Arterial stiffness and mitral regurgitation in arterial hypertension: an intriguing pathophysiological link.

BACKGROUND: We examined the relative impact of arterial stiffness on the presence and/or severity of chronic mitral regurgitation (MR) in hypertensive patients. METHODS: We prospectively enrolled 141 untreated hypertensive patients (mean age 56.6 ±â€¯11.5 years): 94 with MR, 47 without MR. As a measure of arterial stiffness, pulse wave velocity (PWV) was assessed by applanation tonometry. Assessment of MR severity was obtained through calculation of effective regurgitant orifice area (EROA) and vena contracta by standard two-dimensional transthoracic echocardiography. RESULTS: PWV appears to progressively increase according to the presence and severity of MR (no MR = 7.3 ±â€¯1.1 m/s, mild MR = 7.9 ±â€¯1.3 m/s, moderate MR = 9.0 ±â€¯1.7 m/s, severe MR = 13.3 ±â€¯4.1 m/s; P < 0.001 for all comparisons). EROA was positively correlated with age (P = 0.011), left atrial volume index (P = 0.023), PWV (P < 0.001) and augmentation index (P < 0.001), and negatively correlated with left ventricular ejection fraction (P = 0.002) and heart rate (HR) (P = 0.018). On stepwise multivariate logistic regression analysis, only PWV (OR = 2.87, 95% CI 1.750-4.738, P < 0.001) and HR (OR = 0.94, 95% CI 0.895-0.994, P = 0.02) appeared to be independent predictors of severe MR. Receiver operating characteristic curves showed that a cutoff of 9 m/s for PWV provided the best sensitivity/specificity for predicting both the presence of any degree of MR (sensitivity 73%, specificity 87%, AUC = 0.863; P < 0.001) and MR severity (sensitivity 100%, specificity 81%, AUC = 0.954; P < 0.001). CONCLUSION: Reduced arterial elasticity because of increased stiffness may be an important marker for the presence and severity of MR in hypertensive patients.

Effect of type D personality on smoking status and their combined impact on outcome after acute myocardial infarction.

BACKGROUND: Smoking cessation is correlated with several psychological, social, biological, and pharmacological aspects. The combined tendency to experience negative emotions and to inhibit the expression of these emotions is indicated as "type D personality," an independent risk marker for clinical outcome in cardiac disease. Despite this effect of type D personality on cardiovascular disease, it is still unclear whether this personality trait may influence smoking cessation after a myocardial infarction. HYPOTHESIS: we hypothesized that there is a relationship between type D personality and smoking persistence in acute coronary syndrome patients, and this association may predict a worse long-term prognosis. METHODS: The study enrolled 231 patients with ST-segment elevation myocardial infarction, treated with primary percutaneous coronary intervention. Type D scale 14 (ds 14) was administered upon admission to the hospital. RESULTS: After controlling for demographic and clinical confounders, non-type D patients reported statistically significant higher frequencies of smoking cessation when compared with the type D group. In addition, the presence of this psychological factor anticipates significantly the onset of smoking during adolescence. Furthermore, current type D smokers had a higher incidence of cardiovascular events during long-term follow-up. CONCLUSIONS: Type D personality and smoking status increase the risk of cardiac events. An emotionally stressed personality and persistence of smoking after the first cardiac event, and mostly their mutual influence, indicate a population at high cardiovascular risk.

Interleukin 31 and skin diseases: A systematic review.

