Coronary artery calcification, common carotid artery intima-media thickness and aortic pulse wave velocity in patients on peritoneal dialysis.

An increasing body of evidence suggests that atherosclerosis in patients with uremia differs from that found in general population in terms of advancement and localization of vascular lesions. It has also been suggested that different non-invasive techniques of vascular system evaluation are designed to show different types of lesions (i.e. vascular calcification, stiffness or 'classical' atherosclerosis). The aim of the study was to search for possible associations between results obtained with three different non-invasive methods of vascular system assessment in three different vascular sites in patients treated with peritoneal dialysis (PD). 61 patients (28 F, 33 M), mean age of 50.4+/-13.6 years, on maintenance PD for a median period of 10 months (range 1-96 months) were included. Coronary artery disease (CAD) was present in 21 subjects. In all subjects coronary artery calcification score (CaSc) using multi-row spiral computed tomography (MSCT), aortic pulse wave velocity (AoPWV) and ultrasound-based common carotid artery intima-media thickness (CCA-IMT) were performed as methods for assessing coronary calcium burden, arterial stiffness and atherosclerosis, respectively. Median value of CaSc equaled 11.5 Agatston units (range 0-5502.8 units). Median AoPWV was 10.4 m/s (range 7.56-18.1 m/s), and median CCA-IMT-0.6 mm (range 0.3-1.0 mm). In 16 patients (26.2%) at least one plaque in at least one common carotid artery was found on ultrasound. CaSc correlated with AoPWV (R=0.32, p<0.01) and with CCA-IMT (R=0.35, p<0.005), whereas no association was found between AoPWV and CCA-IMT. AoPWV, but not CaSc nor IMT correlated with blood pressure. The values of CCA-IMT and AoPWV increased together with consecutive Agatston categories (with p<0.001 for differences in AoPWV and p<0.05 for CCA-IMT). Patients with at least one plaque found in at least one CCA and patients with CAD were characterized with significantly higher values of CaSc, IMT and PWV, when compared to plaque-free and CAD- negative subjects, respectively. Association between CaSc and both IMT and PWV may suggest that the mechanism of three assessed vascular pathologies may be based, to some extent, on the process of pathologic calcium-phosphate deposition. Lack of correlation found between PWV and IMT may suggest that aortic stiffness and carotid atherosclerosis may partially differ in their pathologic background and/or are dissociated in time.

An association between aortic pulse wave velocity, blood pressure and chronic inflammation in ESRD patients on peritoneal dialysis.

Increased aortic pulse wave velocity (AoPWV) has been identified as a risk factor for cardiovascular morbidity in the general population and in patients on dialysis. Most of the studies in ESRD patients refer to subjects on hemodialysis. Influence of the inflammatory process on aortic stiffening remains largely unknown. The aim of the present study was to evaluate potential relationships between AoPWV and blood pressure, basic anthropometric parameters, selected growth factors and markers of the inflammatory process in ESRD patients treated with peritoneal dialysis. The study population consisted of 43 patients (19 F, 24 M) with a mean age of 50.6 +/- 13.4 years on PD for a mean period of 21.9 +/- 20.7 months. AoPWV was measured using two pressure transducers placed on the carotid and femoral arteries and connected to an automatic processor (Complion Colson AS, Paris, France). Serum levels of Tumor Necrosis Factor alpha (TNFalpha), interleukin 6 (IL-6) and plasma basic Fibroblast Growth Factor (bFGF) were measured with ELISA; C-reactive protein and fibrinogen with nephelometry. Serum lipid profile was also assessed. Blood pressure was measured in an outpatient department under standardized conditions. Mean aortic pulse wave velocity in the study population was 10.7 +/- 2.1 m/s. No difference in AoPWV was found between men and women. AoPWV correlated significantly with age (R = 0.41; p < 0.01) but not with time on dialysis. Positive relationship between AoPWV and body weight and BMI was shown (R = 0.31; p < 0.05 and R = 0.35; p < 0.05, respectively). AoPWV correlated significantly with systolic blood pressure (SBP), mean arterial pressure (MAP) and pulse pressure (PP) (R = 0.46, p < 0.005, R = 0.46, p < 0.005 and R = 0.43, p < 0.01, respectively). AoPWV correlated with serum IL-6 and plasma bFGF (R = 0.32, p < 0.05 and R = 0.4, p < 0.01; respectively). The correlation with serum CRP was borderline significant (p < 0.53). In multiple regression analysis age (beta 0.38; p < 0.005), plasma bFGF level (beta 0.3; p < 0.05), and systolic blood pressure (beta 0.29; p < 0.05) were independently associated with pulse wave velocity. Our results suggest that AoPWV values in patients on PD are associated with factors similar to those encountered in the general population. We suggest that increased aortic stiffening may also be related to the chronic inflammatory process in PD patients.

