Hypertensive emergencies: a new clinical approach.

The expression 'hypertensive urgencies' includes many diseases. The unifying features of these diseases are a high level of arterial pressure and acute distress of one or more organs. The aim of the review was to define the idea of the 'acute hypertension' as a new concept, different from 'chronic hypertension'. Acute hypertension might be related to 'organ damage' because it is the cause, the consequence or an effect of the acute stress. We compounded a narrative review which has included analyses of 373 articles. The structure of the search strategy included a literature search of PubMed, MEDLINE, Cochrane Library and Google Scholar databases. We applied the following inclusion criteria: prospective double-blind randomised controlled trials, experimental animal work studies, case-control studies and recruiting patients representative of the general sick population. In this review, the diseases included in the term 'hypertensive emergencies' share 'acute' hypertension. This is a new idea that emphasises the suddenly increased arterial pressure, irrespective of the initial arterial pressure and independent of the goals of hypertension control. The 'hypertensive emergencies' have been grouped together in three subsets: (1) diseases that result from acute hypertension that is caused by faulty regulation of the peripheral circulation (acute primary hypertension), (2) diseases that produce hypertension (acute secondary hypertension) and 3) diseases that have hypertension as an effect of the acute stress caused by the principle disease (acute associated hypertension). This review highlights a novel idea: acute hypertension is a common sign of different diseases characterised by the sudden surge of arterial pressure, so overwhelming the difference between hypertensive emergencies and urgencies. The judgment of acute hypertension is independent of the initial arterial pressure, normotension or hypertension and is linked with the transient failure of the baroreflex. Hypertensive emergencies are grouped together because all of these diseases require prompt therapy to prevent the negative outcomes of acute hypertension.

Recurrent syncope in patients with carotid sinus hypersensitivity.

Syncope recurrence in pacemaker-implanted subjects for the cardio-inhibitory response to sinus carotid massage (SCM) was investigated. The study-hypothesis was that recurrences had significant vasodepressor responses that could justify the loss of consciousness. Forty-six patients were enrolled (16 patients and 30 controls), followed and revaluated after 5-7 years. At the end of follow-up, significant differences were found between patients and controls in mean SCM SAP (87 versus 106 mmHg) and reduction in mean SCM SAP (59 versus 38 mmHg); in the number of symptomatic subjects soon after SCM (5 versus 1); and in the number of subjects suffering from orthostatic hypotension. A subgroup of 13 patients showed significantly different hypotensive responses to SCM compared with the values observed at study recruitment. The data showed that some subjects with a defined hemodynamic pattern in response to SCM may change their characteristics and have spontaneous and/or provocative symptoms. These data explain the syncopal relapses, and suggest the presence of autonomic dysregulation in individuals with carotid sinus hypersensitivity.

What Happens before Syncope? Study of the Time Frame Preceding Vasovagal Syncope.

Objective. The events characterizing the very last part of the vasovagal crisis has not been determined. The aim of the study was to analyze the variations in respiratory pattern preceding the vaso-vagal syncope full-blown and the relationship between cardiovascular functions in order to assess the temporal sequence. Methods. Eleven consecutive patients were studied. Heart rate, arterial pressure, respiratory frequency, tidal volume, carbon dioxide, and oxygen saturation in time domain from supine and standing recordings were analyzed. Results. The respiratory activity is different in the time frame preceding syncope, both in V(T) and breathing rate, and that the increase of the lung ventilation does not influence the baroreflex control during the presyncopal period but may be cause of the baroreflex failure during the full-blown syncope.

Upper Digestive Bleeding in Atrial Fibrillation: Evaluation of Gastroscopy Prior to Oral Anticoagulant Therapy (GOAT), Prospective, Randomized, Double Blind Study on a Community Population.

