Feasibility and Safety of Adopting Next-Day Discharge as First-Line Option After Transfemoral Transcatheter Aortic Valve Replacement.

OBJECTIVES: Data on next-day discharge (NDD) after transcatheter aortic valve replacement (TAVR) are limited. This study investigated the feasibility and safety of NDD as a first-line option (the very-early discharge [VED] strategy) compared with the early-discharge (ED) strategy (2-3 days as a first-line option) after TAVR. METHODS: We reviewed 611 consecutive patients who had minimalist TAVR (transfemoral approach under conscious sedation) and no in-hospital mortality; a total of 418 patients underwent ED strategy (since December 2013) and 193 patients underwent VED strategy (as part of a hospital initiative to reduce length of stay, since August 2016). NDD in the VED strategy was performed with heart team consensus in patients without significant complications. The primary outcome was a composite of 30-day all-cause mortality/rehospitalization. RESULTS: Sixty-five patients (33.7%) in the VED strategy and 10 patients (2.4%) in the ED strategy were discharged the next day (P<.001). NDD patients had received balloon-expandable (n = 30) or self-expanding valves (n = 45) and showed a similar primary outcome rate compared with non-NDD patients. After adjustment using propensity score matching (172 pairs), post-TAVR length of stay was significantly shorter in the VED group (3.2 ± 3.1 days) than in the ED group (3.5 ± 2.7 days; P<.01). The primary outcome did not differ between the two groups (7.0% vs 11.6%; P=.14), with comparable 30-day mortality rate (1.2% vs 2.3%; P=.68) and rehospitalization rate (5.8% vs 11.1%; P=.08). CONCLUSIONS: Utilization of NDD as a first-line option after minimalist TAVR is feasible and safe, and leads to further reduction in length of stay compared with an ED strategy.

Successful Treatment of Iatrogenic External Iliac Artery Perforation With Covered Stent: Case Report and Review of the Literature.

Retroperitoneal hemorrhage from iliac artery injury is a potentially serious complication of vascular interventional procedures leading to hemorrhagic shock and death if not diagnosed early and treated promptly. We report a 70-year-old male admitted to our facility with non-ST-elevation myocardial infarction, whose heart catheterization revealed left anterior descending artery (LAD) with 80% proximal, 95% mid and 100% distal disease. The left circumflex and right coronary arteries were 100% occluded proximally and received collaterals from the LAD. The patient declined coronary artery bypass surgery; therefore, the decision was made to perform high-risk percutaneous coronary intervention (PCI) of the LAD with Impella left ventricular assist device support. Left femoral artery angiogram revealed severely tortuous and calcified aorta, left external iliac and left common iliac arteries, and was accessed with 14-inch Impella sheath. He developed groin pain with mild hypotension thought to be due to sedation, which responded to intravenous fluids and dopamine. He underwent successful rotational atherectomy of the proximal and mid LAD with deployment of drug-eluting stents. Following PCI, he suffered acute profound hypotension necessitating intravenous fluids and vasopressor support with epinephrine. Emergency transthoracic echocardiogram did not reveal any pericardial effusion, and showed normal left ventricle and right ventricle systolic function. The Impella device was removed and selective left common iliac angiogram from the right femoral access revealed a vascular injury site with shift of the bladder to the right indicative of retroperitoneal hematoma. A digital subtraction angiogram revealed extravasation of blood at the vascular injury site. An 8.0 × 59 mm iCAST covered stent was deployed to the left external iliac artery with successful sealing of the perforation. The Impella device site was closed with two Perclose devices. The patient required 4 units of packed red blood cell transfusion. His hospital course was complicated by transient acute kidney injury, with return of his renal function to baseline at discharge 10 days later. This case underscores the importance of prompt recognition and treatment of vascular complications associated with interventional procedures, and highlights some of the risk predictors of such complications, which should be anticipated and planned for prior to intervention.

Late Presentation of Aortic Aneurysm and Dissection Following Cardiac Catheterization.