The effect of hormone replacement therapy on arterial blood pressure and vascular compliance in postmenopausal women with arterial hypertension.

Arterial pathology is a major contributor to cardiovascular disease, morbidity and mortality. Women are at higher risk of cardiovascular disease after menopause. Arterial stiffness determined by pulse wave velocity, increases with age both in men and women, whereas arterial compliance in premenopausal women is greater than in men of similar age. This difference is lost in the postmenopausal years, with evidence of rapid decline in arterial compliance in the perimenopausal period. Loss of hormonal modulation is a likely explanation for reduced arterial compliance in postmenopausal women. Long-term treatment with hormone replacement therapy (HRT) may be expected to partially reverse the increase in arterial stiffness. The aim of the study was to analyse the effect of HRT on blood pressure and arterial compliance in postmenopausal women with arterial hypertension receiving hypotensive drugs. The results in the present study of postmenopausal women with mild to moderate arterial hypertension receiving HRT showed only a transient tendency towards lower blood pressure. In our study HRT was found to improve arterial compliance at 3 months after HRT, and the effect was maintained throughout 12 months. The increased arterial compliance in women receiving HRT was independent of blood pressure. In parallel with decreasing pulse wave velocity women receiving HRT had lower total and low-density lipoprotein cholesterol. The conclusions were that after 1 year HRT in postmenopausal women with arterial hypertension improves circadian blood pressure pattern, but it does not affect significantly blood pressure values and variability. The present study also shows that HRT significantly inhibits age-related rigidity of large arteries.

Silent myocardial ischaemia in patients with essential arterial hypertension and non-insulin dependent diabetes mellitus.

The concomitant presence of diabetes mellitus and arterial hypertension significantly impairs myocardial function through a direct negative effect on cardiac myocytes, coronary microvessels and precipitation of atherosclerosis in major coronary arteries. The purpose of the present study was to establish to what extent non-insulin dependent diabetes mellitus (NIDDM) modified silent myocardial ischaemia (SMI) in patients with essential hypertension and without documented coronary artery disease (CAD). The study population consisted of 41 patients with essential arterial hypertension associated with NIDDM, treated with diet and oral hypoglycaemic agents (group I) and 40 patients with essential arterial hypertension without diabetes mellitus (group II). Both groups were comparable with respect to age, gender, duration, severity and complications of hypertension. A mean duration of diabetes mellitus in group I was 6.8 years. Conventional and automatic blood pressure and heart rate measurements, continuous ECG recordings, echocardiograms and laboratory tests were obtained in all patients. SMI was more frequent in group I than in group II (29.3% vs 12.5%, P < 0.05). In group I the total duration of SMI was longer (37.3 vs 2.8 min, P < 0.001) and the total number of silent episodes was larger (15.5 vs 2.6, P < 0.001). No inter-group differences were seen in conventional and automatic blood pressure and heart rate measurements. Both groups did not differ significantly in left ventricular mass index (LVMI) or the proportion of patients with left ventricular hypertrophy (LVH) (75.6% vs 60%). Lipid profile in both groups indicated an increased risk of CAD, but without significant differences. In conclusion, in patients with essential arterial hypertension and diabetes mellitus, the incidence and severity of SMI were clearly higher than in hypertensives with normal carbohydrate metabolism. Employment of modern diagnostic techniques in hypertensives permits identification of those at greater risk, which may have further clinical implications.