BACKGROUND: The aim of this study was to investigate the incidence of digestive hemorrhages in patients with non-valvular atrial fibrillation (NVAF), scheduled for oral anticoagulant therapy. METHODS: We conducted, over 24 months, a prospective, randomized, population-based observational study on consecutive patients with recurrent paroxysmal, persistent, or permanent NVAF, scheduled for oral anticoagulant therapy. The study initially included 268 patients with NVAF (162 males and 106 females) with a mean age of 74 years (range 42-86 years). Patients were split into two groups: those undergoing preventive Esophago-Gastro-Duodenoscopy (EGD) (Group A) and those who did not (Group B). All patients positive by EGD underwent medical treatment and subsequent 30-day endoscopic controls showed complete healing. The primary outcome of the study was to determine if previous EGD in patients with NVAF resulted in a low risk of bleeding during oral anticoagulant therapy. The two groups were comparable for most variables. RESULTS: Significant differences were found between groups for the incidence of antiarrhythmic drugs and for early hemorrhage (P <0.001). The incidences of early hemorrhages were significantly different between the two groups with 12 in group B (12%) and 2 in group A (1.7%). CONCLUSIONS: Preventive EGD can identify hidden digestive diseases, which may increase the incidence of early hemorrhages.

Clinostatic hypertension and orthostatic hypotension.

BACKGROUND: The association of clinostatic hypertension (CH) and orthostatic hypotension (OH) is described as the "Hyp-Hyp phenomenon," and it has been found in about 5.5% of hypertensive patients and in up to 50% of patients with OH. The importance of CH/OH in clinical practice is mainly due to the presence of troublesome symptoms, end-organ damage, and difficulties in its clinical management. HYPOTHESIS: The review focuses on the clinical problem of CH and review the international literature for the best management, including the diagnostic work-up and the taylored treatment for this kind of patients. METHODS: A systematic review of the literature was conducted through MEDLINE research to focus the main controversial issues about CH/OH. Included topics: (1) the diagnostic work-up, (2) the association with dysautonomic failure and syncope, and (3) the treatment options and prevention of end-organ damage. RESULTS: Current standard reference for OH diagnosis includes functional assessment of the cardiac vagal nervous system and the sympathetic adrenergic system. The association with dysautonomic failure and with syncope needs further investigation. Pharmacologic treatment of OH is aimed at controlling symptoms rather than restoring normotension. Midodrine is the only medication that has been put to multicenter placebo-controlled trial and subsequently approved by the U.S. Food and Drug Administration (FDA) for OH treatment. Short-acting oral antihypertensive agents at bedtime should be considered in patients with severe, sustained CH. CONCLUSIONS: Data obtained from the literature review showed that clinical diagnosis of the Hyp-Hyp phenomenon is relatively simple, but it remains more difficult to establish the causal disease. In our opinion, it is advisable to define simple diagnostic standards for the selection of patients at risk of dysautonomic impairment so that a subsequent highly specific diagnostic work-up could be initiated.

Early and late outcome of treated patients referred for syncope to emergency department: the EGSYS 2 follow-up study.

AIMS: We evaluated the early (1 month) and late (2 years) death rate and syncopal relapses of patients referred for syncope to 11 general hospitals emergency departments. Patients were enrolled in the Evaluation of Guidelines in SYncope Study 2 (EGSYS 2) study. The guidelines of the European Society of Cardiology were strictly followed in the management of patients. METHODS AND RESULTS: Out of the 465 patients enrolled in the EGSYS 2 study, 398 (86%) underwent a complete follow-up. We excluded 18 patients with non-syncopal attacks. Among the remaining 380 patients, death of any cause occurred in 35 (9.2%). The mean follow-up was 614 +/- 73 days. Six deaths (17% of total) occurred during the first month of follow-up. Patients who died were older, had a higher incidence of structural heart disease and/or abnormal ECG, had injuries related to syncope and higher EGSYS score. Syncope recurred in 63 (16.5%) patients. Syncopal relapses occurred in only one patient during the first month of follow-up. The incidence of syncopal recurrences was unrelated to the mechanism of syncope. No clinical differences were found between patients with or without syncopal recurrence and in patients with EGSYS score < or >or=3. CONCLUSION: A peak of cardiovascular mortality but not of syncopal recurrences was observed in patients attending to the emergency department for syncope within the first month. Late unfavourable outcomes were caused by associated cardiovascular diseases rather than by the mechanism of syncope. The causes of syncope did not determine the recurrence rate.

