Hypertensive crisis in patients with obstructive sleep apnea-induced hypertension.

BACKGROUND: Hypertensive crisis is an urgent/emergency condition. Although obstructive sleep apnea (OSA) in resistant hypertension has been thoroughly examined, information regarding the risk factors and prevalence of hypertensive crisis in co-existing OSA and hypertension is limited. This study thus aimed to determine prevalence of and risk factors for hypertensive crisis in patients with hypertension caused by OSA. METHODS: The inclusion criteria were age of 18 years or over and diagnosis of co-existing OSA and hypertension. Those patients with other causes of secondary hypertension were excluded. Patients were categorized by occurrence of hypertensive crisis. Factors associated with hypertensive crisis were calculated using multivariate logistic regression analysis. RESULTS: There were 121 patients met the study criteria. Of those, 19 patients (15.70%) had history of hypertensive crisis. Those patients in hypertensive crisis group had significant higher systolic and diastolic blood pressure at regular follow-ups than those without hypertensive crisis patients (177 vs. 141 mmHg and 108 vs. 85 mmHg; p value < 0.001 for both factors). After adjusted for age, sex, and Mallampati classification, only systolic blood pressure was independently associated with hypertensive crisis with adjusted odds ratio (95% CI) of 1.046 (1.012, 1.080). CONCLUSIONS: The prevalence of hypertensive crisis in co-existing OSA and hypertension was 15.70% and high systolic blood pressure or uncontrolled blood pressure associated with hypertensive crisis in patients with OSA-associated hypertension.

Lower BMI is a predictor of obstructive sleep apnea in elderly Thai hypertensive patients.

PURPOSE: The prevalence of both hypertension and obstructive sleep apnea (OSA) are increased in patients with age greater than 60 years. We studied the clinical differences of OSA in hypertensive patients with age greater or less than 60 years. In addition, rate of OSA-induced hypertension in Thai population is limited. METHODS: We retrospectively reviewed medical records of patients treated at the hypertension/sleep clinic at Srinagarind Hospital, Khon Kaen University, between 2010 and 2011. The inclusion criteria used were hypertensive patients who had at least one symptom of OSA and had been tested for the sleep study. Rate and clinical features of OSA were studied and categorized by age of 69 years. Factors associated with likelihood of having OSA in hypertensive patients age over 60 years were identified by multiple logistic regression analysis. RESULTS: During the study period, 49 patients met the criteria. Of those, 42 patients (85.71 %) had an apnea-hypopnea index (AHI) of more than 5/h. The average AHI was 22.22 ± 13.86 times/h. The common symptoms of OSA were snoring (100 %), daytime sleepiness (28.57 %), unexplained nocturia (28.57 %), and gastroesophageal reflux disease (28.57 %). The numbers of patients with age less than 60 years and more than 60 years were 20 and 22 cases, respectively. Most patients (88.10 %) had well-controlled blood pressure level. Only BMI was significantly associated with OSA-induced hypertension in patients aged over or equal to 60 years. The adjusted odds ratio was 0.743 (0.560, 0.985). CONCLUSIONS: OSA is very common in Thai hypertensive patients aged 40-70 years who have at least one symptom of OSA. Lower BMI is a predictor of obstructive sleep apnea in elderly Thai hypertensive patients.

Correlation of causes and outcomes in stroke in the young.

BACKGROUND: We studied the association of causes and stroke outcome of stroke in the young in Thailand. METHODS: A retrospective study was performed at Srinagarind Hospital, Khon Kaen University, Thailand. All patients under 45 years of age who were diagnosed with stroke between 1996 and 2010 and who had complete workups for causes of stroke in the young were enrolled. Stroke outcome was defined as favorable or nonfavorable at approximately 1 year of follow-up. If the patient had normal functional ability or mild disability but the patient was fully employed, the outcome was classified as favorable. Clinical features of strokes and the potential stroke risk factors were compared between the favorable and nonfavorable groups. RESULTS: Eighty-five patients were enrolled. About half of patients were male (47 patients; 55.3%). The mean age (SD) was 35.9 (6.2) years. Three-fourths of male patients had a stroke after 30 years of age, while female patients developed stroke in all age ranges equally. More than half of patients (45 patients; 52.9%) had cardiac causes of stroke. Rheumatic mitral stenosis accounted for 68% (31 patients), and 45% (14 patients) had atrial fibrillation. There were 64 patients (79%) who had a favorable outcome. Cardiac causes, particularly mitral stenosis and alcohol intake, were significantly associated with a nonfavorable outcome. CONCLUSIONS: Stroke in the young generally has a favorable outcome. Factors associated with a nonfavorable outcome of stroke in the young were cardiac abnormalities and alcohol intake. A prospective study to evaluate the association of causes and outcome is needed.

