Measurement of resistance-area product by transcranial Doppler: An alternative tool for cognitive screening in hypertensive on drug treatment?

Introduction: Arterial hypertrophy and remodeling are adaptive responses present in systemic arterial hypertension that can result in silent ischemia and neurodegeneration, compromising brain connections and cognitive performance (CP). However, CP is affected differently over time, so traditional screening methods may become less sensitive in assessing certain cognitive domains. The study aimed to evaluate whether cerebrovascular hemodynamic parameters can serve as a tool for cognitive screening in hypertensive without clinically manifest cognitive decline. Methods: Participants were allocated into groups: non-hypertensive (n = 30) [group 1], hypertensive with systolic blood pressure (SBP) < 140 and diastolic blood pressure (DBP) < 90 mmHg (n = 54) [group 2] and hypertensive with SBP ≥ 140 or DBP ≥ 90 (n = 31) [group 3]. Measurements of blood pressure and middle cerebral artery blood flow velocity were obtained from digital plethysmography and transcranial Doppler. For the cognitive assessment, the Mini Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) and a broad neuropsychological battery were applied. Results: Patients in groups 2 and 3 show no significant differences in most of the clinical-epidemiological variables or pulsatility index (p = 0.361), however compared to group 1 and 2, patients in group 3 had greater resistance-area product [RAP] (1.7 [±0.7] vs. 1.2 [±0.2], p < 0.001). There was a negative correlation between RAP, episodic memory (r = -0.277, p = 0.004) and cognitive processing speed (r = -0.319, p = 0.001). Conclusion: RAP reflects the real cerebrovascular resistance, regardless of the direct action of antihypertensive on the microcirculation, and seems to be a potential alternative tool for cognitive screening in hypertensive.

Evaluation of cerebral autoregulation performance in patients with arterial hypertension on drug treatment.

Cerebral autoregulation (AR) keeps cerebral blood flow constant despite fluctuations in systemic arterial pressure. The final common AR pathway is made up of vasomotor adjustments of cerebrovascular resistance mediated by arterioles. Structural and functional changes in the arteriolar wall arise with age and systemic arterial hypertension. This study evaluated whether AR is impaired in hypertensive patients and whether this impairment differs with disease control. Three groups of patients were prospectively compared: hypertensive patients under treatment with systolic blood pressure (SBP) <140 and diastolic blood pressure (DBP) <90 mm Hg (n = 54), hypertensive patients under treatment with SBP > 140 or DBP > 90 mm Hg (n = 31), and normotensive volunteers (n = 30). Simultaneous measurements of cerebral blood flow velocity (CBFV) and BP were obtained by digital plethysmography and transcranial Doppler, and the AR index (ARI) was defined according to the step response to spontaneous fluctuations in BP. Compared to the uncontrolled hypertension, the normotensive individuals were younger (age 43.42 ± 11.14, P < .05) and had a lower resistance-area product (1.17 ± 0.24, P < .05), although age and greater arteriolar stiffness did not affect the CBFV mean of hypertensive patients, whether controlled or uncontrolled (62.85 × 58.49 × 58.30 cm/s, P = .29), most likely because their ARIs were not compromised (5.54 × 5.91 × 5.88, P = .6). Hypertensive patients under treatment, regardless of their BP control, have intact AR capacity.

Systemic arterial hypertension and cognition in adults: effects on executive functioning.

