Urocortin 2 in patients with hypertension treated with angiotensin converting enzyme inhibitors or angiotensin receptor blockers.

Urocortin 2 (Ucn2) - corticotropin-releasing hormone receptor 2 signalling has favourable effects in the cardiovascular system, including vasodilation, lowering of blood pressure and systemic peripheral resistance, increase in cardiac output and cardiac contractility, as well as cardioprotection against ischemia-reperfusion injury. Vasodilation and lowering of blood pressure seem to be very interesting and important effects, but their mechanism and interaction with the antihypertensive drugs have not been evaluated. The aim of the present study was to assess the relationship between Ucn2 concentration and antihypertensive therapy in patients with primary hypertension. We examined a group of 65 patients with primary hypertension receiving at least 3 antihypertensive drugs. In all of them plasma level of Ucn2, anthropometric measurements, biochemical tests, ambulatory blood pressure monitoring (ABPM), and echocardiography were performed. There were no differences in Ucn2 level related to beta-blockers, calcium channel blockers or diuretics, but we observed that in patients treated with angiotensin converting enzyme inhibitors (ACEI) (n = 52) serum Ucn2 levels were significantly higher than in patients treated with angiotensin-receptor blockers (ARBs) (n = 13) (10.93 versus 5.56 ng/mL; P < 0.05). Moreover, we did not observe any differences in terms of blood pressure on ABPM, biochemical measurements, left ventricular mass index, or presence of diabetes. In addition, in a small subgroup receiving alpha-blockers we also found a lower level of Ucn2, with coexisting higher systolic blood pressure at night, higher left ventricle mass index (LVMI) and more frequent occurrences of diabetes compared to non-alpha-blockers. Our findings suggest that the hypotensive action of renin-angiotensin-aldosterone system blockade may be related to the urocortin system. Ucn2 may be an important element in the mosaic of blood pressure-lowering factors in patients treated for essential hypertension.

Arterial structure and function and its short- and long-term changes after bariatric surgery.

Subclinical arterial damage connected with endothelial dysfunction is a common denominator of cardiovascular complications in a variety of metabolic diseases, including obesity. The aims of the study was to assess functional vascular changes measured by flow-mediated dilatation (FMD) and nitroglycerin-mediated dilation (NMD) of brachial artery, and to measure vascular structural alterations estimated by carotid intima-media complex thickness (IMT) in short- (10 days) and medium-term (6 months) time after bariatric surgery in patients with extreme obesity. Anthropometric, blood pressure (BP), FMD, NMD, IMT measurements, and laboratory assessment were performed on patients who met the eligibility criteria for bariatric surgery (age 18 - 60 years old, BMI ≥ 40.0 kg/m2 or with BMI 35.0 - 39.9 kg/m2 and co-morbidities), at baseline and during follow-up. The study population consisted of 71 patients: mean SD aged 45.6 (± 10.9) years; BMI = 47.7 (± 6.1) kg/m2; 45% of them were men). A significant reduction of systolic BP, glucose, HDL cholesterol, leptin, insulin and HOMA-IR were observed 10 days post intervention. A significant increase of FMD values was observed in the entire group 6 months after surgery (median (IQR) 6.2 (2.9 - 10.3) versus 8.5 (6.1 - 16.6), P < 0.05). Changes of NMD were insignificant. Carotid IMT diminished significantly after 6 months (median (IQR) 0.6 (0.5 - 0.7) versus 0.6 (0.5 - 0.6) mm, P < 0.05). A subgroup analysis revealed that FMD parameters had improved significantly after 6 months, mainly in men, hypertensives, and in the Roux-en Y bypass (RYGB) subgroup. In conclusion, endothelial function and subclinical atherosclerosis improved after bariatric surgery in patients with extreme obesity. A lack of changes of the dilatation independent of endothelial function may indicate the persistence of residual changes in the vascular bed.

Infection control: point prevalence study versus incidence study in Polish long-term care facilities in 2009-2010 in the Malopolska Region.