Aortic pulse wave velocity in young normotensives with a family history of hypertension.

OBJECTIVE: To assess the effect of selected clinical and biochemical parameters, with particular consideration of familial hypertension, on the pulse wave velocity (PWV) in young normotensives. SUBJECTS AND METHODS: Seventy voluntary students were enrolled (mean age 22.3+/-2.1 years), 39 men and 31 women, with normal blood pressure. A history was obtained with respect to diabetes mellitus, ischaemic heart disease, lipid disorders and arterial hypertension in the family. The subjects were subdivided into two groups: those with (n = 33) and without (n = 37) a family history of arterial hypertension, and blood pressure and heart rate were measured three times and total cholesterol and its subfractions determined in plasma. The carotid to femoral PWV was measured using an automatic computerized recorder and analysed by the Complior program. RESULTS: The subjects with a family history of arterial hypertension had higher blood pressure levels (systolic and diastolic blood pressure, pulse pressure and mean arterial pressure), as well as mean body mass index and low-density lipoprotein (LDL) cholesterol. The PWV in this group did not differ from that in the subjects without a family history of arterial hypertension (9.69+/-2.8 versus 9.32+/-2.0). However, the PWV was significantly higher in males than females (10.62+/-2.2 versus 7.86+/-1.13, P < 0.0001) and there was a significant positive correlation between male gender and PWV. CONCLUSIONS: Familial arterial hypertension does not significantly affect aortic stiffness in terms of PWV. Male gender in this population of young healthy subjects is one of the most important factors associated with central arterial stiffness.

Ambulatory blood pressure monitoring and postprandial hypotension in elderly patients with isolated systolic hypertension. Systolic Hypertension in Europe (SYST-EUR) Trial Investigators.

The present analysis was undertaken to evaluate postprandial (PP) changes in blood pressure (BP) assessed with ambulatory BP monitoring (ABPM) in elderly subjects with isolated systolic hypertension (ISH) on conventional measurement. A total of 530 patients (335 women and 195 men, aged 60-100 years, median 70 years) who performed an ABPM during the placebo run-in period of the Syst-Eur trial were included into the analysis. The PP changes in BP and heart rate (HR) were calculated by subtracting the mean systolic BP (SBP), diastolic BP (DBP) and HR in the 2 h preceding the main meal from the corresponding means covering the 2 h after the meal. The reproducibility of the postprandial fall in BP and heart rate (PPH) was assessed by contrasting the first and second ABPM in a subgroup of 147 patients who performed two ABPM's during the placebo run-in period. The mean SBP and DBP decreased and reached the nadir 2 h after the main meal while HR did not change. When PPH was assessed by comparing BP in the 2 h before and after the meal, both SBP and DBP decreased significantly (respectively -6.6 mm Hg, -5.4 mm Hg; P < 0.001). In 67.6% of all patients a decrease in SBP was observed and in 24.1% it exceeded 16 mm Hg. The corresponding values for DBP were 71.3% and 24.5% (DBP decreased more than 12 mm Hg). A greater fall in DBP was associated with a greater decrease in HR (r = 0.20, P < 0.001), while changes in SBP and HR were not interrelated. Regression analysis did not identify any significant covariate of PPH. Group means of PPH could be reproduced without significant changes in their values, but the within-subject reproducibility of the PP changes was low. There were no differences in PPH according to the place of residence of the patients. In conclusion, the descriptive analysis of the meal-induced changes in ABPM in elderly subjects with ISH showed that in every day circumstances most of them experience falls in both SBP and DBP within 2 h after the meal.