BACKGROUND: Although the pathophysiology of pruritus has been extensively studied in recent years, with many resultant advancements, management of pruritus is still enigmatic, particularly in chronic cutaneous diseases, such as atopic dermatitis, chronic urticaria, allergic contact dermatitis, cutaneous T-cell lymphoma, and uremic pruritus. The recent finding of the involvement of interleukin (IL) 31 in the pathogenesis of chronic pruritus has provided a novel approach to the management of chronic inflammatory skin disorders. The present report provided an in-depth overview of the role of IL-31 in chronic skin diseases and the possible diagnostic and therapeutic applications in the management of these diseases. METHODS: A systematic review of IL-31 was conducted by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: A review of a total of 45 published research articles revealed that the majority of these articles focused on the role of IL-31 in causation of pruritus and in the worsening of the disease in atopic dermatitis. Other publications examined interleukin in other pruritic diseases (cutaneous T-cell lymphoma, uremic pruritus, allergic contact dermatitis, chronic urticaria). In almost every disease, IL-31 levels were reported to be correlated with the pathology and often with pruritus. The cutaneous injection of IL-31 resulted in a long-lasting itching sensation, and the use of monoclonal antibodies that targeted IL-31 led to a reduction in pruritus. CONCLUSION: The use of monoclonal antibodies against mediators involved in the pathogenesis of chronic skin diseases has shown promising results. Antibodies that target IL-31, in particular, its receptor A, showed interesting results in atopic dermatitis and decreased pruritus. In subsequent years, the use of these new therapeutic strategies could change the scenario of pruritic skin diseases. However, further studies are needed to more rigorously examine the effects of IL-31 cascade blockage in different chronic skin diseases and to confirm efficacy and the safety of these new therapeutic approaches.

Clinical impact of angiotensin I converting enzyme polymorphisms in subjects with resistant hypertension.

Angiotensin I converting enzyme (ACE) insertion/deletion (I/D) polymorphism is thought to affect renin-angiotensin system (RAS) activity and development of cardiovascular disease; significant associations between I/D polymorphism and atherosclerosis, stroke, nephropathy, and early mortality were already found. We investigated whether Southern Italy resistant hypertensives presented an association between the presence of I and/or D alleles and early vascular damage, inflammation, and insulin resistance. One-hundred-fifty resistant hypertensives were enrolled, studied, and genotyped; carotid intima-media thickness (cIMT), arterial stiffness (AS), and HOMA indices were also evaluated. D allele was more prevalent, and 74 patients presented DD homozygosis. Sixty-eight patients had metabolic syndrome (MetS), without significant differences between DD and I allele carriers. DD genotype appeared strongly associated with higher HOMA values (p < 0.001), and also with both Augmentation Index (AIx, p = 0.003) and Pulse Wave Velocity (PWV, p = 0.023). A significant association was found between DD genotype and cIMT (p < 0.005), while no association between ACE genotype and the presence of carotid plaques. HOMA was correlated with AS (PWV: p < 0.001; AIx: p < 0.01). DD genotype appeared to be associated with AS and HOMA index, but not with inflammation, independently from blood pressure values and the presence of other MetS factors, confirming D allele as an independent risk marker. Vascular damage may develop and progress independently from other risk factors in resistant hypertensives, likely through the interplay between ACE gene, RAS activity, and insulin resistance.

Ineffective Treatment of Low-Molecular-Weight Heparin in Obese Subject with Traumatic Fractures of the Leg.

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 9th edition, 2012, suggest no prophylaxis rather than pharmacological thromboprophylaxis in management of venous thromboembolism (VTE) risk of isolated lower leg injuries distal to knee requiring leg immobilization. Low-molecular-weight heparin (LMWH) is a class of drugs commonly used as antithrombotics in surgery and in case of prolonged bed rest and hypomobility. A 35-year-old obese man with no history of health disease (height, 170 cm; weight, 95 kg; and body mass index, 32.9 kg/m2) was involved in a car accident, and as a result of the trauma he suffered the compound fracture of left tibia and fibula. Tibial intramedullary nailing was performed. The injury was near the knee, and the patient was advised long-term bed rest. For these reasons, he was treated with enoxaparin 40 mg once daily subcutaneously. On the 7th day of hospitalization, the leg became edematous and reddish. A Doppler ultrasonography evaluation was performed which showed a massive deep vein thrombosis of left leg and then a pulmonary angiotomography showed a massive pulmonary embolism. In this clinical case, there was a pharmacological treatment failure to prevent VTE after orthopedic surgery and related long-term rest using enoxaparin at prophylaxis dosage in a patient without history of health disease but at high risk of VTE for obesity, trauma, orthopedic surgery, and immobilization. Enoxaparin dosage to prevent VTE in patients with high risk should be reconsidered and especially in obese a weight-adjusted dosage can be better than a fixed dosage.

