Central systolic blood pressure (cSBP) to brachial systolic blood pressure (brachSBP) ratio reproducibility during antihypertensive therapy.

OBJECTIVES: Higher CSBP than brachial SBP in individual patient increases cardiovascular (CV) risk. For follow-up it is important to assess the reproducibility of such measurements. The aim of this study was to assess the reproducibility of these differences, expressed as a CSBP/BrachSBP ratios. SUBJECTS AND METHODS: Eighty-three patients on antihypertensive therapy were analysed for the reproducibility of such ratios after time interval of several month up to several years. For CSBP estimation, we used the Arteriograph (Tensiomed Ltd.), based on blood pressure measurements by cuff on oscillometric principle, using pulse wave analysis (PWA) for assessment of CSBP. RESULTS: The proportion of patients retained the same characteristics (either higher central or higher peripheral SBP) between the first and second measurement was 71.1 %. The association between 1st and 2nd measurement, was statistically significant, p < 0.001. CONCLUSION: In our study, a high proportion (60 %) of treated hypertensive patients had CSBP higher than brachial SBP, which may adversely influence their prognosis. This characteristic is highly reproducible. Taking into the account these differences may increase the exactness of CV risk estimation and may contribute to explanation of residual risk of individual patient (Tab. 3, Fig. 1, Ref. 28).

Holter ECG findings in diabetics with medial arterial calcification.

OBJECTIVES: Medial arterial calcification (MAC) is a nonobstructive condition leading to reduced arterial compliance. The disease most commonly occurs in diabetes mellitus. Decreased ankle-brachial pressure index (ABI) is a well-known marker of increased cardiovascular mortality. However, also the values of ABI above 1.3, typical in MAC, are associated with increased mortality. METHODS: By means of Holter ECG monitoring, we investigated 41 patients (25 men, 16 women) with mean age of 59±8 years, suffering of type 2 diabetes mellitus and identified as having MAC, and Holter ECG monitoring with an average duration of recording 22.36 hours, was carried out by GE-Marquette MARS ECG Holter system. RESULTS: We found frequent incidence of cardiac arrhythmias and myocardial ischemia in 22 patients (53.7 %). Only 19 patients (46.3 %) had normal Holter ECG recordings. ABI values were significantly higher in patients with abnormal ECG Holter recordings. CONCLUSION: Our results confirm the importance of ABI estimation in clinical practice. As the central goal of therapy for patients with myocardial ischemia and/or complex forms of cardiac arrhythmias is the reduction or elimination of these episodes. Ambulatory Holter ECG monitoring plays an important role in the management of these patients (Tab. 7, Ref. 16).

Central systolic blood pressure increases with aortic stiffness.

OBJECTIVES: Central systolic blood pressure (CSBP) is the pressure in the root of aorta, which directly influences organs such as brain, heart and kidneys and is related to organ damage. Its value increases with the aortic stiffness. The aim of this study was to analyze the relationships of CSBP to aortic stiffness parameters. METHODS: Central blood pressure (BP) and related parameters were measured by Arteriograph, working based on oscillometric principle, using pulse wave analysis (PWA) approach. We examined 123 patients (69 females, 54 males) with a primary hypertension. RESULTS: Using a linear correlation analysis, we found that CSBP was correlated to aortic pulse wave velocity (PWV), aortic and brachial pulse pressure (PP), aortic augmentation index, return time of reflected pressure wave (RT) and aortic and brachial augmentation indexes. Multivariate analysis defines the aortic pulse pressure (PPao) as the most powerful parameter influencing CSBP. By an individual analysis of BP in each patient separately, we defined two different types of central hemodynamics; those with a higher CSBP than brachial SBP occur in stiffer aorta. CONCLUSION: The CSBP increases with aortic PP, the most powerful stiffness parameter of aorta. Higher CSBP than brachial SBP usually accompanies a stiffer aorta (Tab. 5, Ref. 19).

Metabolic syndrome and its effect on aortic stiffness in premenopausal women.