Orthostatic hypotension as cause of syncope in patients older than 65 years admitted to emergency departments for transient loss of consciousness.

BACKGROUND: Syncope due to orthostatic hypotension (OH) refers to loss of consciousness caused by hypotension induced by the upright position; it is an important risk factor for fall-related physical injuries, especially in the elderly adults. We evaluated the prevalence of OH syncope and the clinical characteristics of patients older than 65 years with syncope due to OH in the Evaluation of Guidelines in Syncope Study 2 group population. METHODS: Two hundred fifty nine patients older than 65 years consecutively admitted to the emergency department because of loss of consciousness in a period of a month were submitted to a standardized protocol approved by the European Task Force for the diagnosis of syncope; all the patients were studied by a trained physician who interacted with a central supervisor as the management of syncope was concerned, using a decision-making software. RESULTS: Prevalence of OH syncope was 12.4%. Patients with OH syncope were more likely to be affected by Parkinson's disease and by other neurological diseases. ST changes and longer values of QTc were found in OH syncope group, and they took a greater number of diuretics, nitrates, and digoxin. In multivariate analysis, Parkinson's disease (p = .001) and use of nitrates (p = .001) and diuretics (p = .020) were independently related to OH syncope. CONCLUSIONS: In patients older than 65 years, Parkinson's disease and neurological comorbidity are strictly related to OH syncope. Moreover, this study suggests the independent link between OH syncope and the use of vasoactive drugs, identifying the majority of cases as adverse drug reaction, a preventable risk factor for syncope and falls in the older population.

Outcome of patients with elevated cardiac troponin I level after mild trauma.

The objective of this study was to evaluate whether increased c-Tnl in patients suffering from mild trauma without cardiac disease may be prognostic for future cardiac events. Consecutive patients suffering from mild trauma were recruited and evaluated for levels of creatinine, creatine-kinase (CK) and c-Tnl. Patients with elevated c-Tnl were selected and followed up for six months for cardiac events (cardiac death, Myocardial Infarction, Acute Coronary Syndromes, cardiac syncope, pacemaker or Intracardiac Device Implantation, Percutaneous Cardiac Intervention, and aortic-coronary bypass). No relationship was found between levels of c-Tnl and CK or creatinine. Patients with elevated c-Tnl suffered significantly more of cardiac events than did patients with normal levels of c-Tnl. Increased of c-Tnl in patients experiencing mild trauma but not cardiac diseases may be a preclinic index of future cardiac disease.

Compliance with therapy in hypertensive patients.

OBJECTIVE: This study investigated pharmacological compliance in hypertensive patients recruited during a 24-month period at the Hypertension Clinic of the S. Maria Nuova Hospital. METHODS: The compliance profile scale was developed in order to classify compliance as sufficient, or poor. Compliance was evaluated according to patients' (1) global cardiovascular risk (hypertensive) and (2) complexity of prescribed treatment at enrolment (drug, number of pills). RESULTS: A total of 367 patients were recruited; 82 were excluded owing to changes in therapeutic schedule or medication necessitated by other medical or surgical disease. Compliance was evaluated in 285 patients, 66% were male; the mean age was 72 +/- 12 years. Compliance was evaluated at a series of follow-ups at 3-month intervals and at 36 months of observation. Compliance at 36 months was good or sufficient in 56% of patients, but differed according to hypertensive and drug status. Compliance was better in patients with a higher level vs. lower level of hypertension severity. Specifically, compliance was better in hypertensives with co-morbidity (76%) than in hypertensives without co-morbidity (37%) or hypertensives with risk factors (65%). Moreover, compliance was better in patients with a more complex therapeutic regimen (drug 1 through 3: 47, 59 and 66%). CONCLUSIONS: These data demonstrate a relationship between disease severity and compliance, independent of the prescribed therapeutic regimen. This suggests that the most important factor for therapy adherence is disease awareness and severity, and patients with a higher level of disease are more likely to be compliant.

Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals.