We report a 63-year-old female with hypertension, hyperlipidemia, and prior pacemaker insertion for atrial fibrillation with symptomatic bradycardia, who was admitted with substernal chest pressure and diaphoresis. Her electrocardiogram revealed atrial fibrillation with demand ventricular pacing and her cardiac biomarkers were negative for acute coronary syndrome. Echocardiogram revealed normal left ventricular systolic function and normal aortic root diameter. Coronary angiography revealed 60-70% obtuse marginal lesion, otherwise mild disease. She was treated medically and discharged in stable condition. She was readmitted 1 month later with recurring chest pain, and shortness of breath which started shortly after her most recent discharge. Blood pressure was 152/93 mm Hg, and heart rate was 105 bpm. BNP was elevated at 1,400 pg/mL, and other cardiac biomarkers were negative. She was treated with diuretics, which resulted in decrease of her blood pressure to 81/51 mm Hg. Repeat echocardiogram revealed severely dilated aortic root, measuring 6.7 cm, with aortic dissection flap and moderate to severe aortic regurgitation. CT angiogram revealed aortic dissection extending proximally to the aortic root above the coronary ostia and distally to the left subclavian artery takeoff. She underwent surgery; she, however, could not be weaned off from cardiopulmonary bypass and died in the operating room. This case illustrates the importance of having a high index of suspicion for iatrogenic aortic dissection following cardiac catheterization as a cause of recurrence of cardiac symptoms, as early detection may help avert a catastrophic outcome, as we report in our patient.

Coronary-Cameral Fistula Connecting the Left Anterior Descending Artery and the First Obtuse Marginal Artery to the Left Ventricle: A Rare Finding.

Coronary-cameral fistulas are rare congenital malformations, often incidentally found during cardiac catheterizations. The majority of these fistulas are congenital in nature but can be acquired secondary to trauma or invasive cardiac procedures. These fistulas most commonly originate in the right coronary artery and terminate into the right ventricle and least frequently drain into the left ventricle. Depending upon their size and location, coronary-cameral fistulas can lead to congestive heart failure, myocardial infarction, and bacterial endocarditis. We describe a case of 49-year-old woman who presented with worsening exertional dyspnea and leg swelling. Transthoracic echocardiogram revealed an ejection fraction of 35%. Cardiac catheterization demonstrated a fistula connecting the left anterior descending artery and the first obtuse marginal artery to the left ventricle. In this report, the authors provide a concise review on coronary fistulas, complications, and management options.

Bone Mineral Density as a Predictor of Atherosclerosis and Arterial Wall Stiffness in Obese African-American Women.

Bone demineralization is associated with higher cardiovascular event rates, possibly due to vascular calcification and accelerated atherosclerosis. African-Americans have less bone loss and less calcium content within atherosclerotic plaques. However, whether loss of bone mass is related to atherosclerosis has not been examined in African-Americans. The objective of this study was to evaluate possible associations between bone mineral density (BMD), carotid intimal-medial thickness (CIMT), and arterial stiffness. We studied 100 obese African-American women (BMI: 26.6 ± 6.2; age: 63 ± 14 years) referred for BMD estimation by dual-energy X-ray absorptiometry scan. BMD (g/cm(2)) was obtained at the lumbar spine (L1-L4), femoral neck, and total hip. Arterial stiffness was evaluated by the heart rate-corrected augmentation index (AI@75) and pulse wave velocity (PWV) using applanation tonometry. CIMT was measured by vascular ultrasound. Mean CIMT, AI@75, and PWV were 0.72 ± 0.14 mm, 28.8 ± 9.0%, and 8.9 ± 1.6 m/s, respectively. Mean BMD values at the lumbar spine, femoral neck, and hip were 0.96 ± 0.19, 0.80 ± 0.16, and 0.91 ± 0.17 g/cm(2). Older subjects had higher CIMT (r = 0.61, p < 0.001) and AI@75 (r = 0.42, p < 0.001). There was a significant correlation between AI@75 and CIMT (r = 0.45, p < 0.001). BMD was negatively correlated with AI@75 (lumbar: r = -0.22, p = 0.03; femoral neck: r = -0.24, p = 0.01; hip: r = -0.21, p = 0.03). BMD was unrelated to CIMT (lumbar: r = -0.09, p = 0.42; femoral neck: r = -0.15, p = 0.17; hip: r = -0.13, p = 0.23). On multivariate analysis, age (p < 0.001), hypertension (p = 0.02), and lumbar BMD (p = 0.01, R(2) = 0.30) were independent predictors of increased AI@75 after adjusting for age, height, and cardiovascular risk factors. These findings were unchanged upon substitution of femoral neck BMD (p = 0.05, R(2) = 0.28) into the model. There was a trend with hip BMD (p = 0.06, R(2) = 0.28) in the regression model. Age-matched comparison between normal BMD (n = 25) and osteoporotic patients (n = 34) demonstrated a significant difference in AI@75 (26.6 ± 8.9 vs. 31.6 ± 9.1%, p = 0.04). In summary, women with lower BMD had increased arterial stiffness. There was no relationship between BMD and atherosclerosis. In conclusion, age, hypertension, and BMD are independent predictors of higher arterial stiffness. Vascular changes are related to bone mineral loss, suggesting lower BMD may increase cardiovascular risk in African-Americans.