OBJECTIVE: The objective of this study was to evaluate the epidemiology of infection in Polish long-term care facilities (LTCFs) and to analyse the capabilities and legitimacy of implementing continuous targeted surveillance. METHODS: The study investigated the relationship between the presence of infection and health status, tested using a point prevalence study (PPS) and incidence study. A 1-day PPS was carried out in October 2009, with prospective continuous surveillance between December 2009 and November 2010. Infections were defined according to McGeer's criteria. RESULTS: The surveillance encompassed 193 people. The prevalence was 14.0 % in residential homes (RHs) and 18.7 % in the nursing home (NH). Various types of infections (in the PPS) were observed significantly more frequently in patients with asthma, wounds, atherosclerosis of lower extremities, tracheotomy tubes and conditions in patients hospitalised in intensive care units (ICUs) up to 1 year before the PPS day. The incidence rate was 2.7/1,000 patient days (pds). CONCLUSIONS: The factors determined to be important for the risk of infection (in the continuous study) include the general status of patients, expressed using Barthel, abbreviated mental and Katz scales, as well as limited physical activity, stool incontinence and urinary catheterisation. In the PPS study, only a slight relationship was shown between the general status of residents and the risk of infection. None of the general status scales used clinically were shown to be helpful in estimating that risk, similarly to the five-point physical activity scale. Prospective continuous surveillance shows a possibility of limiting the range of infection control in the LTCFs within targeted surveillance in a population of patients that requires intensive nursing procedures. As a marker, one could point to the low score in the Barthel or Katz scales or low physical activity/bedridden persons.

Neurogenic and myogenic resting skin blood flowmotion in subjects with masked hypertension.

The aim of our study was to investigate, whether masked hypertension (MH) and sustained hypertension (HT) are associated with alteration of resting skin blood flow and flowmotion. Subjects recruited to the study were assigned to three groups according to the results of blood pressure (BP) measurements. Resting blood flow (RF) and an index of cutaneous vascular conductance (CVC), were measured by Laser Doppler Flowmetry (LDF). Total power of the studied interval and five subintervals related to: endothelium, sympathetic, myogenic, respiration and heart activity, were analyzed. Serum glucose, sodium level, lipid profile, as well as insulin, endothelin and norepinephrine levels were measured. The study population consisted of 82 persons: 29 NT, 17 MH and 36 HT. There were no differences between the study groups with respect to age and gender, but they significantly differed with respect to body mass index (p=0.04) and waist circumference (p=0.02), triglyceride levels (p=0.04; highest in HT group), norepinephrine levels (p=0.01; highest in MH group). RF as well as CVC RF were similar in NT, MH and HT groups. Power spectrum of sympathetic origin was significantly different in the study groups (p=0.03), with highest values in MH group. Moreover, the subjects with MH revealed increased power spectrum of myogenic activity, both absolute (p=0.05) and relative (p=0.08). Daytime systolic BP was the most consistent predictor of sympathetic and myogenic origin of elevated skin blood flowmotion in multiple regression models. Our findings suggest that subjects with MH revealed altered microcirculation with elevated resting flowmotion of sympathetic and myogenic origin.

Normal blood pressure values as perceived by normotensive and hypertensive subjects.

In spite of considerable progress, the control of hypertension in most countries is still insufficient. One of the reasons may be the poor awareness of the blood pressure (BP) cutoff values that define hypertension. The aim of this report is to verify the hypothesis that patients with hypertension accept higher BP levels as normal. The study was performed during a street-based BP screening project carried out across Poland, in summer 1997. In 444 persons who voluntarily participated in Cracow's part of the project, BP was taken on the left arm, in the sitting position, after a minimum of 5 min of rest, using a semiautomated device (Digital Blood Pressure UA-702). A questionnaire investigated participants' age, weight, height, level of education, history of hypertension and perception of normal values of BP. We compared measured BP values with those perceived as normal, and with the values recommended by WHO/ISH guidelines (<140/90 mmHg). To analyse the data we used Student's t-test and linear regression with adjustment for age and body mass index (BMI). Hypertensive subjects, compared with normotensives, were less aware of normal BP values (47.4 vs 83.9%, P<0.001, for systotic blood pressure, and 77.4 vs 88.4%, P<0.01, for diastotic blood pressure). Measured BP was positively related to BP values stated as normal. A similar relation was observed for age and BMI. In conclusion, poor awareness of normal BP values in hypertensives can be an important factor hindering better BP control. Education strategies might prove to be highly effective in helping to tackle the epidemics of hypertension.