AIMS: The study hypothesis was that a decision-making approach improves diagnostic yield and reduces resource consumption for patients with syncope who present as emergencies at general hospitals. METHODS AND RESULTS: This was a prospective, controlled, multi-centre study. Patients referred from 5 November to 7 December 2001 were managed according to usual practice, whereas those referred from 4 October to 5 November 2004 were managed according to a standardized-care pathway in strict adherence to the recommendations of the guidelines of the European Society of Cardiology. In order to maximize its application, a decision-making guideline-based software was used and trained core medical personnel were designated-both locally in each hospital and centrally-to verify adherence to the diagnostic pathway and give advice on its correct application. The 'usual-care' group comprised 929 patients and the 'standardized-care' group 745 patients. The baseline characteristics of the two study populations were similar. At the end of the evaluation, the standardized-care group was seen to have a lower hospitalization rate (39 vs. 47%, P=0.001), shorter in-hospital stay (7.2+/-5.7 vs. 8.1+/-5.9 days, P=0.04), and fewer tests performed per patient (median 2.6 vs. 3.4, P=0.001) than the usual-care group. More standardized-care patients had a diagnosis of neurally mediated (65 vs. 46%, P=0.001) and orthostatic syncope (10 vs. 6%, P=0.002), whereas fewer had a diagnosis of pseudo-syncope (6 vs. 13%, P=0.001) or unexplained syncope (5 vs. 20%, P=0.001). The mean cost per patient and the mean cost per diagnosis were 19 and 29% lower in the standardized-care group (P=0.001). CONCLUSION: A standardized-care pathway significantly improved diagnostic yield and reduced hospital admissions, resource consumption, and overall costs.

A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals.

AIMS: The guidelines of the European Society of Cardiology (ESC) define the current standard for the management of syncope, but are still incompletely applied in the clinical setting. METHODS AND RESULTS: Prospective systematic evaluation, on strict adherence to the guidelines, of consecutive patients referred for syncope to the emergency departments of 11 general hospitals. In order to maximize the application, a decision-making guideline-based software was used and trained core medical personnel were designated-both locally in each hospital and centrally-to verify adherence to the diagnostic pathway and give advice on its correction. A diagnostic work-up consistent with the guidelines was completed in 465/541 patients (86%). A definite diagnosis was established in 98% (unexplained in 2%): neurally mediated syncope accounted for 66% of diagnosis, orthostatic hypotension 10%, primary arrhythmias 11%, structural cardiac or cardiopulmonary disease 5%, and non-syncopal attacks 6%, respectively. The initial evaluation (consisting of history, physical examination, and standard electrocardiogram) established a diagnosis in 50% of cases. Hospitalization for the management of syncope was appropriate in 25% and was required for other reasons in a further 13% of cases. The median in-hospital stay was 5.5 days (interquartile range, 3-9). Apart from the initial evaluation, a mean of 1.9+/-1.1 appropriate tests per patient was performed in 193 patients and led to a final diagnosis in 182 of these (94%). CONCLUSION: The results of this study assess the current standard for the management of syncope on the basis of a rigorous adherence to guidelines of the ESC and provide a frame of reference for daily activity when dealing with syncope.

Plasma volume and hematocrit changes in recurrent fainters.

The pooling of blood in the limbs is the beginning of a chain of events which brings about the reflex syncope. Observations have confirmed that the reduction of plasma volume is also a factor pathogenetically determinant in the provocation of a faint. During orthostatic stress, plasma volume shifts towards the interstitial spaces of the infra-diaphragmatic vascular network, thus, contributing greatly to the reduction in the circulating volume. The aim of the present study was to calculate whether during orthostasis there was indeed a reduction in plasma volume and to what extent in a population at high risk for fainting. A comparative study of 50 recurrent fainters and 37 controls was performed. Each group was studied both in a supine (before) and orthostatic (after) position. Blood samples were taken to determine the hematocrit and hemoglobin values. The percentage variation of these values was calculated in order to obtain the reduction in plasma volume, i. e., the expression of the amount of plasma accumulated in the interstitial spaces. A significant difference in hematocrit and hemoglobin variation (before vs. after) was found between patients and controls. Plasma volume variation before vs. after (17.1 % in patients vs. 8.6 % in controls) was then calculated using these measurements. The difference in plasma volume variation between patients and controls can be interpreted as a co-factor together with the pooling of plasma in the pathogenesis of reflex fainting. This study illustrates an easy way to evaluate the role of plasma volume reduction in the pathogenesis of vasovagal syncope.