BACKGROUND: Central nervous system changes associated to systemic arterial hypertension (SAH) are progressive and may cause negative effects on cognitive performance. The objective of this study was to investigate the relation between SAH and the components of executive functions (EF), inhibitory control (IC), updating and shifting, comparing a control group (without SAH) to patients with SAH, in two levels of severity. METHODS: The protocol included the following tests to evaluate EF components: T.O.V.A. Test (IC), Backward Digit Span from Wechsler Adults Intelligence Scale (WAIS-III), Phonemic and Semantic Verbal Fluency (updating), and Trail Making Test Part B (shifting). RESULTS: A total of 204 participants was included: 56 from the Control Group (CG), 87 SAH stage 1, and 61 SAH stage 2. The groups were not different for age (52.37±12.29) and education (10.98±4.06). As to controlled blood pressure (BP), duration of hypertension treatment and number of drugs, the SAH 2 group had a worse BP control, longer duration of hypertension treatment and use of more drugs when compared to the SAH 1. The findings revealed that patients with more severe hypertension presented worse performance in updating (Backward Digit Span, phonemic and semantics VF) and shifting (Trail Making Test Part B). CONCLUSION: The results suggest that patients with SAH have a significant impairment in EF, more specifically in updating and shifting. Besides that, such damage may be directly proportional to the severity of SAH. It is suggested that future studies include neuroimaging exams to exclude possible cerebrovascular diseases.

Systemic arterial hypertension and cognition in adults: effects on executive functioning / Hipertensão arterial sistêmica e cognição em adultos: efeitos no funcionamento executivo

ABSTRACT Background: Central nervous system changes associated to systemic arterial hypertension (SAH) are progressive and may cause negative effects on cognitive performance. The objective of this study was to investigate the relation between SAH and the components of executive functions (EF), inhibitory control (IC), updating and shifting, comparing a control group (without SAH) to patients with SAH, in two levels of severity. Methods: The protocol included the following tests to evaluate EF components: T.O.V.A. Test (IC), Backward Digit Span from Wechsler Adults Intelligence Scale (WAIS-III), Phonemic and Semantic Verbal Fluency (updating), and Trail Making Test Part B (shifting). Results: A total of 204 participants was included: 56 from the Control Group (CG), 87 SAH stage 1, and 61 SAH stage 2. The groups were not different for age (52.37±12.29) and education (10.98±4.06). As to controlled blood pressure (BP), duration of hypertension treatment and number of drugs, the SAH 2 group had a worse BP control, longer duration of hypertension treatment and use of more drugs when compared to the SAH 1. The findings revealed that patients with more severe hypertension presented worse performance in updating (Backward Digit Span, phonemic and semantics VF) and shifting (Trail Making Test Part B). Conclusion: The results suggest that patients with SAH have a significant impairment in EF, more specifically in updating and shifting. Besides that, such damage may be directly proportional to the severity of SAH. It is suggested that future studies include neuroimaging exams to exclude possible cerebrovascular diseases.

RESUMO Introdução: As alterações do sistema nervoso central associadas à hipertensão arterial sistêmica (HAS) são progressivas e podem ocasionar efeitos negativos no desempenho cognitivo. O objetivo deste estudo foi investigar a relação entre a HAS e os componentes das funções executivas (FE), controle inibitório (CI), atualização e alternância, comparando um grupo controle (sem HAS) a pacientes com HAS, em dois níveis de gravidade. Métodos: O protocolo incluiu os seguintes testes para avaliar os componentes das FE: T.O.V.A. Test (CI), Dígitos Ordem Indireta da Escala de Inteligência Wechsler para Adultos (Wechsler Adults Intelligence Scale - WAIS-III), Fluência Verbal fonêmica e semântica (atualização) e Teste de Trilhas parte B (alternância). Resultados: Foram incluídos 204 participantes, sendo 56 do Grupo Controle (GC), 87 HAS estágio 1 (HAS 1) e 61 de HAS estágio 2 (HAS 2). Os grupos não foram diferentes em relação à idade (52,37±12,29) e escolaridade (10,98±4,06). Em relação à pressão arterial (PA) controlada, tempo de tratamento da HAS e número de medicações, o grupo HAS 2 apresentou pior controle de PA, mais tempo de tratamento da HAS e uso de maior número de medicações quando comparado ao grupo HAS 1. Os achados revelaram que os pacientes com HAS em estágio mais grave apresentaram pior desempenho nos testes de alternância (Teste de Trilhas parte B) e atualização (Dígitos Ordem Indireta, FV fonêmica e semântica). Conclusão: Esses resultados sugerem que pacientes com a HAS possuem prejuízo significativo em FE, especificamente em alternância e atualização, e que esse prejuízo pode ser diretamente proporcional à gravidade da HAS. Sugere-se que, em estudos futuros, incluam-se exames de neuroimagem com o objetivo de excluir possíveis doenças cerebrovasculares.