BACKGROUND: Metabolic syndrome (MS) is a cluster of proatherogenic risk factors (RF) (abdominal obesity, atherogenic dyslipidemia, impaired fasting glucose or type 2 diabetes mellitus, higher blood pressure or antihypertensive therapy) that move patients into a higher risk for development of cardiovascular disease (CVD) and type 2 diabetes. The preclinical (subclinical) target organ diseases (SOD) are early signs of atherosclerosis. An increased aortic stiffness characterised by an increased pulse wave velocity in aorta (PWV Ao) is one of SOD.The aim of the present study was to assess the impact of metabolic syndrome (MS) on aortic wall stiffness and the risk profile in premenopausal women. METHODS: The aortic stiffness was measured using Arteriograph-Tensiomed, based on oscillometric measurement and analysis of the shape of brachial pulse wave, giving the PWV Ao. The results of measurements characterise a global aortic stiffness. RESULTS: We examined 81 premenopausal women (without history of CVD). The MS (according to the 2009 "harmonizing" definition) was present in 31 women (mean age 41.5 y), in the control group, there were 50 women (39 y). The most frequent components of MS were abdominal obesity (93 % vs 42%), arterial hypertension (68 % vs 10 %) and dyslipidemia (29 % vs 8 %). The PWV Ao was significantly higher in women with MS (9.26 m/s) compared to the control group (7.44 m/s). CONCLUSION: The aortic stiffness in women with MS compared to controls was significantly higher despite a presumed general protective hormonal effect on cardiovascular system in women with child-bearing potential (Tab. 4, Ref. 25).

[Impact of aortic stiffness on central hemodynamics and cardiovascular system]. / Vplyv tuhosti aorty na centrálnu hemodynamiku a na kardiovaskulárny systém.

Arterial stiffness increases as a result of degenerative processes accelerated by aging and many risk factors, namely arterial hypertension. Basic clinical examination reveals increased pulse pressure as its hemodynamic manifestation. The most serious consequence of increased vascular stiffness, which cannot be revealed by clinical examination, is a change of central hemodynamics leading to increased load of left ventricle, left ventricular hypertrophy, diastolic dysfunction and to overall increase of cardiovascular risk. This review aimed to point at some patophysiological mechanisms taking part in the development of vascular stiffness, vascular remodeling and hemodynamic consequences of these changes. This work also gives an overview of noninvasive examination methods and their characteristics enabling to evaluate the local, regional and systemic arterial stiffness and central pulse wave analysis and their meaning for central hemodynamics and heart workload.

[Left ventricular end-systolic wall stress during antihypertensive treatment]. / Systolický wall stress l'avej komory srdca pri antihypertenzívnej liecbe.

INTRODUCTION: The mechanical load of left the ventricular wall by blood pressure generated during systole causes a strain associated with the impedance to ventricular emptying. Among several indices, the circumferential systolic wall stress is used to describe this load. The calculated stress depends on systolic blood pressure, wall thickness and ventricular cavity dimension. Methods enabling noninvasive quantification of those indices are based on echocardiographic examinations and blood pressure measurements. Left ventricular hypertrophy in hypertension is considered as a compensatory mechanism allowing the heart to withstand the hemodynamic strain associated with increased arterial pressure. SUBJECTS AND METHODS: In the group of 25 female patients with treated arterial hypertension with suboptimal blood pressure levels in the initial evaluation, we realized echocardiographic examination and calculated left ventricular mean circumferential systolic wall stress. The re-evaluation was done after achieving the target blood pressure levels (below 140/90 mm Hg) in the time interval of 6 month to 2 years. RESULTS: The statistically significant decrease of systolic wall stress was mainly due to lowering of blood pressure. The next favourable factor was diminishing of the left ventricular end-diastolic diameter, though the difference was not statically significant. By the multiple regression analysis we found that the final significant lowering of systolic wall stress was influenced also by favourable geometrical remodelling of the left ventricle by the tendency of diminishing of left ventricular diastolic diameter and the increase of relative wall thickness. CONCLUSION: We considered repeated echocardiographic examination and the systolic wall stress calculation (which integrates the ventricular geometry with the blood pressure values achieved) as an appropriate parameter for evaluation of the effect of antihypertensive therapy in the long-term management of hypertensive patients.

[Risk profile of hypertensive patients]. / Rizikový profil hypertonika.

INTRODUCTION: Arterial hypertension is an important component of global cardiovascular risk profile of an individual patient. Estimation of global cardiovascular risk besides the blood pressure level incorporates all risk factors (RF), preclinical cardiovascular diseases (hypertension--induced target organ disease--TOD) and associated clinical conditions, and it should influence the therapy and long-term patient management. A group of metabolic risk factors comprizes several modifyable risk factors, detection of which influences the antihypertensive drug selection. The main goal of antihypertensive therapy is to achieve maximum reduction in the long-term total risk of cardiovascular disease, treating all modifyable risk factors in hypertensive patients. PATIENTS AND METHODS: In this work we present the results of group of 60 hypertensive patients examined for different risk factors detection and subsequent total cardiovascular risk estimation. RESULTS: The mean number of risk factors per patient was 4,1 (3% of patients had two RF, 22% of patients had three RF, 37% patients had four factors and 38% patients had five RF present). The ischaemic heart disease was found more frequently among hypertensives with higher number of RF. Metabolic syndrom (MS) was present in 53% of patients. Hypertensives with MS have higher rate of RF (4.9 per person) comparing to thouse without MS (3.6 RF per person). CONCLUSION: We found a quite high number of RF per individual hypertensive patient; the serious unfavourable consequence of this finding was the increased rate of coronary heart disease with the increasing number of risk factors found.