Blood pressure, insulin resistance and left ventricular function in alcoholics.

OBJECTIVE: To estimate the arterial blood pressure, left ventricular function and insulin secretion in alcoholics. DESIGN: We examined hospitalized patients between the second and seventh day of acute alcohol withdrawal and after a month of abstinence by 24 h ambulatory blood pressure monitoring, a standard oral glucose-tolerance test with determination of insulinaemia, two-dimensional and M-mode echocardiography and pulsed-wave Doppler statistical analysis was performed using Student's t test P < 0.05 was considered statistically significant PATIENTS: Fifty alcoholics aged 36.3 +/- 5.4 years with a history of alcohol abuse for a mean of 12 years. MAIN OUTCOME: We expected the cessation of drinking to exert an influence by lowering the blood pressure and left ventricular function with a concomitant lowering of the insulin resistance. RESULTS: During acute alcohol withdrawal the systolic (121.6 +/- 7.7 versus +115.8 +/- 8.7 mmHg) and diastolic blood pressures (74.5 +/- 6.3 versus 72.0 +/- 7.9 mmHg) were significantly higher. The nocturnal fall in blood pressure was smaller and the variability of the blood pressure was blunted. This period was characterized by hyperinsulinaemia detected by the glucose-tolerance test [In (SUMins) 8957 +/- 0.47 versus 8558 +/- 0.651] correlated to hyperdynamic circulation (cardiac index 3.38 +/- 0.86 versus 3.09 +/- 0.69 I/min per m2). The early: late atrial filling ratio had increased significantly after 1 month of abstinence (1.98 +/- 0.43 versus 2.08 +/- 0.50). CONCLUSIONS: One month of abstinence from drinking decreases the blood pressure and improves the diurnal profile of the blood pressure and the left ventricular diastolic function. Hyperinsulinaemia, which is observed during acute restriction of alcohol consumption, could be one of the causes responsible for hyperdynamic circulation.

Effect of exercise rehabilitation on heart rate variability in hypertensives after myocardial infarction.

OBJECTIVE: The aim of the study was to find out whether the presence of hypertension affects heart rate variability in patients rehabilitated after myocardial infarction. DESIGN: Echocardiography, exercise testing and 24 h Holter monitoring were performed before and after 27 days of early postdischarge cardiac rehabilitation. PATIENTS: The study population consisted of 64 patients aged 34-65 years (mean+/-SD 51.6+/-6.6) discharged from hospital after a first myocardial infarction who were subdivided into two groups, group A comprising 34 patients with arterial hypertension which had lasted 4.8+/-2.1 years and group B comprising 30 normotensives. MAIN OUTCOME: We expected exercise rehabilitation to affect heart rate variability, exercise tolerance and myocardial ischemia in patients after myocardial infarction with and without arterial hypertension. RESULTS: At baseline no intergroup differences were seen in the duration of exercise, workload and heart rate variability parameters. All parameters increased significantly after cardiac rehabilitation (P < 0.01): SD of all normal RR intervals 123.4+/-30.0 versus 123.8+/-30.0 ms; SD of the averages of normal RR intervals in all 5-min segments of the entire recording 115.1+/-30.5 versus 116.3+/-28.3 ms; mean of the SD of all normal RR intervals for all 5-min segments of the entire recording 49.0+/-12.5 versus 48.3+/-11.8 ms; square root of the mean of the sum of the squares of differences between adjacent RR intervals 29.7+/-9.1 versus 28.0+/-8.5 ms; percentage of differences between adjacent RR intervals > 50 ms 7.9+/-6.0 versus 7.1+/-6.1% (group A versus group B, respectively, NS). The duration of exercise and the workload were significantly increased (the rise was higher in normotensives). No differences were seen in the frequency and severity of silent myocardial ischemia. CONCLUSIONS: Early stationary exercise rehabilitation after myocardial infarction improves heart rate variability parameters and exercise tolerance both in hypertensives and in normotensives.