Gender differences of aortic wave reflection and influence of menopause on central blood pressure in patients with arterial hypertension.

BACKGROUND: Evidences suggest that central hemodynamics indexes are independent predictors of future cardiovascular events and all-cause mortality. Multiple factors have been pointed to have potential influence on central aortic function: height, heart rate, left ventricular ejection duration and blood pressure level. Data related to the influence of gender and postmenopausal status on aortic waveform reflection is scarce. We aim to evaluate the impact of gender and menopause on central blood pressure of hypertensive patients. METHODS: In a cross sectional study 122 hypertensive patients (52 men and 70 women) were studied. Hypertension was defined as blood pressure (BP) levels ≥140/90 mmHg or use of antihypertensive drugs. Central arterial pressure, augmentation index (AIx) and augmentation index normalized to 75 bpm (AIx75) were obtained using applanation tonometry. Menopause and postmenopause history were accessed by a direct series of questions. Postmenopause was defined as at least one year since last menstruation. Patients were paired by age, gender and menopausal status, and the data were compared considering gender and menopausal status. RESULTS: Height and weight were significantly lower in women than in men at the same age. Conversely, AIx (32.7 ± 9.8% vs. 20.1 ± 11.7%, p < 0.01), AIx75 (29.6 ± 6.7% vs. 18.3 ± 9.4%, p < 0.01) and central systolic blood pressure (136 ± 30 vs. 125 ± 23 mmHg, p = 0.03) were higher in women than men. The menopausal women (mean age of menopause = 48 years) had the worst indexes of aortic wave reflection, compared to men at the same age and younger women. CONCLUSION: Hypertensive women had both higher reflected aortic pressure waveform and central blood pressure indexes than hypertensive men, and these findings were worsened by the menopausal status.

Impact of hypertension severity on arterial stiffness, cerebral vasoreactivity, and cognitive performance / Impacto da gravidade da hipertensão na rigidez arterial, vasorreatividade cerebral e desempenho cognitivo

ABSTRACT. Aging, hypertension (HTN), and other cardiovascular risk factors contribute to structural and functional changes of the arterial wall. Objective: To evaluate whether arterial stiffness (AS) is related to cerebral blood flow changes and its association with cognitive function in patients with hypertension. Methods: 211 patients (69 normotensive and 142 hypertensive) were included. Patients with hypertension were divided into 2 stages: HTN stage-1 and HTN stage-2. The mini-mental state examination (MMSE), Montreal Cognitive Assessment (MoCA) and a battery of neuropsychological (NPE) tests were used to determine cognitive function. Pulse wave velocity was measured using the Complior®. Carotid properties were assessed by radiofrequency ultrasound. Central arterial pressure and augmentation index were obtained using applanation tonometry. Middle cerebral artery flow velocity was measured by transcranial Doppler ultrasonography. Results: Both arterial stiffness parameters and cerebral vasoreactivity worsened in line with HTN severity. There was a negative correlation between breath holding index (BHI) and arterial stiffness parameters. Cognitive performance worsened in line with HTN severity, with statistical difference occurring mainly between the HTN-2 and normotension groups on both the MMSE and MoCA. The same tendency was observed on the NPE tests. Conclusion: Hypertension severity was associated with higher AS, worse BHI, and lower cognitive performance.