[Metabolic syndrome and aortic stiffness]. / Metabolický syndróm a tuhost' aorty.

INTRODUCTION: The metabolic syndrome (MS) is a cluster of risk factors that move the patient into higher level of risk category of cardiovascular disease and the probability of type 2 diabetes mellitus manifestation. Definition of MS is s based on the presence of selected risk factors as: abdominal obesity (lager waist circumpherence), atherogenic dyslipidemia (low value of HDL-cholesterol and increased level of triglycerides), increased fasting blood glucose (or type 2 DM diagnosis), higher blood pressure or antihypertensive therapy. In 2009 there were created harmonizing criteria for MS definition; the condition for assignment of MS is the presence of any 3 criteria of 5 mentioned above. The underlying disorder of MS is an insulin resistance or prediabetes. The patients with MS more frequently have subclinical (preclinical) target organ disease (TOD) which is the early sings of atherosclerosis. Increased aortic stiffness is one of the preclinical diseases and is defined by pathologically increased carotidofemoral pulse wave velocity in aorta (PWV Ao). With the aim to assess the influence of MS on aortic stiffness we examined the group of women with arterial hypertension and MS and compare them with the group of women without MS. PATIENT AND METHODS: The aortic stiffness was examined by Arteriograph--Tensiomed, the equipment working on the oscillometric principle in detection of pulsations of brachial artery. This method determines the global aortic stiffness based on the analysis of the shape of pulse curve of brachial artery. RESULTS: From the cohort of 49 pts 31 had MS, the subgroups did not differ in age or blood pressure level. The mean number of risk factors per person in MS was 3.7 comparing with 1.7 in those without MS. In the MS group there was more frequently abdominal obesity present (87% vs 44%), increased fasting blood glucose (81% vs 22%) and low HDL-cholesterol level. The pulse wave velocity in aorta, PWV Ao, was significantly higher in patients with MS (mean value 10,19 m/s vs 8,96 m/s without MS). CONCLUSION: The higher PWV Ao indicates a higher aortic stiffness in patients with MS and more severe subclinical target organ damage of cardiovascular system.

24-h ambulatory blood pressure, daytime and nighttime urinary albumin and retinol-binding protein excretion in type I diabetic patients.

We studied 24-h ambulatory blood pressure (SBP, DBP), actual glycemic control assessed from seven blood glucose measurements, 16-h daytime and 8-h nighttime urinary excretion of albumin (UAE) and retinol-binding protein (URBP) in 20 normoalbuminuric (group A, nighttime UAE < 20 micrograms/min) and 20 microalbuminuric and low-proteinuric type I diabetic patients (group B, nighttime UAE 20-500 micrograms/min) matched for age and diabetes duration. Glycemic control was similar in the two groups. Daytime and nighttime SBP and DBP were higher in group B compared to group A (p < 0.01). Nighttime decrease in SBP and DBP correlated with nighttime decrease in UAE in group B (p < 0.05, p < 0.001), but not in group A. There was no correlation between BP and actual glycemic control in either group. We found higher daytime and nighttime URBP in group B compared to group A (p < 0.05). We conclude that, in microalbuminuric and low-proteinuric patients, daytime and nighttime BP was elevated but still in the normal or borderline range, and nighttime decrease in BP correlated with nighttime decrease in UAE but not with actual glycemic control. Increased URBP in these patients suggests slightly impaired proximal tubular function in early stages of diabetic nephropathy.

[Thrombolytic therapy of acute myocardial infarct]. / Trombolytická liecba akútneho infarktu myokardu.