Echocardiographic determination of epicardial adipose tissue in healthy bonnet macaques.

BACKGROUND: Nonhuman primates have served as models for human cardiovascular (CV) and metabolic diseases. Recently, echocardiographic measurement of epicardial adipose tissue (EAT) thickness has been shown to be a reliable marker of visceral adiposity, and greater EAT is associated with increased CV risk, left ventricular (LV) hypertrophy, and metabolic syndrome. The objective of the present study was to determine EAT thickness in apparently healthy bonnet macaques and assess its relations with anthropometric and CV variables. METHODS: Echocardiography was performed on 61 monkeys (41 females and 20 males, mean age 13.0 +/- 4.7 years). EAT was measured on the right ventricular free wall in parasternal windows. Applanation tonometry was performed in 25 unselected monkeys using a SphygmoCor pulse wave system. RESULTS: The mean EAT thickness was 2.4 +/- 0.6 mm. EAT thickness was directly correlated with age (r = 0.26, P = 0.04), male gender (r = 0.47, P < 0.01), weight (r = 0.42, P < 0.01), crown-rump length (r = 0.45, P < 0.01), BMI (r = 0.38, P < 0.01), diastolic BP (r = 0.46, P = 0.01), and HR (r = -0.49, P < 0.01). EAT thickness also correlated with augmentation index (r = 0.42, P = 0.04), LV mass (r = 0.48, P < 0.01), and left atrial (LA) diameter (r = 0.26, P = 0.04). Intra- and interobserver coefficients of variation between measurements of EAT were 1.4% and 3.7%. On multivariate analysis adjusting for age, gender, weight, and CRL, EAT was independently related to age and weight (r2 = 0.47, P < 0.01). CONCLUSION: This study found echocardiography to be a feasible and practical method to evaluate EAT in nonhuman primates. In bonnet macaques, EAT thickness correlates with LV and LA dimensions and augmentation index, and is independently related to age and weight.

Effect of reactive hyperemia on carotid-radial pulse wave velocity in hypertensive participants and direct comparison with flow-mediated dilation: a pilot study.

UNLABELLED: This pilot study assessed the effects of hyperemia on carotid-radial pulse wave velocity (PWV) in 39 normotensive (NT) and 23 hypertensive (HT) participants using applanation tonometry. Pulse wave velocity was measured at 1- and at 2-minute intervals. Baseline PWV was similar between the groups (P = .59). At 1 minute, PWV decreased (8.5 +/- 1.2 to 7.1 +/- 1.4 m/s, P < .001) in NT but not in HT (P = .83). Hyperemic PWV (DeltaPWV) response differed between the groups (-16% vs + 1.0%, P < .001). On multivariate analysis, HT, not age or blood pressure was independently related to DeltaPWV (R(2) = .43, P < .01). Among patients with cardiovascular risk factors/disease, DeltaPWV was inversely related to flow-mediated dilation (FMD; R( 2) = .43, P < .003). CONCLUSION: hyperemia decreases PWV(1min) in NT but not in HT. DeltaPWV is inversely related to FMD. Blunted hyperemic PWV response may represent impaired vasodilatory reserve.

Prolongation of QRS duration and axis deviation in the right bundle branch block are not markers for left ventricular systolic dysfunction.