[Knowledge about hypertension and blood pressure level]. / Wiedza o nadcisnieniu tetniczym a wysokosc cisnienia tetniczego krwi.

BACKGROUND: The improvement of efficacy of the hypertension prevention and patient education largely depend on determination of the hypertension risk factors and increase in knowledge about hypertension. The aim of this study was to assess correlation between the environmental factors and knowledge about hypertension and occasionally measured blood pressure values. MATERIALS AND METHODS: The studied group consisted of 485 subjects, who voluntarily participated in the street-based hypertension screening program in Cracow (summer 1997). All subjects were asked to fill out a questionnaire concerning their health behaviours (i.e. stress, smoking and drinking habits) and a test to evaluate their knowledge about hypertension and its risk factors. The blood pressure measurement were taken using semiautomatic device (Digital Blood Pressure UA-702), in the sitting position, after a rest minimum five minutes. The study group consisted of persons with negative history of hypertension (n = 440), and untreated hypertensive patients (n = 45). In order to assess the influence of different factors on blood pressure level, the subjects were divided into two groups according to the presence or absence of a particular risk factor. In the statistical analysis Student's t-test, chi 2 and linear regression analysis with adjustment for possible confuses were used. All values were presented as mean +/- SD. RESULTS: The mean age was 37.1 +/- 17.8 years. Participants were well educated (75.9% had finished college or high school), and there were more women than men in the study group (57.5% vs 42.5%). 24.1% of participants had blood pressure values exceeding 140/90 mmHg. Multiple linear regression demonstrated that age, body mass index and knowledge about hypertension significantly influenced the level of systolic blood pressure; while only body mass index was among the factors determining diastolic blood pressure. CONCLUSIONS: This study confirms the influence of age, male gender, body mass index, alcohol consumption, stress and the snoring on the blood pressure level. The association between the knowledge about hypertension risk factors or hypertension and occasionally measured blood pressure values has been demonstrated.

QT dispersion and hypertensive heart disease in the elderly.

AIM: To determine the predictors and risk of increased QT dispersion in the elderly hypertensive patients. METHODS: A 12-lead electrocardiogram (ECG), M-mode echocardiography and ambulatory blood pressure as well as Holter monitoring were performed for 67 patients over 60 years of age with essential hypertension (I and II(o) WHO). The presence of ischaemic changes on ECG was evaluated based on the Minnesota Code. QT intervals were corrected with Bazett's formulae and QT dispersion was determined as the difference between maximal and minimal QTc intervals. Interventricular septal thickness (IVSTd), left ventricular internal diameter (LVDd) and posterior wall thickness (PWTd) were measured and left ventricular mass index (LVMI) was calculated. Subjects were divided according to the median of QTc dispersion (0.10 s). The differences between groups were assessed using chi-squared and Student's t-test. RESULTS: Subjects with increased QTc dispersion did not differ from those with low QTc dispersion when age, gender and body mass index were analysed. Similarly, the average systolic blood pressure, diastolic blood pressure and blood pressure variability were comparable in both groups. The mean QTc interval was similar in both groups. In patients with increased QT dispersion, left ventricular hypertrophy (LVH) and ischaemic changes on ECG were more frequently recognized (respectively 41.2 versus 18.2%, P < 0.001; 47.1 versus 21.2%, P < 0.05). Moreover, these subjects presented a significantly greater number of premature ventricular beats (317.1 +/- 665.6 versus 64.88 +/- 188.6, P < 0.05) and higher classes of Lown's arrhythmia scale (classes III-IV, 23.35% versus 9.1%). LVMI was insignificantly higher in the group with greater QTc dispersion (165.82 +/- 54.5 versus 145.07 +/- 36.47 g/ m2). Other echocardiographic indices of LVH were similar in both groups. On the other hand, the analysis of regression indicated positive correlation between the dispersion of QTc interval and thickness of left ventricle walls (for IVSd - r = 0.37; for PWd - r = 0.31), relative wall thickness (r = 0.28) and LVMI (r = 0.28). CONCLUSIONS: QTc dispersion is increased in the elderly hypertensive individuals, with the presence of LVH and myocardial ischaemia on ECG. These patients are more likely to demonstrate severe ventricular dysrhythmias.