In the period of two years the authors treated at the coronary care unit 146 patients inflicted by the acute myocardial infarction (AMI). In 15 of them (13 men, 2 women, 13 times Q and twice non-Q, 5 times anterior, 10 times inferior) they performed intravenous thrombolytic treatment by use of streptokinase. The success rate of the thrombolytic therapy was evaluated by noninvasive markers: 1.) rapid withdrawal of chest pain, 2.) rapid (in 6 hours) and essential improvement of ST segment elevation and 3.) presence of reperfusion arrhythmias (in 6 hours). The authors detected insufficient medicinal conciousness among their health district population as regard to their response after the AMI origin (absolute majority of patients delayed their arrival). Minor complications due to therapy (allergy and minor local hemorrhage) occurred in 4 patients. Nobody died. Only those cases were considered as being successful, in which all three success rate markers were present. This condition was fulfilled in 8 patients (i.e. in 53% of cases) and with minor insufficiencies in further two patients (which would increase the percentage of the success rate to 67%). This success rate of the thrombolytic therapy ranges within the limits given by literature. In five patients the authors evaluated the behaviour of the left ventricular asynergy (its range and index) prior to and following the thrombolytic therapy and this examination they consider to be appropriate for observance of the thrombolytic therapy success rate in patients with AMI. (Tab. 3, Ref. 20.).

[The pre-hospitalization period in acute myocardial infarct]. / Predhospitalizacná fáza akútneho infarktu myokardu.

The therapy of AMI is aimed at the prevention of death, minimalization of discomfort caused by the disease and the reduction of the infarction focus (as soon and as markedly as possible) since the success of this step links with the later short-term as well as the long-term prognoses of the patient. (Tab. 2, Ref. 15.)

[Left ventricular hypertrophy in hypertension]. / Hypertrofia l'avej komory u hypertonikov.

Left ventricular hypertrophy LVH is supposed to be a useful marker of cardiovascular complications during the course of hypertension. Occurrence of other risk factors of atherosclerosis in these hypertensive patients such as hyperlipidemia and smoking deteriorate the prognosis too. The authors compared clinical findings in hypertensive patients with and without left ventricular hypertrophy defined by echocardiography. Hospital records of 185 hypertensive patients treated at our medical department during years 1996-1999 were analysed. Left ventricular hypertrophy was defined by echocardiography (Penn convention) as left ventricular mass index > 134 g/m2 in men and > 110 g/m2 in women. Presence of LVH was found in 109 patients (mean age 66.7 years), absence of LVH in 76 patients (mean age 64.7 years). Both groups of hypertensive patients were matched by demographic parameters by the presence of hyperlipidemia and by smoking habits. Hypertensive patients with diabetes mellitus and obesity were excluded. They were statistically significant in the incidence of heart failure, myocardial infarction, renal failure and mitral regurgitation, and non-significant in the incidence of left ventricular diastolic dysfunction. There were more cardiovascular complications in LVH-positive patients than in those with LVH-negative findings. The incidence of stroke was slightly higher in LVH-negative patients. Left ventricular hypertrophy in patients with hypertension brings usually a complicated course of the disease. The authors recommend to examine the patients with arterial hypertension for the presence of left ventricular hypertrophy as it complicates the course of the disease significantly. (Tab. 3, Fig. 2, Ref. 26.)

[Time delay in acute myocardial infarct]. / "Time-delay" pri akútnom infarkte myokardu.

The authors present their experience concerning the time-delay in 357 patients with acute myocardial infarction admitted to the coronary unit over the years 1988-1991. This time indicator was evaluated by using two approaches, i.e. the global time-delay (the time between the onset of the patient's complaints and his/her admission to the coronary unit) and patient's time-delay (the time between the onset of the patient's complaints and his/her decision to notify the health care service). Arbitrary criteria were set up: 10 hours for the former and 5 hours for the latter parameter. The established criteria were met by 40% of the patients. Only 24% of the patients presented at the coronary unit within 6 hours, and these could receive thrombolytic treatment. The decision time (patient's time-delay) amounted that the education level of our population has to be enhanced so as to increase the number of patients with acute myocardial infarction presenting at the coronary unit at an early stage. (Tab. 1, Ref. 9.)

The occurrence of malignant carcinoid syndrome in patients with carcinoid tumors.

