[Etiology of severe pulmonary hypertension--possible role of metabolic syndrome].

BACKGROUND: In clinical practice the association between obesity and pulmonary hypertension (PH) is not rare. AIM: The aim of this study was to examine the prevalence of obesity and metabolic syndrome in patients with severe PH, especially cases without significant cardiac, pulmonary or vascular causes. METHODS: We retrospectively anaLyzed the records of 91 patients with severe PH in order to establish its causes. RESULTS: A total of 64% of the patients were women. The women were older than the men, 76.5 years vs 74.0. The BMI of the women was higher than the men, 37.0 vs 30.07. The most common causes of severe PH seen in an internal medicine ward are: severe heart failure (45.1%), chronic lung disease (16.5%) or a combination of both (12.1%). Overall, 11% of our study patients were morbidly obese without significant cardiac, pulmonary or vascular causes of PH. This group was characterized by high incidence of diabetes meLLitus, arterial hypertension, hyperlipidemia, atrial fibrillation and left ventricular (LV) diastolic dysfunction. CONCLUSION: Our results point to a possible association between metabolic syndrome and PH.

The influence of smoking cessation on hemodynamics and arterial compliance.

Cigarette smoking is associated with consistent changes in small arteries and arterioles. Recently, arterial compliance was determined in smokers; however, the effect of smoking cessation on arterial compliance has not yet been investigated. The objective of the study was to assess how smoking cessation, achieved with use of behavioral and pharmacologic therapy, influences vascular compliance and arterial stiffness in smokers. In an open-label study, 60 habitual smokers were treated for 2 months with buproprion 300 mg per day and personal and group conversations in order to facilitate smoking cessation. Hemodynamic variables, including vascular compliance and augmentation index (AI), were measured twice, at the beginning of the study and after 6 months. Of the 60 smokers, 35 stopped smoking and 25 failed at the end of the 2-month treatment period. Of the 35 who were initially successful, 12 went back to smoking, and thus only 23 remained nonsmokers at the end of 6 months. Smoking cessation was accompanied by significantly lower arterial pressure and heart rate but by weight gain. Among the 23 subjects who stopped smoking for 6 months capacitive compliance (C(1)) did not change but oscillatory compliance (C(2)) rose significantly (from 5.1 +/-2.3 to 6.3 +/-3.0 p<0.01), and AI decreased significantly (from 63.1 +/-22 to 50.6 +/-17 p<0.05), whereas in smokers who still smoked after this period, both C(1) and C(2) and augmentation index did not change significantly from their basal values. The authors conclude that smoking cessation improves arterial stiffness as assessed by the augmentation index, owing mainly to increasing the small artery compliance, which is known to be an early index of endothelial damage.

Evaluation of arterial compliance in polycythemia vera patients: short and long-term influence of phlebotomy.

BACKGROUND: Thrombosis is a major cause of morbidity and mortality in polycythemia vera. Hypercoagulability is principally due to hyperviscosity of the whole blood, an exponential function of the hematocrit. PV is also associated with endothelial dysfunction that can predispose to arterial disease. Reduction of the red cell mass to a safe level by phlebotomy is the first principle of therapy in PV. This therapy may have some effect on the arterial compliance in PV patients. OBJECTIVES: To estimate the influence of phlebotomies on large artery (Cl) and small artery compliance (C2) in PV patients by using non-invasive methods. METHODS: Short-term hemodynamic effects of phlebotomy were studied by pulse wave analysis using the HDI-Pulse Wave CR2000 (Minneapolis, MN, USA) before and immediately after venesection (350-500 ml of blood). We repeated the evaluation after 1 month to measure the long-term effects. RESULTS: Seventeen PV patients were included in the study and 47 measurements of arterial compliance were performed: 37 for short-term effects and 10 for long-term effects. The mean large artery compliance (C1) before phlebotomy was 12.0 ml/mmHg x 10 (range 4.5-28.6), and 12.6 ml/mmHg x 10 (range 5.2-20.1) immediately after phlebotomy (NS). The mean small artery compliance (C2) before and immediately after phlebotomy were 4.4 mg/mmHg x 10 (range 1.2-14.3) and 5.5 mg/mmHg x 10 (range 1.2-15.6) respectively (delta C2-1.1, P < 0.001). No difference in these parameters could be demonstrated in the long-term arm. CONCLUSIONS: Phlebotomy immediately improves arterial compliance in small vessels of PV patients, but this effect is short lived.

Effect of weight loss on blood pressure, arterial compliance, and insulin resistance in normotensive obese subjects.

BACKGROUND: Obesity is characterized by insulin resistance and hyperinsulinemia that may elevate arterial pressure due to sympathetic overactivity and volume overload. The aim of the study is to measure hemodynamic parameters and metabolic variables in obese normotensive subjects. METHODS: Twenty-four normotensive, overweight subjects from our medical staff were enrolled. They had personal and group meetings with a physician, dietician, and psychologist to improve their compliance with regard to physical activity and personal low-calorie diet. In addition, each subject was given orlistat 120 mg three times daily for 12 weeks. Noninvasive hemodynamic parameters including arterial compliance were measured using radial artery pulse wave analysis, at the beginning and 1 month after taking the last dose of Orlistat, and insulin resistance was calculated using HOMA score. RESULTS: At the end of the 3-month period, the average weight was reduced from 89.5 +/- 12 kg to 81.5 +/- 9 kg. The systolic arterial pressure was reduced from 128 +/- 12 mm Hg to 121 +/- 10 mm Hg and diastolic arterial pressure was reduced from 75.4 +/- 9 mm Hg to 69.6 +/- 7 mm Hg. Arterial compliance measurements showed significant improvement in large artery compliance from 13 +/- 4 to 15.8 +/- 3.6 while no change occurred in small arteries. The insulin sensitivity assessed by HOMA score improved significantly from 6.5 +/- 4.5 to 4.8 +/- 3.1 with weight reduction. CONCLUSIONS: Our data show that weight loss is accompanied by lowering of blood pressure, even in normotensive obese patients. This weight loss brings about an improvement in insulin resistance and a rise in large artery compliance, whereas no change occurs in small artery compliance.