Circadian blood pressure changes and cardiac geometry in essential arterial hypertension.

To study a relationship between ambulatory blood pressure (BP) and left ventricular geometry in mild to moderate arterial hypertension, 24 h ambulatory blood pressure monitoring (ABPM) at half-hourly intervals in the daytime and hourly at night (Spacelabs 90207) and echocardiographic examinations were performed in 60 hypertensives aged 42 +/- 7.9 years and in eight normotensives. The patients were subdivided into four groups according to the relative wall thickness (RWT) and left ventricular mass index (LVMI). Concentric remodelling was identified on the basis of increased RWT, eccentric hypertrophy in case of increased left ventricular mass, and concentric hypertrophy when both parameters were increased. Group I consisted of 15 patients with normal left ventricle; group II, 19 patients with concentric remodelling; group III, 7 patients with eccentric hypertrophy; and group IV, 19 patients with concentric hypertrophy. Analysis of correlations of maximal and mean systolic (SBP) and diastolic BP (DBP) values and BP variability with left ventricular mass and relative wall thickness revealed the strongest correlation in group IV between concentric hypertrophy and peak SBP in the entire 24 h and in the daytime, mean SBP in the daytime and SBP variability in the entire 24 h. No significant correlations were found in groups I, II, III or controls. In conclusion, SBP variability assessed non-invasively with ABPM correlates positively with left ventricular mass. BP variability seems insignificant for left ventricular geometry.

[Certain characteristics of myocardial infarction in young patients as compared with those over 65 years old]. / Niektóre odrebnosci zawallu serca u ludzi mlodych w porównaniu z grupa wiekowa powyzej 65. roku zycia.

Death rate due to myocardial infarction shows constantly growing tendency, especially in young subjects. This fact is even referred to as overmortality of young and middle-aged men. The aim of the present study was to evaluate certain clinical elements of myocardial infarction in young subjects. Out of 668 patients with acute myocardial infarction treated at the I Cardiac Department in Cracow from 1979 to 1988 a group of 102 patients (5 women, 97 men) below 45 years of age (mean = 40) was selected. The control group consisted of 241 patients with myocardial infarction, including 146 men and 98 women over 65 years of age (mean = 73). The following clinical date were analyzed: sex, presence of retrosternal pain and its aggravation, time from the onset of pain to hospitalization, anginal pain preceding the infarction and such complication as sudden cardiac arrest, pulmonary edema, cardiogenic shock, in-hospital deaths. The infarction in patients below 45 years of age occurred mainly in men. They experienced retrosternal pain more frequently than the elderly patients. It did not, however, affect the time of hospitalization. Serious complications of the infarction developed less frequently in younger patients and the in-hospital mortality was also lower in that group.

["White coat hypertension" syndrome in resistant essential hypertension]. / Zjawisko "nadcisnienia bialego fartucha" w opornym na leczenie pierwotnym nadcisnieniu tetniczym.

The study population included 51 patients, aged 34-67 years with essential arterial hypertension treated with 3-5 hypotensive drugs at the Outpatient Antihypertensive Department. Based upon frequent measurements of elevated arterial blood pressure values they were found to be therapy resistant. 24-h ambulatory blood pressure monitoring recorded at one hour intervals (Space Labs) excluded 8 patients (15.7%) from the resistant hypertension group as the number of values > 140/90 mm Hg did not exceed 25% of the measurements. In these patients white coat hypertension was the reason for diagnosing resistance. In 18 patients (35.3%) the initial diagnosis was confirmed as the number of increased values was 80-100%. The severity of eye fundus changes, higher blood pressure values and male predominance characterized the resistant group. The use of long-term noninvasive automatic blood pressure recording helps us to exclude pseudo-resistance and avoid further intensification of treatment.