Risk factors of left ventricular hypertrophy in obstructive sleep apnea.

Obstructive sleep apnea (OSA) and left ventricular hypertrophy (LVH) are both related to major cardiovascular diseases. Previous studies have indicated that, compared with non-OSA, OSA is related to LVH with an odds ratio (OR) of 1.70 (95% CI: 1.44-2.00), particularly in patients with coronary artery disease. Meta-analysis has revealed that the severity of OSA is significantly associated with left ventricular mass compared with non-OSA controls. There is, however, limited data on the risk factors of LVH in patients with OSA. The present study aimed to assess the prevalence and clinical factors that are predictive of LVH in patients with OSA. A retrospective analysis of adult patients diagnosed with OSA who had undergone echocardiography was performed. LVH defined by echocardiography indicated an enlarged LV mass index. Clinical factors predictive of LVH were assessed using multivariate logistic regression analyses. An unadjusted OR and an adjusted OR with 95% confidence intervals (CI) were determined. During the study period, 130 patients met the study criteria, with an LVH prevalence of 27.69% (36 patients). The final predictive model of LVH comprised six factors: Age, sex, unrefreshed sleep, body mass index, systolic blood pressure and apnea-hypopnea index. Only age was independently associated with LVH, with an adjusted OR of 1.048 (95% CI: 1.002-1.096). The prevalence rate of LVH in patients with OSA was 27.69%. Older age was independently related to LVH in patients with OSA.

Prevalence and factors correlated with hypertension secondary from obstructive sleep apnea.

BACKGROUND: In 2003, the JNC 7 reported obstructive sleep apnea (OSA) as a cause of secondary hypertension. The prevalence of OSA in hypertension ranges from 30-80%. There are limited data on the prevalence and risk factors of OSA in hypertensive patients. This study thus aimed to evaluate prevalence and clinical predictors of obstructive sleep apnea (OSA) in these patients. METHODS: This was a cross-sectional study and conducted at the hypertension clinic at Khon Kaen University's Srinagarind Hospital, Thailand. We enrolled patients with hypertension treated at the clinic. OSA was defined as apnea-hypopnea index of 5 events/hour or over according to cardiopulmonary monitoring. Patients whose hypertension was due to any other causes were excluded. The prevalence of OSA was calculated and risk factors for OSA were analyzed using multivariate logistic regression. RESULTS: There were 726 hypertensive patients treated at the clinic. Out of those, 253 (34.8%) were randomly studied and categorized as either non-OSA (147 patients, 58.1%) or OSA (106 patients, 41.9%). There were four independent factors associated with OSA-induced hypertension: age, sex, history of snoring, and history of headache. Headache had an adjusted odds ratio (95% confidence interval) of 3.564 (95% confidence interval of 1.510, 8.411). CONCLUSION: Age, male sex, history of snoring, and headache were independent predictors of hypertension caused by OSA.

How common is obstructive sleep apnea in young hypertensive patients?

Obstructive sleep apnea (OSA) has been reported to be a cause of hypertension in 40-80% of hypertensive patients. However, there are limited data available on the prevalence and predictors of OSA in young hypertensive patients. This study was conducted between October 2017 and October 2018. The inclusion criteria were (1) age over 18 and under 35 years (2) diagnosis with hypertension and (3) available respiratory polysomnography results. Patients with other causes of secondary hypertension were excluded. Predictors for OSA were analyzed using multivariate logistic regression analysis. There were 593 consecutive young patients who were diagnosed with hypertension during the study period. Of those, 475 (80.10%) were excluded due to their hypertension having renal causes (429; 90.32%), endocrine-related causes (40; 8.42%), or cardiovascular causes (6; 1.26%). Of the remaining patients (118 patients) who were eligible for the study, 105 (88.98%) of whom were diagnosed with OSA. The median age of the patients with OSA did not differ from those without OSA (29 vs 23 years; p value 0.065). There were two independent predictors for OSA: age and body mass index with adjusted odds ratios (95% confidence interval) of 1.280 (1.049, 1.562) and 1.258 (1.083, 1.462), respectively. In conclusion, after excluding other possible causes of hypertension, we found OSA to be highly prevalent in hypertensive patients younger than 35 years old. Increasing age and high body mass index were predictors for OSA in young hypertensive patients.