[Lack of treatment continuance: an obstacle for controlling blood pressure].

INTRODUCTION: Blood pressure is one of the most prevalent risk factors for CVD. Despite the large arsenal of medications, the rate of BP control is not optimal. We studied the amount of attention family physicians pay to BP readings and treatment recommendations of hypertensive patients that were discharged from the hospital. METHODS: We included 98 consecutive hypertensive patients (mean age 68.5 +/- 1.1, 44% males) admitted to the hospital. Excluded were patients referred to the hospital from a nursing home. BP measurements were obtained at ER, admission to the ward, 2nd day of admission and day of discharge. Recommended treatment was obtained from the discharge letter. A phone call was made to each patient, 4-8 weeks after discharge, and data was obtained regarding recent BP levels and the current treatment. RESULTS: BP control was achieved in 48% of the patients at hospital discharge and 47% at follow-up. Among patients that received different treatment at follow-up because of the physician's advice or because they were considered to have a high BP (24 patients), BP control was reduced from 63% at discharge to 50% at follow-up. This reduction was attributed to decreased dosage of medications and to the replacement of medications with drugs from the same group, but given at nonequivalent doses. Ten patients that were controlled at discharge but not at follow-up were given fewer medications than recommended (2.7 vs. 3.2). Among the noncontrolled patients with BP > 140/90 at follow-up, treatment was not changed for 48%. CONCLUSION: The blood pressure treatment guidelines are not implemented, and the data regarding BP control that appears in the discharge letter is not adequately used by the family physicians. A better relationship between hospitals and family practice should be obtained to aid in controlling BP.

Small artery compliance in cirrhotic patients during total paracentes.

BACKGROUND: Hemodynamic changes, including systemic vascular resistance, in cirrhotic patients during massive paracentesis have been reported, but large and small artery compliance has not yet been investigated. OBJECTIVE: To investigate hemodynamic variables, including small and large artery compliance, in cirrhotic patients during total paracentesis. METHODS: The study included 15 cirrhotic patients admitted for an episode of tense diuretic-resistant ascites. Hemodynamic variables including vascular compliance were measured using an HDI pulse wave cardiovascular profiling instrument CR-2000. The variables were measured in these patients before, immediately after, and 24 hours following large volume (mean 5.6 L) paracentesis. RESULTS: Cardiac output increased immediately after paracentesis due to increment in stroke volume, with no change in heart rate. However, 24 hours later the cardiac output decreased to below the basal level. The fluctuation was statistically significant (P < 0.05). There was no change in large artery compliance, but small artery compliance increased after paracentesis (P < 0.05) and partially retumed to the basal level after 24 hours. Systemic vascular resistance measurement showed the same pattern of change: vasodilatation occurred during paracentesis and was attenuated 24 hours later. CONCLUSIONS: Large volume paracentesis with albumin replacement caused an accentuation of the vasodilatation (small but not large artery) already present in these patients. This may be the first sign of enhanced vasodilatation due to large volume paracentesis before the clinical expression of impaired hemodynamics and deterioration of renal function.

Hemodynamic effects of anemia correction by recombinant human erythropoietin in predialysis patients with renal failure.

Most patients with chronic renal failure have anemia, which can be corrected by recombinant human erythropoietin (rHuEpo) treatment. Increase in arterial pressure (AP) was reported in some studies and was related to higher systemic vascular resistance induced either by the rise of erythrocyte mass or the change in various endogenous vasopressors, including the direct action of rHuEpo itself. We investigated the effect of rHuEpo treatment on hemodynamic variables, including small and large arterial compliance in 20 patients with chronic renal failure who were not receiving dialysis (CCT 29 +/- 12 mL/min), with Hb levels of 40.4 +/- 0.58 g/dL. They were treated with 2,000 units intravenously followed by 80 to 120 s/c units/kg/body weight, with dosage titration according to Hb level. Noninvasive hemodynamic evaluation was performed before the first rHuEpo treatment, 30 min after the first IV rHuEpo administration and at least 3 months later when target hemoglobin (Hb) and hematocrit (Hct) were reached. No rise in AP occurred after rHuEpo administration either short term or long term. The significant hemodynamic changes were a fall in pulse pressure and a rise in large artery compliance, with no change in small artery compliance after 3 months of rHuEpo treatment when Hb and Hct levels were corrected. These findings show improvement in arterial stiffness when Hb is corrected with rHuEpo treatment.

Malignant pericardial effusion and cardiac tamponade as a late complication of endometrial carcinoma.

Malignant pericardial effusion, as a complication of gynecological cancer, is a rare occurrence. A review of the literature reveals only four cases of malignant pericardial effusion from endometrial carcinoma diagnosed during life. All of them were followed by cardiac tamponade a short time after being diagnosed and were associated with extensive myometrial invasion and multiple metastases. We describe a case of malignant pericardial effusion and cardiac tamponade due to recurrence of endometrial carcinoma characterized by the long period from diagnosis to clinical evidence of pericardial involvement. The causes of long-term disease-free interval are discussed.