Isolated systolic hypertension: pathophysiology, consequences and therapeutic benefits.

During recent decades the importance of perceiving isolated systolic hypertension (ISH) in cardiovascular pathophysiology has been changed from a benign condition to the major cardiovascular risk factor. Aging is per se associated with the deterioration in arterial compliance through both structural and functional changes in large arteries which mainly involves the intima and media. The observed changes result in a decrease of the lumen-to-wall ratio, the overall lumen cross-sectional area and an increase of arterial stiffness which especially involve the aorta and other elastic arteries. In addition to the structural changes in vessel walls, aging is associated with certain functional changes such as an increase in sympathetic system activity probably due to the age-related decreased sensitivity of beta-receptors. While the function of arterial wall alpha-receptors remains intact, in elderly subjects a shift towards arterial vasoconstriction can be observed. In many of the published studies the definition of ISH was based on the criterion 160/95 mm Hg or 160/90 mm Hg while in recognition of the high risk associated with systolic blood pressure (SBP) the WHO/ISH guidelines and Report of the Sixth Joint National Committee on Hypertension indicated that ISH should be diagnosed with SBP as > or =140 mm Hg and diastolic BP (DBP) as <90 mm Hg. Thus the setting down of normal values of SBP will lead to an earlier diagnosis and treatment of ISH. Several prospective studies, such as the US Hypertension Detection and Follow-up Programme, confirmed this and the Multiple Risk Factor Intervention Trial demonstrated that for any given level of DBP, higher SBP was associated with an increase in cardiovascular risk. Moreover, data from the Framingham Study show that ISH was associated not only with increased mortality but also cardiovascular morbidity. Risk of non-fatal stroke and myocardial infarction was increased three and two-times respectively in the presence of ISH. Three major up-to-date studies that included patients with ISH have been published. In concordance to the previously published SHEP and MCR trials, the most recent, the Systolic Hypertension in the Elderly Trial (SYST-EUR), demonstrated that active treatment significantly reduces the risk of stroke and all fatal and non-fatal cardiac end-points, including sudden death. Of note, these benefits were demonstrated with new anti-hypertensive classes such as dihydropiridyne calcium channel blocker (nitrendipine) and the angiotensin-converting enzyme inhibitor (enalapril). The necessity to carefully balance the benefits and risks of anti-hypertensive therapy in the elderly indicates that patients with suspected ISH should undergo careful BP measurements on at least three different occasions before the diagnosis is established and an orthostatic reaction should be evaluated. If non-pharmacological procedures fail, drug therapy should be considered, especially in elderly patients with a SBP over 160 mm Hg, since their risk of complications is markedly higher. Pharmacological treatment should also be strongly considered in patients with a SBP between 140 and 160 mm Hg with such concomitant cardiovascular risk factors as diabetes, angina pectoris, and left ventricular hypertrophy. The drug regimen should be simple, starting with a low dose of a single drug that is titrated slowly. The selection of the first-line anti-hypertensive agent should be based on a careful assessment of pathophysiological and clinical parameters in each individual geriatric patient.

Obesity and blood pressure in the elderly free-living population.