Predictive factors of systemic embolism in patients with mitral stenosis in sinus rhythm.

BACKGROUND: Systemic embolism is one of the major complications in patients with mitral stenosis (MS) who are in atrial fibrillation; however, this serious complication can also occur in patients with MS in sinus rhythm. OBJECTIVE: The purpose of the present study was to identify the predictive factors of systemic emboli in patients with MS in sinus rhythm. MATERIAL AND METHOD: Twenty patients with MS in sinus rhythm with recent cerebral embolism and 32 with MS in sinus rhythm without any history of systemic embolism were studied between January 2004 and May 2006. Clinical and echocardiographic data were assessed using stepwise logistic regression for prediction of systemic embolism. RESULTS: Age (odds ratio [OR], 1.14; 95% confidence interval [CI] 1.04-1.26) and left atrial spontaneous echo contrast (LASEC) grade 3+ and 4+ (OR, 46.42; 95% CI, 5.00-436.49) were associated with, and predictive of systemic emboli, whereas left atrial appendage contraction flow velocities, left atrial size and mitral valve area were not. CONCLUSION: The present study demonstrates that age and LASEC are the major predictive factors of systemic embolism in patients with MS in sinus rhythm. It would therefore be prudent to give anticoagulants to patients in atrial fibrillation as well as to those in sinus rhythm at risk of systemic embolism.

Predictors of in-hospital mortality in non-ST elevation acute coronary syndrome in Thai Acute Coronary Syndrome Registry (TACSR).

OBJECTIVE: To determine baseline prognostic factors of in-hospital mortality in Thai patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). MATERIAL AND METHOD: Among 5,537 NSTE-ACS patients enrolled in Thai Acute Coronary Syndrome Registry, a univariate analysis and multivariate analysis were used to estimate the relationship of baseline clinical variables and in-hospital mortality. Variables examined included demographics, history and presenting characteristics. RESULTS: The in-hospital mortality rate was 9.5%. The statistically significant, adjusted baseline prognostic factors of in-hospital death were older age > or =65 years) (odds ratio [OR] 2.2, 95% confidence interval [CI] = 1.54-3.09), shock at presentation (OR 4.6, 95%CI = 2.91-7.32), heart failure (OR 3.1, 95%CI = 2.15-4.38), positive cardiac marker (OR 1.7, 95%CI = 1.18-2.53), arrhythmia (OR 12.3, 95%CI = 8.71-17.35), major bleeding (OR 2.9, 95%CI = 1.84-4.51), and cerebrovascular accident (OR 4.9, 95% CI = 2.42-9.97). While dyslipidemia (OR 0.6, 95%CI = 0.45-0.87), having percutaneous coronary intervention (OR 0.6, 95% CI = 0.39-0.94), receiving aspirin (OR 0.6, 95%CI = 0.33-0.94), beta-blocker (OR 0.5, 95% CI = 0.40-0.73), angiotensin converting enzyme inhibitor (OR 0.6, 95% CI = 0.43-0.78) and nitrate (OR 0.5, 95%CI= 0.35-0.76) were associated with lower in-hospital mortality. CONCLUSION: The in-hospital mortality is higher in Thai NSTE-ACS patients compared to other populations. The present study supports and confirms the prognostics importance of several baseline characteristics reported in previous studies.

Effect of hormone therapy on lipid profile in menopausal women.

OBJECTIVE: To study lipid profile of menopausal women with hormone therapy. MATERIAL AND METHOD: Two hundred and sixty eight menopausal women in good health conditions, separated into natural and surgical menopause group, received service at Menopausal clinic in Srinagarind Hospital, Faculty of Medicine, Khon Kaen University since 1996-2004. They regularly took a single type of hormone therapy for about 12 months and obtained blood cholesterol levels for pre- and post-hormone therapy of about 12 months period. The data were analyzed with SPSS v. 10.0.5. RESULTS: The average age of the sample groups were 50.91 +/- 5.93 years and 52.83 +/- 5.28 respectively. Both sample groups have similar mean level of cholesterol levels during pretreatment period. Surgical menopausal group has greater HDL level than the naturally menopausal group with the average level of 64.24 +/- 15.32 mg/ dl. and 58.80 +/- 17.20 mg/dl. respectively. However after taking hormone therapy, blood cholesterol level was significantly changed in both groups. The mean level of LDL decreased (8.59% and 11.49% respectively) and mean level of HDL increased (15.43% and 6.89% respectively). CONCLUSIONS: Hormone therapy in menopausal women can improve cholesterol levels by decreasing LDL and increasing HDL with statistical significance (p < 0.05).