Postural hypotension in hypertensive patients.

BACKGROUND: The association between orthostatic hypotension and supine hypertension (Hypo-Hyper) has been reported in previous studies on selected populations. The present longitudinal study aimed to characterize the haemodynamic patterns, comorbidity, prognostic implications and eventual effect of therapy in patients with the Hypo-Hyper pattern. METHODS: Ambulatory blood pressure monitoring (AMAP) and clinical evaluation were performed on 615 consecutive patients recruited from the Hypertension Clinics of five Italian Hospitals: 34 patents were identified as Hypo-Hyper, and underwent 10-month follow-up. RESULTS: The incidence of the Hypo-Hyper pattern was 5.5% in the hypertensives studied. Hypo-Hyper was more frequent in the elderly (mean age 58 years), and the affected population exhibited different kinds of underlying pathologies. Multivariate analysis showed no association between antihypertensive treatment and Hypo-Hyper pattern. Patients with AMAP features of higher blood pressure values at night-time than at daytime displayed higher rates of myocardial hypertrophy and pacemaker implantation during the follow-up. CONCLUSIONS: Although the study design did not aim to identify any pathophysiological mechanism for Hypo-Hyper pattern, these first data show that the Hypo-Hyper association is the effect of a particular subtype of hypertension, with significantly different prognostic implications.

Vasovagal syncope in emergency room patients: analysis of a metropolitan area registry.

The aim of this study was to assess the epidemiology of syncope in unselected patients referred to an emergency room and eventually admitted to the clinical wards to perform a complete work-up, and to analyze the costs of hospitalization. The clinical charts of all patients referred for all causes to the emergency rooms of three hospitals in the Florence area during the year 2000 and of all patients admitted from the emergency rooms to the clinical wards with a diagnosis of lone-related (vasovagal) or disease-related syncope were revised. A total of 1,290 (3.36%) cases of syncope out of 38,330 presentations were registered; among these, 702 cases (1.83% of all presentations, 54% of all syncopes) were directly discharged, and 443 cases (1.14% of all presentations, 34% of all syncopes) were hospitalized. The remaining 149 cases (12% of all syncopes) refused admission. Following admission, 500 patients were discharged with the diagnosis of syncope: 115 lone-related (23%) and 385 disease-related syncopes (77%). A cost-benefit analysis of the hospitalized patients showed that admitting patients with lone syncope leads to an economical loss to the hospital.

Impaired sympathetic regulation of cerebral blood flow in patients with cirrhosis of the liver.

Continuous recording of mean cerebral blood flow velocity (MCBFV) by Doppler ultrasound allows detection of low-frequency (LF) oscillations, which reflect sympathetic activity in the cerebral circulation. To establish whether the sympathetic drive to the cerebral circulation is altered in patients with compensated cirrhosis, and, if so, where alterations take place, LF oscillations of MCBFV, heart rate (RR interval) and systolic arterial pressure (SAP) were analysed in 10 patients with cirrhosis and 10 control subjects during supine rest and on stimulation of carotid baroreceptors using a neck chamber applying sinusoidal suction. Bivariate analysis was used to study the relationship between pairs of oscillations. In the case of a significant association, the delay in the appearance of the oscillation in MCBFV, SAP and RR was calculated. Baroreceptor stimulation induced significant increases in SAP LF and RR LF power in both groups, while MCBFV LF power increased only in controls. During baroreceptor stimulation, the lag phase between SAP LF and MCBFV LF power was significantly lower in cirrhotic patients than in control subjects (0.96 compared with 1.59 rad; P<0.01), indicating altered sympathetic regulation of the cerebral circulation. The baroreflex arc was intact, as indicated by the similar pattern of RR-SAP interval in patients and controls. Plasma noradrenaline levels increased significantly in both groups in response to head-up tilt. These results indicate that patients with cirrhosis have an altered sympathetic regulation of the cerebral circulation that is characterized by an inadequate response of resistance microvessels, despite adequate baroreceptor function.