Association between HMGB1 and COPD: A Systematic Review.

HMGB1 is an alarmin, a protein that warns and activates inflammation. Chronic obstructive pulmonary disease (COPD) is characterised by a progressive airflow obstruction and airway inflammation. Current anti-inflammatory therapies are poorly effective in maintaining lung function and symptoms of COPD. This underlines the need for finding new molecular targets involved in disease pathogenesis in order to block pathology progression. This review aims to analyse latest advances on HMGB1 role, utilisation, and potential application in COPD. To this purpose we reviewed experimental studies that investigated this alarmin as marker as well as a potential treatment in chronic obstructive pulmonary disease. This systematic review was conducted according to PRISMA guidelines. In almost all the studies, it emerged that HMGB1 levels are augmented in smokers and in patients affected by COPD. It emerged that cigarette smoking, the most well-known causative factor of COPD, induces neutrophils death and necrosis. The necrosis of neutrophil cells leads to HMGB1 release, which recruits other neutrophils in a self-maintaining process. According to the results reported in the paper both inhibiting HMGB1 and its receptor (RAGE) and blocking neutrophils necrosis (inducted by cigarette smoking) could be the aim for further studies.

Combination therapy with aliskiren versus ramipril or losartan added to conventional therapy in patients with type 2 diabetes mellitus, uncontrolled hypertension and microalbuminuria.

HYPOTHESIS/INTRODUCTION: The aim of this study was to assess the antihypertensive efficacy and safety of aliskiren versus ramipril or losartan in hypertensive patients with type 2 diabetes mellitus, microalbuminuria and uncontrolled hypertension, despite the use of optimal conventional antihypertensive therapy. MATERIALS AND METHODS: In this open-label active comparator study, 126 patients were randomly assigned to receive 24 weeks of additional therapy with aliskiren (Group A) or either losartan or ramipril (Group B), according to whether a patient was already treated with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, respectively. RESULTS: After 24 weeks, both treatment groups experienced a significant reduction of systolic blood pressure (-11.37% and -8.47%, respectively; both p <0.001 vs. baseline) and diastolic blood pressure levels (-10.67% and -9.28%, respectively; both p <0.001 vs. baseline), with a greater reduction of mean systolic values in Group A compared with Group B (p <0.001). Furthermore, after six months microalbuminuria was significantly decreased in both treatment groups (-67.62% and -49.1%, respectively; both p <0.001), with a reduction rate in Group A significantly higher than in Group B (p<0.001). CONCLUSIONS: The addition of aliskiren to optimal conventional therapy provided a higher reduction of blood pressure and urinary albumin excretion when compared with the addition of losartan or ramipril.

[Echo-Doppler evaluation of recent onset chronic venous insufficiency in elderly patients: does the heart have a role?]. / Valutazione eco-Doppler dell'insufficienza venosa cronica di recente insorgenza in soggetti anziani: il cuore potrebbe avere un ruolo?

The onset in elderly subjects of clinical signs of chronic venous insufficiency (CVI), without a previous history of venous disease of the lower limbs, raises questions about the etiology. In our study we evaluated the possible causes investigating the venous system of the lower limbs and right heart function in elderly subjects with signs of CVI. The alterations found were on the reduction of TAPSE, a significantly higher body mass index and a reduced ability to walk compared to the control group. The differences described could explain edema and skin changes of recent onset. If it is CVI functional type or of congestive heart failure in the preclinical stage will be clarified only by adequate follow-up.