RESUMO. A idade, hipertensão arterial (HA), e outros fatores de risco cardiovascular contribuem para as alterações estruturais e funcionais da parede arterial. Objetivo: Avaliar o quanto a rigidez arterial está relacionada com as alterações do fluxo sanguíneo cerebral e sua associação com a função cognitiva em pacientes com hipertensão. Métodos: Foram incluídos 211 pacientes (69 normotensos e 142 hipertensos). Os pacientes com hipertensão foram divididos em dois estágios: HA-1 e HA-2. O mini exame do estado mental (MEEM), Montreal Cognitive Assessment (MoCA) e uma bateria de testes neuropsicológicos foram usados para avaliar a função cognitiva. A velocidade da onda de pulso foi medida usando o Complior®. As propriedades da artéria carótida foram avaliadas usando o ultrassom de radiofrequência. A pressão arterial central e o índice de incremento foram obtidos usando a tonometria de aplanação. A velocidade de fluxo sanguíneo da arterial cerebral média foi medida pelo ultrassom com Doppler Transcraniano. Resultados: Tanto os parâmetros da rigidez arterial quanto a vasorreatividade cerebral foram piores com a gravidade da hipertensão. Houve uma correlação negativa entre o índice de apnéia e os parâmetros da rigidez arterial. O desempenho cognitivo foi pior com a gravidade de hipertensão arterial com diferença estatística ocorrendo principalmente entre os grupos HA-2 e normotensão tanto no MEEM quanto no MoCA. A mesma tendência foi observada em relação aos testes neuropsicológicos. Conclusão: A gravidade de hipertensão arterial foi associada com maior rigidez arterial, pior índice de apneia, e menor desempenho cognitivo.

Intermittent claudication and severe renal artery stenosis are independently associated in hypertensive patients referred for renal arteriography.

OBJECTIVE:: The purpose of this study was to evaluate the association between the presence of clinical symptoms of peripheral artery disease and severe renal artery stenosis in patients referred for renal angiography. METHOD:: We included 82 patients with clinical suspicion of renovascular hypertension and performed an imaging investigation (renal Doppler ultrasound and/or renal scintigraphy) for possible renal artery stenosis. All patients underwent renal arteriography and were examined for peripheral artery disease based on the presence of intermittent claudication and ankle-brachial index test results. Severe renal artery stenosis was defined as a lesion causing 70% obstruction. RESULTS:: Severe renal artery stenosis was present in 32 of 82 (39%) patients. Patients with severe renal artery stenosis were older (63±12 vs 56±12 years, p=0.006), had more intermittent claudication (55 vs 45%, p=0.027), and had a greater prevalence of an ankle-brachial index <0.9 (44% vs 20%, p=0.021) than patients without severe renal artery stenosis. Multivariate logistic regression analysis showed that the presence of intermittent claudication was independently associated with renal artery stenosis ≥70% (OR: 3.33; 95% CI 1.03-10.82, p=0.04), unlike the ankle-brachial index, which showed no association (OR: 1.44; 95% CI 0.37-5.66, p=0.60). CONCLUSION:: Intermittent claudication is independently associated with severe renal artery stenosis (≥70%) in patients clinically suspected of having renovascular hypertension.

Intermittent claudication and severe renal artery stenosis are independently associated in hypertensive patients referred for renal arteriography

OBJECTIVE: The purpose of this study was to evaluate the association between the presence of clinical symptoms of peripheral artery disease and severe renal artery stenosis in patients referred for renal angiography. METHOD: We included 82 patients with clinical suspicion of renovascular hypertension and performed an imaging investigation (renal Doppler ultrasound and/or renal scintigraphy) for possible renal artery stenosis. All patients underwent renal arteriography and were examined for peripheral artery disease based on the presence of intermittent claudication and ankle-brachial index test results. Severe renal artery stenosis was defined as a lesion causing 70% obstruction. RESULTS: Severe renal artery stenosis was present in 32 of 82 (39%) patients. Patients with severe renal artery stenosis were older (63±12 vs 56±12 years, p=0.006), had more intermittent claudication (55 vs 45%, p=0.027), and had a greater prevalence of an ankle-brachial index <0.9 (44% vs 20%, p=0.021) than patients without severe renal artery stenosis. Multivariate logistic regression analysis showed that the presence of intermittent claudication was independently associated with renal artery stenosis ≥70% (OR: 3.33; 95% CI 1.03-10.82, p=0.04), unlike the ankle-brachial index, which showed no association (OR: 1.44; 95% CI 0.37-5.66, p=0.60). CONCLUSION: Intermittent claudication is independently associated with severe renal artery stenosis (≥70%) in patients clinically suspected of having renovascular hypertension.