A prognostic model for predicting the disappearance of left atrial thrombi among candidates for percutaneous transvenous mitral commissurotomy.

OBJECTIVES: We sought to develop a prognostic model to predict the disappearance of left atrial thrombi (LAT) among candidates for percutaneous transvenous mitral commissurotomy (PTMC). BACKGROUND: Complete LAT resolution can be achieved with oral anticoagulation, allowing a number of patients to safely undergo PTMC. METHODS: We randomly allocated 108 PTMC candidates with LAT into two subsets---one to derive the model and the other to validate it. The existence of LAT and its size were measured by transesophageal echocardiography. Patients were given oral anticoagulation and followed up for 6 to 34 months. There was a 62% disappearance rate of LAT. RESULTS: We developed the following model: P = 1/(1 + exponential [-8.1 + 1.8 NYHA + 0.7 area]), where NYHA = New York Heart Association functional class (from I to IV), and area = LAT area (in cm(2)). The model was well calibrated (goodness-of-fit test, p = 0.82) and well discriminated (area under the receiver-operating characteristics [ROC] curve = 0.92). Performance in the validating sample was equally good (area under the ROC curve = 0.94; goodness-of-fit test, p = 0.16). When a cut-off point of p > 0.7 was used to designate the LAT disappearance in the validating set, the model had a sensitivity, specificity and positive and negative predictive values of 93.3%, 79.2%, 84.9% and 90.5%, respectively. CONCLUSIONS: Combined clinical (NYHA functional class) and echocardiographic (LAT area) variables are predictive of the 34-month outcome of oral anticoagulation for LAT resolution among PTMC candidates. This simple and highly predictive model might be potentially useful for clinical assessment and proper management.

Resolution of left atrial thrombus after 6 months of anticoagulation in candidates for percutaneous transvenous mitral commissurotomy.

BACKGROUND: Resolution of left atrial thrombus after long-term oral anticoagulation enhances safe percutaneous transvenous mitral commissurotomy (PTMC); however, the short-term benefit has not been defined. OBJECTIVES: To estimate the resolution rate of left atrial thrombus among PTMC candidates after 6 months of oral anticoagulation and to determine its main predictors. DESIGN: Prospective cohort. SETTING: Community-based university medical center. PATIENTS: 219 PTMC candidates with thrombus demonstrated by multiplane transesophageal echocardiographic studies. MEASUREMENTS: The primary outcome was the status of the thrombus at the first 6-month follow-up; secondary measures were bleeding or thromboembolic complications. RESULTS: Among 219 PTMC candidates with left atrial thrombus (mean age [+/-SD], 39.6 +/- 7.4 years [range, 19 to 62 years]), complete resolution of thrombus, with an overall disappearance rate of 24.2% (95% CI, 18.5% to 29.9%), was demonstrated in 53 patients who subsequently underwent successful PTMC. In another 166 patients, the thrombus size was reduced by 24% (P < 0.001). No thrombus resolution was observed in the 27 patients with a left atrial body thrombus. Eighteen patients had minor bleeding. The significant predictors of thrombus resolution were a New York Heart Association class of 2 or less, a left atrial appendage thrombus size of 1.6 cm2 or less, a left atrial spontaneous echocardiographic contrast grade of 1 or less, and an international normalized ratio (INR) of at least 2.5. Patients with all of these predictors had a 94.4% chance of complete thrombus resolution (CI, 84.4% to 98.1%). CONCLUSIONS: After 6 months of oral anticoagulation, the left atrial thrombus disappeared in about a quarter of PTMC candidates so they could safely undergo PTMC. Less clinical severity, lower grading of the left atrial spontaneous echocardiographic contrast, a smaller thrombus, and a higher INR level predict thrombus resolution.

