Nocturnal Non-dipping Blood Pressure Profile in Black Normotensives Is Associated with Cardiac Target Organ Damage.

PURPOSE: A non-dipping pattern of nocturnal blood pressure in hypertensive patients is an established predictor of cardiovascular risk, especially in Blacks. However, data on non-dipping normotensives and cardiovascular risk in this population is sparse. In this study, we aim to determine if a non-dipping profile in a cohort of Black normotensives is associated with cardiac target organ damage. METHODS: We studied ambulatory blood pressure patterns in 43 normotensive Black patients of Caribbean origin and classified their profiles as dippers (DP) and non-dippers (NDP) based on their nocturnal blood pressure profiles. Cardiac target organ damage was estimated from 2-D echocardiogram. RESULTS: The mean age of the cohort was 52 years. Both groups were similar with respect to baseline age, sex, weight, height, body mass index and daytime ambulatory BP. There was a statistically significant difference in nocturnal blood pressure between DP and NDP groups (112 ± 7/64 ± 2 mm Hg vs 117 ± 3/69 ± 2 mm Hg, P=.004). The NDP cohort showed evidence of cardiovascular target damage on echocardiography with a significantly increased relative wall thickness (.35 ± .07 cm vs .42 ± .05 cm, P=.001), left ventricular mass index (95 ± 14 vs 105 ± 14 g/m(2), P=.018) and left atrial volume index (26 ± 3.5 vs. 30 ± 3.4, P=.001). Left ventricular geometry in the non-dippers also showed increased concentric remodeling, concentric and eccentric hypertrophy. CONCLUSIONS: Our study demonstrates that nocturnal non-dipping of blood pressure in normotensive Blacks of Caribbean origin may be associated with cardiovascular end organ damage thereby providing new surveillance and therapeutic targets.

Focused cardiac ultrasound in pregnancy.

Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.

COVID-19 and the heart: An update for clinicians.

SARS-CoV-2, the cause of the COVID-19 pandemic has significantly impacted cardiovascular healthcare. Patients with pre-existing cardiovascular disease are at higher risk of morbidity and mortality. The virus may affect the heart directly and indirectly with clinical syndromes of acute myocardial injury, myocarditis, acute coronary syndromes, heart failure, arrhythmias, and venous thromboembolism. Some therapeutics under investigation for COVID-19 may also have adverse cardiac effects. The involvement of the RAAS system in viral entry makes it pertinent to consider the effects of medications that modulate the system. Comprehensive knowledge of peculiar cardiovascular manifestations of COVID-19 and the role of RAAS in the prognosis of COVID-19 disease is needed for optimal patient management.

Sub-Saharan Africa Tackles COVID-19: Challenges and Opportunities.

As of May 2020, the global COVID-19 pandemic had reached 187 countries with more than 3.7 million confirmed cases and 263,000 deaths. While sub-Saharan Africa (SSA) has not been spared, the extent of disease is currently far less than in Europe or North America leading some to posit that climatic, genetic or other conditions will self-limit disease in this location. Nonetheless, infections in tropical Africa continue to rise at an alarming pace with the potential to soon exceed health resource availability and to exhaust a health care workforce that is already grossly under supported and ill-equipped. This perspective outlines the context of COVID-19 disease in Africa with a focus on the distinctive challenges faced by African nations and a potential best path forward.

Signal-averaged P-wave analysis of normal controls and patients with paroxysmal atrial fibrillation: a study in gender differences, age dependence, and reproducibility.

BACKGROUND: Atrial fibrillation is often first recognized after a complication such as embolic stroke has occurred. Limited data are available for the prospective identification of patients at risk for developing atrial fibrillation. HYPOTHESIS: Demonstration of areas of slow conduction in the atrium by means of P-wave signal averaging may identify individuals at risk for atrial fibrillation. METHODS: P-wave signal averaging from the surface electrocardiogram was performed in 199 normal controls and 81 patients with paroxysmal atrial fibrillation using an automated, P-triggered, high-resolution signal for analysis. RESULTS: Of the variables measured, the filtered P-wave duration and P-wave integral were significantly different between controls and patients (filtered P-wave duration 120 +/- 9 vs. 145 +/- 21 and P-wave integral 666 +/- 208 vs. 868 +/- 352), whereas the terminal root-mean-square (RMS) voltages (RMS 20, RMS 30, RMS 40) showed no significant differences between the two groups. Regression analysis of the first and second measurement of the filtered P-wave duration obtained during consecutive tests showed excellent reproducibility (r and r2 of 0.96 and 0.92). The duration of the filtered P wave showed no age dependence but was shorter in women. CONCLUSION: Utilizing the 90th percentile value of the filtered P-wave duration of 133 ms in men and 130 ms in women, the sensitivity was 80 and 81%, the specificity 92 and 90%, the positive predictive value 84 and 73%, and the negative predictive value 90 and 93%, respectively.

Improving cardiovascular disease prevention and management in Africa: issues to consider for the 21st century.

There is substantial evidence that cardiovascular diseases, and their associated risk factors, are becoming an increasing threat to the health of a large portion of the populace in many areas of Africa, particularly sub-Saharan Africa. If not adequately addressed, this epidemic will place an even greater burden on the poor economies and weak public health infrastructures of this continent. Important strategies for curtailing this epidemic will include primordial, primary, and secondary prevention, population-based prevention programs, improved research and surveillance, and increased governmental accountability for the adequate appropriation of public health.

Myocardial Contrast Echocardiography in the Evaluation of Hypertensive Heart Disease.

Myocardial contrast echocardiography (MCE) has an established role in left ventricular assessment by improving the ventricular opacification and endocardial border definition especially in patients with sub-optimal echocardiographic images. With advances in cardiac ultrasound imaging technology and the development of new contrast agents, the clinical utility of this technique has greatly expanded to include assessment of coronary reperfusion in the setting of acute myocardial infarction, determination of myocardial viability within infarct zones as well as assessment of coronary microcirculation and flow reserve in patients with microvascular coronary disease. Improvements in image quality with intravenous contrast agents can facilitate image acquisition and enhance delineation of regional wall motion abnormalities at peak levels of exercise. Numerous studies have confirmed the clinical utility of contrast enhancement during echocardiographic studies, particularly in patients undergoing stress testing. In this paper, we explore the evidence in support of MCE and its potential clinical applications. Our review aims to summarize (1) the basic principles of myocardial contrast echocardiography including recent advances in the ultrasound technology and contrast agents (2) its clinical applications in the diagnosis of cardiovascular diseases and finally, (3) its potential role in risk stratification and assessment of microvascular perfusion in patients with hypertensive heart disease.