril group (154 +/- 22; P < 0.001). No significant differences were observed between the two groups in mean baseline or final measurements of blood pressure, mean heart rate, or frequency of adverse events. CONCLUSIONS: Our results suggest that FDTV is more effective than trandolapril in reducing proteinuria in normotensive, type 2 diabetic patients. This effect on proteinuria is not related with blood pressure reduction.

Correlation between biopterin levels and intimal-media thickness in type-2 diabetic hypertensive patients.

BACKGROUND: Biopterins have a crucial role in the function of nitric oxide synthase, uncoupling of the enzyme leads to endothelial dysfunction and vascular damage, The aim of this study was to evaluate the relationship between the levels of biopterins with carotid intima-media thickness (CIMT) in hypertensive type-2 diabetic patients. METHODS: We studied 30 hypertensive type-2 diabetic patients and 30 normotensive non-diabetic age-matched subjects, in whom biopterins levels were measured by reverse phase high performance liquid chromatography with fluorescence detection. Additionally, the CIMT of both the common and internal carotid arteries was measured. The levels of biopterins and CIMT were correlated using the Pearson correlation coefficient test. RESULTS: We did not find a significantly correlation between biopterins levels and CIMT. However, we found a significantly inverse correlation between the BH4/BH2 ratio and the CIMT in patients (r = -0.54, p < 0.01). A multiple regression analysis revealed that the CIMT correlated significantly and independently with the BH4/BH2 ratio. CONCLUSION: Our results suggest that the BH4/BH2 ratio seems to be a better marker of vascular disease than biopterin levels.