BACKGROUND: Right bundle branch block (RBBB) is not commonly associated with structural heart disease and left ventricular (LV) systolic dysfunction. The purpose of the present study was to determine whether the QRS duration and degree of right axis deviation (RAD) or left axis deviation (LAD) in patients with RBBB predicted a subset of patients with significant LV systolic dysfunction. METHODS: In the present prospective study, 75 of 200 consecutive patients with RBBB had their ejection fraction (EF) evaluated by echocardiography. The relationship among QRS duration, axis and EF was derived. RESULTS: There were no significant differences in sex and EF among the patients with a normal axis, RAD or LAD. The EFs of patients with a normal axis (n=27), RAD (n=15) and LAD (n=33) were 52±15%, 49±14% and 46±17%, respectively (P=0.35). The mean EF (46±16%) of patients with a QRS duration of 150 ms or greater (n=53) was not significantly different from the mean EF (49±18%) of patients with a QRS duration of less than 150 ms (n=22) (P=0.54). For patients with a QRS of 120 ms or greater and less than 150 ms (n=22), QRS of 150 ms or greater and 180 ms or less (n=48), and QRS of greater than 180 ms (n=5), the mean EFs were 49±18%, 47±16% and 44±7%, respectively (P=0.78). There was no significant correlation between QRS duration and EF in all patients (r=0.03, P=0.83), EF and RAD (r=0.38, P=0.16) or EF and LAD (r=0.26, P=0.14). CONCLUSIONS: In patients with RBBB, the QRS duration and axis do not have a significant relationship with EF. Furthermore, prolongation of the QRS duration (150 ms or greater) in the presence of RBBB is not a marker of significant LV systolic dysfunction.

The effects of passive leg raising on arterial wave reflection in healthy adults.

BACKGROUND: Passive leg raising (PLR) produces hemodynamic and physiological changes related to centralizing blood volume and baroreceptor activation. METHODS/RESULTS: To evaluate the effects of PLR on central hemodynamics, we prospectively studied 50 healthy participants (80% male, age 37 +/- 12 years). Central aortic blood pressures (CA-BPs) and reflected wave properties were evaluated using applanation tonometry at baseline and upon 1 min of PLR. Heart rate (HR) was unchanged. Brachial artery (BA)-systolic BP, BA-diastolic BP, and BA-pulse pressure (PP) all decreased from baseline to PLR. Changes in BA-PP were significantly greater than changes in CA-PP. Reflected wave augmentation pressure (P(s)-P(i)), HR corrected augmentation index (AIx@75), and augmentation index decreased significantly [(P(s)-P(i)): 5 +/- 6 vs. 4 +/-5, P < 0.001; AIx@75%: 10 +/- 13 vs. 7 +/- 12, P = 0.004; AI%: 14 +/- 12 vs. 12 +/- 12, P = 0.014, respectively]. HR corrected ejection duration (ED(c)), round trip travel time (deltat(p)), and reflected wave systolic duration (deltat(r)) all increased upon PLR [ED(c): 433 +/- 15 vs. 444 +/- 17, P < 0.001; deltat(p): 149 +/- 18 vs. 156 +/- 20, P = 0.003; deltat(r): 174 +/- 33 vs. 179 +/- 32, P = 0.046, respectively]. Indices of left ventricular (LV) workload including wasted LV energy and tension-time index decreased upon PLR. CONCLUSION: PLR decreases the amplitude and delays the onset of the reflected aortic pressure wave. This decreases wasted LV pressure energy and workload.

Indices of arterial stiffness in African American and African Caribbean subjects.

BACKGROUND: African American and African Caribbeans have high cardiovascular morbidity/mortality. Increased arterial stiffness is a marker of subclinical atherosclerosis, predicts higher cardiovascular risk, and causes isolated systolic hypertension. The objectives of the study were to compare arterial stiffness indices in African Americans and African Caribbeans and obtain reference values. METHODS/RESULTS: We prospectively studied 449 African Americans and 454 African Caribbeans. Using applanation tonometry, mean augmentation index and carotid-to-radial pulse-swave velocity were similar between the 2 groups (23 +/- 15 vs 24 +/- 14%, p = .20) and (9.0 +/- 1.9 vs 9.0 +/- 2.0 m/s, p = .86). On multivariate analysis, age, weight, gender, mean arterial pressure, heart rate, and family history of coronary artery disease were independently associated with augmentation index in African Americans (R2, 0.46) and African Caribbeans (R2, 0.49). Among 94 African American and 98 African Caribbean healthy subjects without cardiovascular risk factors/disease, augmentation index (20 +/- 14 vs 18 +/- 16%, p = .43) and pulse-wave velocity (8.9 +/- 1.9 vs 9.0 +/- 1.5 m/s, p = .92) were similar. Age-based normative values were determined. CONCLUSION: Augmentation index and pulse-wave velocity and their related clinical factors are similar between African Americans and African Caribbeans. Age, weight, female gender, mean arterial pressure, heart rate, and family history of coronary artery disease are independent predictors of higher augmentation index in African Americans and African Caribbeans. Whether increased arterial stiffness improves risk stratification in these populations merits further study.