Impact of hypertension severity on arterial stiffness, cerebral vasoreactivity, and cognitive performance.

Aging, hypertension (HTN), and other cardiovascular risk factors contribute to structural and functional changes of the arterial wall. OBJECTIVE: To evaluate whether arterial stiffness (AS) is related to cerebral blood flow changes and its association with cognitive function in patients with hypertension. METHODS: 211 patients (69 normotensive and 142 hypertensive) were included. Patients with hypertension were divided into 2 stages: HTN stage-1 and HTN stage-2. The mini-mental state examination (MMSE), Montreal Cognitive Assessment (MoCA) and a battery of neuropsychological (NPE) tests were used to determine cognitive function. Pulse wave velocity was measured using the Complior®. Carotid properties were assessed by radiofrequency ultrasound. Central arterial pressure and augmentation index were obtained using applanation tonometry. Middle cerebral artery flow velocity was measured by transcranial Doppler ultrasonography. RESULTS: Both arterial stiffness parameters and cerebral vasoreactivity worsened in line with HTN severity. There was a negative correlation between breath holding index (BHI) and arterial stiffness parameters. Cognitive performance worsened in line with HTN severity, with statistical difference occurring mainly between the HTN-2 and normotension groups on both the MMSE and MoCA. The same tendency was observed on the NPE tests. CONCLUSION: Hypertension severity was associated with higher AS, worse BHI, and lower cognitive performance.

A idade, hipertensão arterial (HA), e outros fatores de risco cardiovascular contribuem para as alterações estruturais e funcionais da parede arterial. OBJETIVO: Avaliar o quanto a rigidez arterial está relacionada com as alterações do fluxo sanguíneo cerebral e sua associação com a função cognitiva em pacientes com hipertensão. MÉTODOS: Foram incluídos 211 pacientes (69 normotensos e 142 hipertensos). Os pacientes com hipertensão foram divididos em dois estágios: HA-1 e HA-2. O mini exame do estado mental (MEEM), Montreal Cognitive Assessment (MoCA) e uma bateria de testes neuropsicológicos foram usados para avaliar a função cognitiva. A velocidade da onda de pulso foi medida usando o Complior®. As propriedades da artéria carótida foram avaliadas usando o ultrassom de radiofrequência. A pressão arterial central e o índice de incremento foram obtidos usando a tonometria de aplanação. A velocidade de fluxo sanguíneo da arterial cerebral média foi medida pelo ultrassom com Doppler Transcraniano. RESULTADOS: Tanto os parâmetros da rigidez arterial quanto a vasorreatividade cerebral foram piores com a gravidade da hipertensão. Houve uma correlação negativa entre o índice de apnéia e os parâmetros da rigidez arterial. O desempenho cognitivo foi pior com a gravidade de hipertensão arterial com diferença estatística ocorrendo principalmente entre os grupos HA-2 e normotensão tanto no MEEM quanto no MoCA. A mesma tendência foi observada em relação aos testes neuropsicológicos. CONCLUSÃO: A gravidade de hipertensão arterial foi associada com maior rigidez arterial, pior índice de apneia, e menor desempenho cognitivo.

Prognostic Value of Serum Uric Acid in Patients on the Waiting List before and after Renal Transplantation.