OBJECTIVE: The aim of presented analysis was to determine the relationship between blood pressure (BP) and different indices of obesity in the elderly free-living population. DESIGN AND METHODS: In 317 inhabitants of the randomly chosen area of Cracow (70 years old and older) who could come to the out-patient clinic for an interview, BP, weight and height were taken. Body mass index (BMI) was used to classify the population into lean (BMI < 25 kg/m2), overweight (25 < or = BMI < 30 kg/m2) and obese (BMI > or = 30 kg/m2) subjects. In order to separate the effect of adipose tissue and lean body mass, weight of total adipose tissue (AT) and lean body mass (LBM) were calculated according to the anthropometric CT-calibrated equations. RESULTS: Obese patients had a significantly higher systolic BP (SBP) when compared with lean subjects (respectively SBP [mm Hg] 175.7 +/- 27.5 vs 161.8 +/- 21.8), and higher diastolic BP (DBP) [mm Hg] in comparison with both other groups (obese: 93.7 +/- 12.4 vs lean: 85.34 +/- 10.6, overweight: 87.15 +/- 12.73). The relationship between systolic and diastolic BP, and weight (respectively for SBP: r = 0.256, DBP: r = 0.216), BMI (SBP: r = 0.261, DBP: r = 0.216) and AT (SBP r = 0.269, DBP r = 0.22, P < 0.01) was found only in women but not in men. CONCLUSIONS: Our results suggest that in the elderly the importance of obesity in the pathogenesis of hypertension depends partially on gender and it may be essential in women but not in men.

Influence of long-term treatment with nifedipine on blood pressure, left ventricular mass and cardiac arrhythmias in elderly hypertensive patients.

To determine the benefits of the long-term monotherapy with nifedipine in the elderly hypertensive patients, 100 subjects > 60 years old were included to the trial. Therapeutic efficacy of nifedipine was confirmed in 69% of the patients and resulted in reduction of SBP by 20.9% and DBP by 19.0% of their initial values, from 179.7/101.3 to 142.1/82.9 mmHg (p < 0.001). On the other hand, the range of circadian changes in systolic and diastolic BM did not decrease (67.1 and 37.0 mmHg before treatment and 65.0 and 36.2 mmHg at the end of the trial). Although cardiac output and ejection fraction significantly improved, the patients showed neither a significant reduction of left ventricular mass (313.6 g before and 282.4 g after therapy) nor a decrease in cardiac arrhythmias. Usefulness of long-term monotherapy with nifedipine in elderly patients is diminished by side-effects (11%), as well as a preserved high circadian BP variability and the unchanged left ventricular morphology that may result in persistent cardiac arrhythmias despite of the significant fall in BP.

[Use of nifedipine in elderly patients with essential hypertension: patient compliance, safety and efficacy of therapy]. / Zastosowanie nifedypiny u ludzi starszych z pierwotnym nadcisnieniem tetniczym; wspólpraca leczonych, bezpieczenstwo i skutecznosc.

The aim of the study was to evaluate chronic treatment with Cordafen (nifedipine) in the out-patients over 60 years of age with established arterial hypertension. Out of 100 out-patients aged 60-83 years 69 subjects completed one-year study. The main reasons of drop-outs were: lack of patient compliance (12%), severe side effects (11%), ineffective monotherapy (5%) and other (3%). Less severe adverse effects were found in further 20 subjects. After one-year therapy hematological and biochemical parameters of the homeostasis did not deteriorate except an increase in alkaline phosphatase. Regular drug intake in a dose of 20-80 mg/daily (mean = 46.0) produced a significant decrease in the blood pressure level and an improvement of cardiac function indices (CO nad EF). In contrast Cordafen did not reduce the differences between extreme blood pressure values recorded automatically, and it did not produce a significant regression of left ventricular mass and cardiac arrhythmias. Nifedipine in mild or moderate hypertension in the elderly patient any be an adequate form of monotherapy in about 70% of them. Higher motivation for treatment in this age group and better drug tolerance may further improve this efficacy.

Distribution of blood pressure and prevalence of arterial hypertension in the old population of Cracow.