Characterization of arterial wave reflection in healthy bonnet macaques: feasibility of applanation tonometry.

Nonhuman primates are commonly used in cardiovascular research. Increased arterial stiffness is a marker of subclinical atherosclerosis and higher CV risk. We determined the augmentation index (AI) using applanation tonometry in 61 healthy monkeys (59% female, age 1-25 years). Technically adequate studies were obtained in all subjects and required 1.5 +/- 1.3 minutes. The brachial artery provided the highest yield (95%). AI was correlated with heart rate (HR) (r = -0.65, P < .001), crown rump length (CRL) (r = 0.42, P = .001), and left ventricular (LV) mass determined using echocardiography (r = 0.52, P < .001). On multivariate analysis, HR (P < .001) and CRL (P = .005) were independent predictors of AI (R2 = 0.46, P < .001). Body Mass Index (BMI) and AI were independent predictors of higher LV mass on multivariate analysis (P < .001 and P = .03). In conclusion, applanation tonometry is feasible for determining AI. Reference values are provided for AI in bonnet macaques, in whom higher AI is related to HR and CRL, and in turn contributes to higher LV mass.

QPV interval as a measure of arterial stiffness in women with systemic lupus erythematosus.

BACKGROUND: Systemic lupus erythematosus (SLE) is associated with premature atherosclerosis and increased arterial stiffness. The QPV interval has been proposed as a measure of arterial stiffness. The QPV interval is based on the premise that transit time from cardiac ejection to brachial artery flow is shortened in patients with increased arterial stiffness. HYPOTHESIS: The objective of this study was to determine the significance of the QPV interval as a measure of arterial stiffness in patients with SLE. METHODS: We prospectively studied 46 female SLE patients. The QPV interval was calculated as the time from onset of the QRS complex to peak flow velocity of the brachial artery during ultrasound examination. Measurements of arterial stiffness: augmentation index (AI) and pulse wave velocity (PWV) were obtained by applanation tonometry while patients were on a stable medical regimen. RESULTS: Mean age was 44+/-14 y and mean QPV interval was 198+/-18 msec QPV interval correlated inversely with age (r=-0.39, p=0.008), AI (r=-0.41, p=0.004), PWV (r=-0.39, p=0.007), and aortic pulse pressure (PP) (r=-0.45, p=0.002). On multivariate regression analysis, QPV interval was found to be an independent predictor of PWV after adjusting for age (R2=0.26, p<0.001). CONCLUSION: In women with SLE, QPV decreases with age and is inversely related with measures of arterial stiffness. QPV may be useful in identifying SLE patients with higher arterial stiffness in the clinical or research setting. Further larger studies are needed to confirm these preliminary results.

Relationship between aortic atherosclerosis and dental loss in an inner-city population.

Prior studies have suggested an association between atherosclerosis and periodontal disease, both of which are more prevalent in certain minority and economically disadvantaged groups. Few studies have addressed the relationship between cardiovascular disease and dentition among ethnically diverse populations. We studied 131 subjects (60% females, age 59 +/- 15 years) who were referred for clinically indicated transesophageal echocardiography. Dental loss was more severe in patients with hypertension (P < .001), diabetes (P = .05), coronary artery disease (P = .04), and calcium channel blocker use (P = .04). On univariate analysis, maximal aortic intima-media thickness (MAIMT) was significantly correlated with dental loss (r = .40; P < .001). Age was correlated with MAIMT (R = .41; P < .001) and with dental loss (r = .57; P < .001). On multivariate analysis, dental loss (P = .03) and history of coronary artery disease (P = .04) were independent predictors of MAIMT ( R2 = .44). In this inner-city predominantly African American population, atherosclerosis and dental loss are age dependent and are interrelated independent of age.

Left ventricular systolic and diastolic function in healthy adult bonnet macaques (Macaca radiata). New echocardiographic indices in Old World monkeys.