Resolution of left atrial thrombi with anticoagulant therapy in candidates for percutaneous transvenous mitral commissurotomy.

BACKGROUND AND AIMS OF THE STUDY: Little is known of the fate of left atrial thrombus (LAT) among candidates for percutaneous transvenous mitral commissurotomy (PTMC) after oral anticoagulation (OA) therapy. The aim of this study was to estimate the resolution rate of documented LAT, and to determine its significant predictors among this population. METHODS: In this prospective cohort study all consecutive candidates for PTMC with documented LAT were followed between August 1996 and December 1999. All patients underwent both transthoracic (TTE) and transesophageal echocardiography (TEE) and received OA therapy (INR 2.0-3.0). The fate of LAT was studied serially using both TTE and TEE. RESULTS: A total of 75 patients was followed for six to 34 months (mean 12.2+/-6.2 months; total 914 patient-months). The LAT was completely resolved in 48 patients (5.25 per 100 pt-months; 95% CI 3.96-6.97). The overall resolution rate was 63.0 per 100 patients per year (95% CI 47.5-83.6). Patients with resolved LAT underwent uneventful PTMC. The median duration of LAT resolution was 16 months (95% CI 12.7-19.3). Significant predictors of LAT resolution were the size of the LAT (RR = 0.8 for each 1 cm2 increase in LAT; 95% CI 0.6-0.9; p = 0.012) and severity of the left atrial spontaneous echo contrast (LASEC) detected by TEE (RR = 0.6 for each 1 level increase of the LASEC severity score; 95% CI 0.4-0.9; p = 0.032). CONCLUSION: The smaller the LAT and the less severe the LASEC, the greater the likelihood of LAT resolution after OA therapy and the enhanced possibility of safely performing PTMC.

Prevalence of dyslipidemia and goal attainment after initiating lipid-modifying therapy: a Thai multicenter study.

Previous studies focused on attaining low-density lipoprotein cholesterol (LDL-C) goals after lipid-modifying therapy (LMT), but data on achieving normal levels of triglyceride and high-density lipoprotein cholesterol (HDL-C) are limited. We reviewed medical records of patients initiated on LMT. High risk was defined as patients with coronary heart disease, diabetes, or 10-year Framingham risk >20%. Among 806 patients enrolled, 429 were at high risk. Prior to initiation of LMT, 66%, 35%, and 44% overall and 69%, 35%, and 45% in the high-risk group had elevated LDL-C, elevated triglyceride, and low HDL-C, respectively. After 12 months of LMT, 21%, 32%, and 39% overall and 26%, 25%, and 43% in the high-risk group still had elevated LDL-C, elevated triglyceride, and low HDL-C, respectively. Approximately 1 of 5 patients continued to experience elevated LDL-C coupled with elevated triglyceride and/or low HDL-C. In conclusion, a substantial proportion of patients initiated on LMT continued to have lipid abnormalities.

Lipid-lowering therapy using statins in patients with cardiovascular risk in clinical practice in Thailand.

BACKGROUND: Since the release in Thailand in 2001 of the Third Guidelines by the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults or the Adult Treatment Panel (ATP III), there have been no nationwide studies on the proportion of dyslipidaemic patients who have achieved the low-density lipoprotein cholesterol (LDL-C) goals. The authors therefore aimed to estimate the percentage achievement of LDL-C goals based on the modified NCEP ATP III guidelines in intermediate- to high-risk patients. METHODS: The authors conducted a hospital-based, cross-sectional, epidemiological survey. Patients (1240) were selected consecutively from 50 hospitals across Thailand. Patients were included if they had been treated with statins for at least 3 months. RESULTS: Two-thirds were female, and the mean age was 61.7±9.5 years. The median duration of statin treatment was 21 months. Half (633/ 1240) of the patients achieved the LDL-C goal levels as defined by the NCEP guidelines (51.1%, 95% CI 48.3% to 53.8%). The very-high-risk group had the lowest percentage achievement (11.6%; 95% CI 1.6% to 21.6%), compared with 54.2% (95% CI 50.9% to 57.4%) for the high-risk group and 47.0% (95% CI 41.1% to 52.8%) for the moderate-risk group. More males achieved the LDL-C goals than females (55.6% vs 48.9%; p=0.029). CONCLUSIONS: Overall, 51.1% of the patients with cardiovascular risk, on statins treatment, achieved the NCEP ATP III LDL-C goal levels.