The aim of the present epidemiological study was to recognize the distribution of blood pressure (BP) and the prevalence of arterial hypertension (AH) in the aged (> or = 70 years) population in Cracow. The data were obtained from the studied group of 512 persons (153 men and 359 women) which corresponds to 72.4% of the randomly chosen group. The mean systolic BP was 159.7 in males and 164.3 mmHg in females (p < 0.05). Diastolic BP was 86.3 mmHg and 87.3 mmHg (n.s.), respectively. We observed the single peaked distribution of BP. According to the WHO epidemiological criteria of AH (BP > or = 160 = 95 mmHg) hypertension was found in 60.6% (49.7% M and 64.8% F) with systolic AH 32.3%, systolic+diastolic in 25.4% and diastolic AH alone in 2.9% of this group.

[Bradycardia following reserpine injection requiring cardiac pacing]. / Bradykardia po wstrzyknieciu rezerpiny z koniecznoscia czasowej elektrostymulacji.

A case of bradycardia is reported developing after intramuscular injection of Serpasil. In the treatment temporary endocavitary pacing was used.

[Electrocardiography in elderly inhabitants of Krakow. Epidemiological study]. / Elektrokardiogramy u starszych wiekiem mieszkanców krakowa. Badania epidemiologiczne.

The electrocardiographic records were performed in the randomly chosen area of Cracow. The results were obtained from 512 persons (153 M and 359 F) aged 70-93 years. Normal electrocardiograms observed in 25.4% of the studied population. The prevalence of electrocardiographic abnormalities was as follows: ST segment depression--40.0%, patterns of infarction--17.2% and left ventricular hypertrophy--10.4%. On the contrary right axis deviation, bradycardia, sinus arrest, II and III of a-v blocks were rarely observed. The prevalence of electrocardiographic abnormalities in the aged in Cracow is in the accordance with the findings observed in the countries with high risk of cardiovascular diseases.

Ventricular arrhythmias and echocardiographic parameters of the left ventricular morphology in elderly patients with arterial hypertension.

An analysis of cardiac arrhythmias in relation to left ventricular morphology and function was performed in 68 hypertensive patients 60 to 83 years of age. The study comprised Holter monitoring and echocardiography. Our results suggest that in elderly patients with primary arterial hypertension a correlation exists between left ventricular mass and the incidence of ventricular arrhythmias but not between left ventricular mass and supraventricular arrhythmias.

[Nifedipine level in the blood and its immediate hypotensive effect after its sublingual administration to aged patients]. / Stezenie nifedypiny we krwi a jej dorazny efekt hipotensyjny po podjezykowym podaniu leku u osób w wieku podeszlym.

In 28 aged patients (means = 73.1 years) with arterial hypertension nifedipine has been administered sublingually in a single dose of 20 mg and the hypotensive effect of that drug under the control of its concentration in the blood serum was evaluated. The nifedipine concentration was determined by the use of gas chromatography with electron capture detector. The mean drug concentration increased from 38.1 ng/ml to 82.3 ng/l during the 2nd hour of observation. After 3 hours the lowering of the nifedipine concentration and the decrease of its hypotensive effect was observed. After 15 min from the drug application the systolic pressure lowered by the average 22.1 mmHg whereas the diastolic pressure was 7.0 mmHg lower. The most significant pressure decrease (mean of systolic pressure 52.7 mmHg) 7.03 kPa and that of diastolic pressure 23.2 mmHg (3.1 kPa) occurred after 2 and 1.5 hours. The decrease of pressures after nifedipine correlated with the start-point value of systolic pressure. The frequency of the heart action in the whole group did not altered significantly, however, in individual cases both the acceleration of that action (34 per min) or acceleration (42 systoles per min) was noted. Slight typical side-effects were noted in 5 treated patients. A single-dose sublingual 20 mg nifedipine (Cordafen--Polfa) administration enabled in all the subjects the obtaining of therapeutic drug level in the blood and in the aged patients with hypertension may be regarded as efficacious antihypertensive treatment.