OBJECTIVES: Macaques are used in cardiovascular and metabolic research. We determined echocardiographic-derived reference values of left ventricular (LV) systolic and diastolic function in healthy adult bonnet macaques (Macaca radiata). METHODS: Transthoracic echocardiography was performed during ketamine sedation in 83 (67% female) healthy monkeys (age 7-26 years). RESULTS: Technically adequate studies were obtained in all subjects and required 10.1 +/- 1.3 min of scanning time. Age correlated inversely with the following Doppler indices: E (r = -0.44, p < 0.001), E/A (r = -0.26, p = 0.02), E' (r = -0.45, p < 0.001, E'/A' (r = -0.44, p < 0.001), E/E' (r -0.25, p = 0.03), S' (r = -0.33, p = 0.003), Vp (r = -0.26, p = 0.049). LV mass was more strongly correlated with crown rump length (r = 0.72, p < 0.001) and body surface area (r = 0.70, p < 0.001) than with body mass index (r = 0.47, p < 0.001) and weight (r = 0.63, p < 0.001). CONCLUSIONS: This study demonstrates echocardiography is feasible for characterizing LV function. Age-related changes in Doppler indices in primates are similar to those in humans. LV mass is more closely related to fat-free mass indices. We provide reference values for LV systolic and diastolic function in adult bonnet macaques across the captive life span.

The relationship between effective arterial capacitance and pulse wave velocity is dependent on left ventricular stroke volume.

BACKGROUND: increased arterial stiffness is a predictor of cardiovascular events. The stroke volume (SV) to pulse pressure (PP) ratio is an estimate of arterial capacitance. Pulse wave velocity (PWV) is a measure of arterial stiffness. This study evaluated the effect of left ventricular (LV) SV on the SV/PP-PWV relationship. METHODS: 97 patients had applanation tonometry and echocardiography to measure arterial capacitance (SV/PP), PWV, and central aortic pressure. RESULTS: 50 patients had normal SV and 47 had low SV. For all patients, PWV inversely correlated with SV/PP. PWV and SV/PP correlated more strongly in the normal SV group than in the low SV group. Aortic PP was significantly correlated with PWV in all patients, in the normal SV group, and in the low SV group. CONCLUSION: effective arterial capacitance correlates with PWV. The presence of decreased SV weakens the relationship.

Home blood pressure monitoring in an ethnically diverse inner-city cardiology practice.

OBJECTIVES: To evaluate home blood pressure monitoring (HBPM) in an inner city cardiology practice. DESIGN: Retrospective study. SETTING: Inner city cardiology practice. PATIENTS: Consecutive patients were evaluated for hypertension and had > or = 8 home blood pressure recordings during 2-4 weeks while clinically stable on a medical regimen. MAIN OUTCOME MEASURES: Blood pressure differences, blood pressure load, defined as %HBPM systolic blood pressure readings > 140 and/or diastolic blood pressure readings > 90 mm Hg. RESULTS: 55 patients, (33 female, age 62 +/- 12.5 years). Office systolic, diastolic and mean BPs were higher than HBPM values (147 +/- 19 mmHg vs 139 +/- 17 mmHg, P = < .0001), (86 +/- 10 mm Hg vs 79 +/- 10 mm Hg, P < .0001), and (106 +/- 11 mm Hg vs 99 +/- 10 mmHg, P < .0001) respectively. Office and home pulse pressure (PPs) were similar (61 +/- 17 mm Hg vs 60 +/- 17 mm Hg, P = .42). Office and home PPs were more strongly correlated (r = .78, P < .0001) than were systolic (r = .51, P < .0001), diastolic (r = .51, P < .0001). Blood pressure load increased in a step-wise manner with increasing office blood pressure, 7.5% for patients with office blood pressure < 120/80 mm Hg to 73.5% in patients with office blood pressure > 160/100 mm Hg (P = .02). Office BPs showed 10/55 patients were normal or controlled (blood pressure < 140/ 90 mmHg) and 45 were high or uncontrolled (blood pressure > or = 140/90 mmHg). HBPM reclassified 2/10 patients as high/uncontrolled whereas 17/45 patients became normal/controlled. CONCLUSIONS: Office systolic and diastolic BPs are 7-8 mm Hg higher than home recordings in ethnically diverse patients. Office and home PPs are more strongly correlated than systolic, diastolic or mean arterial BPs. Blood pressure load is related to office BPs. HBPM reclassified approximately one third of the patients. HBPM appears useful in managing minority populations with hypertension.