Background. High serum uric acid (UA) is associated with increased cardiovascular (CV) risk in the general population. The impact of UA on CV events and mortality in CKD is unclear. Objective. To assess the relationship between UA and prognosis in hemodialysis (HD) patients before and after renal transplantation (TX). Methods. 1020 HD patients assessed for CV risk and followed from the time of inception until CV event, death, or TX (HD) or date of TX, CV event, death, or return to dialysis (TX). Results. 821 patients remained on HD while 199 underwent TX. High UA (≥428 mmol/L) was not associated with either composite CV events or mortality in HD patients. In TX patients high UA predicted an increased risk of events (P = 0.03, HR 1.6, and 95% CI 1.03-2.54) but not with death. In the Cox proportional model UA was no longer significantly associated with CV events. Instead, a reduced GFR (<50 mL/min) emerged as the independent risk factor for events (P = 0.02, HR 1.79, and % CI 1.07-3.21). Conclusion. In recipients of TX an increased posttransplant UA is related to higher probability of major CV events but this association probably caused concurrent reduction in GFR.

Avaliação dos benefícios funcionais de um programa de reabilitação cardíaca / Evaluation of the functional benefits of a cardiac rehabilitation program

Fundamentos: Um grande número de estudos tem confirmado que o treinamento físico é um dos métodos mais eficazes para melhorar a capacidade funcional e o bem-estar dos pacientes cardiopatas. Objetivo: Avaliar os benefícios clínicos e funcionais do Programa de Reabilitação Cardíaca em pacientes encaminhados ao Centro de Cardiologia do Exercício do Instituto Estadual de Cardiologia Aloysio de Castro, Rio de Janeiro. Métodos: Foi realizado um estudo retrospectivo tipo coorte, comparativo antes e depois da participação no Programa de Reabilitação Cardíaca numa amostra de 88 indivíduos (60 homens e 28 mulheres) com idade entre37 anos e 81 anos. A maioria dos pacientes era portadora de doença coronariana estável. As principais variáveis analisadas dos testes ergométricos foram a duração doexercício, consumo de oxigênio do pico de exercício (VO2pico), o equivalente metabólico (MET), o déficit aeróbico funcional (FAI), o duplo-produto no pico do exercício(DP pico), a redução da frequência cardíaca no primeiro minuto da recuperação, a presença de isquemia, a classe funcional segundo a NYHA e a aptidão cardiorrespiratória (APCR) segundo a American Heart Association. Resultados: Houve melhora significativa da maioria das variáveis analisadas tais como da capacidade funcional,da duração do exercício, do VO2 pico, da quantidade deMET obtidos, do FAI, e da APCR (p<0,0001). Não foram observadas diferenças significativas em relação ao duplo produto(p=0,1359). Conclusão: O Programa de Reabilitação Cardíaca utilizado neste estudo proporcionou significativa melhora dos parâmetros fisiológicos, hemodinâmicos, funcionais e autonômicos dos pacientes e, consequentemente, no desempenho cardiovascular e metabólico no exercício.

Background: A great number of studies have confirmed that physical training is one of the most effective methods of improving functional capacity and well-being in patients with heart disease.Objective: To evaluate the clinical and functional benefits of the Cardiac Rehabilitation Program in patients referred to the Cardiac Exercise Center at the Aloysio de Castro State Institute of Cardiology in Rio de Janeiro, Brazil.Methods: A retrospective comparative cohort study was conducted of a sample of 88 individuals (60 men and 28 women) between 37 and 81 years old. Most of the patients had stable coronary artery disease. The main parameters analyzed for the treadmill tests wereexercise duration, peak oxygen consumption (peak VO2), metabolic equivalent (MET), functional aerobicimpairment (FAI), peak exercise double product (peak DP), reduction in heart rate for the first minute of recovery, presence of ischemia, NYHA functional class and American Heart Association cardiorespiratory fitness. Results: There was significant improvement in mostof the parameters analyzed, such as functional capacity, exercise duration, peak VO2, MET achieved, FAI and cardiorespiratory fitness (p<0.0001). There was no significant difference for the double product (p=0.1359). Conclusion: The Cardiac Rehabilitation Program used in this study provided significant improvements in the physiological, hemodynamic, functional and autonomic parameters of the patients and consequently their cardiovascular and metabolic exerciseperformance.