Association of beta-blocker use with increased aortic wave reflection.

Studies have found less cardiovascular risk reduction in patients treated with beta-blockers (BBs) compared with other agents. We compared the severity of aortic atherosclerosis, arterial stiffness, and wave reflection in patients treated and not treated with BBs. Seventy-two patients, 37 treated with BBs and 35 not treated, referred for transesophageal echocardiography were studied. Augmentation index (AI), heart-rate-corrected AI (AI-75), aortic systolic (SBP) and diastolic blood pressure, pulse wave velocity (PWV), and aortic intima-media thickness (MAIMT) were measured. There were no differences in MAIMT (2.8 +/- 1.6 mm vs. 2.4 +/- 1.2 mm, P = .20) and PWV (8.9 +/- 2.0 m/s vs. 8.5 +/- 2.6 m/s, P = .46) between the BB and non-BB groups. The BB group had higher AI (28.7 +/-11.9% vs. 22.3 +/- 14.1%, P = .04), AI-75 (27.7 +/- 10.7% vs. 20.1+/- 11.0%, P = .005), aortic SBP (140 +/- 21 mm Hg vs. 125 +/- 21 mm Hg, P = .01), and aortic pulse pressure (62 +/- 20 mm Hg vs. 47 +/- 19 mm Hg, P = .01) than the non-BB group despite similar brachial blood pressure. BB use was associated with increased aortic wave reflection despite similar degree of aortic atherosclerosis.

The effects of head-out-of-water immersion on arterial wave reflection in healthy adults.

Swimming/hydrotherapy produces hemodynamic and physiological changes related to water immersion (WI). To evaluate the effects of head out (HO) WI on central hemodynamics, we prospectively studied 21 healthy subjects (62% male, age 37 +/- 13 years). Central aortic blood pressures (CA-BPs) and reflected wave properties were evaluated using applanation tonometry at baseline and upon 2 minutes of waist (W) and mid-chest (C) HOWI. Heart rate (HR) decreased from 83 +/- 15 to 73 +/-10 beats/min (P < .001). Brachial artery pulse pressure (PP) was unchanged (45 +/- 11 to 46 +/- 7 mm Hg; P = .20), CA-PP increased stepwise (27 +/- 7 to 32 +/- 8 to 33 +/- 6 mm Hg; P < .001). Reflected wave amplitude (P(s) - P(i)), and HR-corrected augmentation index (AI(a)@75) increased stepwise from baseline-W-C level HOWI [(P(s) - P(i)): 2 +/- 3 to 7 +/- 4 mm Hg, P < .001; AI(a)@75: 8 +/- 11 to 19 +/- 10%; P < .001]. HR-corrected ejection duration (ED(c)) and reflected wave systolic duration (Deltat(r)) increased progressively (ED(c): 389 +/- 23 to 408 +/- 25 to 435 +/- 13 milliseconds; P < .001; Deltat(r): 106 +/- 32 to 165 +/- 21 ms; P < .001). Indices of left ventricular (LV) workload including wasted LV energy subendocardial viability and tension time index increased upon HOWI. HOWI increases the amplitude and the duration of the reflected aortic pressure wave, increases wasted LV pressure energy, workload, and oxygen demand.

Relationship between aortic atherosclerosis and non-invasive measures of arterial stiffness.

Both increased arterial stiffness and atherosclerosis are risk factors for cardiovascular morbidity and mortality. We studied the relationship between aortic atherosclerosis, assessed by measuring maximal aortic intima-media thickness (MAIMT) on transesophageal echocardiography and aortic stiffness, measured by applanation tonometry. Eighty-one patients (28 men, 53 women, mean age 61+/-13 years) referred for transesophageal echocardiography were studied. Augmentation index (AI) and carotid-radial pulse (PWV) wave velocity were measured using a SphygmoCor tonometer (Atcor Med., Australia). MAIMT was correlated with AI and age (r=0.35, p=0.002 and r=0.36, p=0.001), respectively. There were no relations between MAIMT and either aortic pulse pressure (A-PP) (r=0.10, p=0.35) or PVW (r=-0.38, p=0.76). Multivariate regression analysis revealed that AI and age were independently related to MAIMT. In this middle-aged predominantly African-American population structural aortic atherosclerosis and aortic stiffness as measured by AI are age dependent and are inter-related, independent of age.