BACKGROUND: The carcinoid syndrome occurs in about 10% of patients with carcinoid tumors. OBJECTIVES: The main objective of the present study was to determine the presence of the carcinoid syndrome in a group of patients with carcinoid tumor. SUBJECTS AND METHODS: 35 pts with carcinoid tumors (group A--24 pts with metastatic disease, group B--11 pts after resection of the primary tumor with no metastases detected at the time of the investigation) were included into the study. The localisation and the diameter of the primary tumor were ascertained. Somatostatin receptor scintigraphy--Octreoscan and echocardiography were done. The urinary excretion of 5-HIAA was performed. We estimated the presence of the carcinoid syndrome in all patients. RESULTS: We confirmed the difference in the diameter of the primary carcinoid tumor in patients with metastases--group A 3.0 (2.5-4.2) cm by comparison with group B 0.7 (0.6-0.8) cm, (p < 0.001). Patients in the metastatic group are older 64 year (42-70) than pts without metastases--33 y (20-54) (p < 0.01). The amount of the 5-hydroxyindolacetate acid in urine in pts with metastatic carcinoid was statistically significantly higher than in the pts without metastases (p < 0.001). The carcinoid syndrome in the metastatic group was found in 6 patients (25%), with maximum (12.5%) localised in midgut. Out of the whole sample it counts up to 15.1%. During the follow up period, 8 patients from group A died. CONCLUSION: The large diameter of the primary carcinoid tumor and the higher age are the bad prognostic factors in patients with carcinoid tumors. (Tab. 4, Ref. 27.)

Predhospitalizacna faza akutneho infarktu myokardu.

The therapy of AMI is aimed at the prevention of death, minimalization of discomfort caused by the disease and the reduction of the infarction focus (as soon and as markedly as possible) since the success of this step links with the later short-term as well as the long-term prognoses of the patient. (Tab. 2, Ref. 15.)

Is left ventricular hypertrophy a risk factor in hypertensive patients?

BACKGROUND: Left ventricular hypertrophy (LVH) is supposed to be a risk factor of cardiovascular (CV) complications in hypertensive patients. AIM: To compare clinical events in hypertensives with and without LVH. PATIENTS AND METHODS: 319 hypertensives with LVH (mean age 64.1+/-10.6 ys) and 177 hypertensives without LVH (mean age 62.5+/-11.3 ys). LVH defined by echo Penn convention as left ventricular mass index >134 g/m2 in men and >110 g/m2 in women. Clinical events--heart failure (EF<40 %), left ventricular diastolic dysfunction (echo-doppler: transmitral-flow where peak A>peak E), myocardial infarction (history, ECG, cardiac enzymes), chronic atrial fibrillation (more than 2 weeks duration), mitral regurgitation (echo) and renal involvement (creatininemia>120 micromol/l). The two groups of hypertensives were matched by demographic criteria, duration and intensity of hypertension, obesity, diabetes mellitus, lipid serum levels and smoking habits. RESULTS: There were statistically significant at least p<0.05 more CV events (heart failure, left ventricular diastolic dysfunction, myocardial infarction, chronic atrial fibrillation, and mitral regurgitation cases) and renal involvement in LVH-positive patients than in LVH-negative patients. CONCLUSION: LVH is a strong risk factor for clinical events in hypertensives, which necessitates their more intensive treatment, mainly with drugs producing also LVH regression. (Tab. 5, Ref. 48.)

Relation of left ventricular hypertrophy to cardiovascular complications in diabetic hypertensives.

The presence of diabetes mellitus and other risk factors of atherosclerosis, such as obesity, smoking and hyperlipidemia, in hypertensive patients makes the prognosis worse. Authors compared the clinical findings in diabetic hypertensive patients with and without left ventricular hypertrophy, the presence of which was diagnosed and defined by echocardiography. The study is based on the analysis of hospital records of 115 hypertensive patients treated at our department during the period 1998-1999. Left ventricular hypertrophy (LVH) was defined by echocardiography as left ventricular mass index > 134 g/m2 in men and > 110 g/m2 in women. Left ventricular hypertrophy was found in 79 patients (mean age 64.6 ys) but not in 36 patients (mean age 63.3 ys). Both groups were matched as to age and sex, intensity and duration of hypertension and diabetes, obesity, smoking and hyperlipidemia. In LVH-positive patients, there was a statistically significant incidence of heart failure, mitral regurgitation and renal involvement and a more non-significant incidence of left ventricular diastolic dysfunction, myocardial infarction, chronic atrial fibrillation and stroke than in LVH-negative ones. Left ventricular hypertrophy usually complicates the course of hypertension. Authors recommend to investigate the presence of left ventricular hypertrophy in hypertensives as it carries a much more complicated course of the disease. (Tab. 5, Ref. 28.)

[The electrocardiogram in primary pulmonary hypertension]. / Elektrokardiogram u primárnej plúcnej hypertenzie.

Primary pulmonary hypertension is a rare disease characterized by a rise of arterial pressure in the pulmonary artery without a known cause. The authors define, based on a case-history, the etiopathogenesis of the disease, its diagnosis and approach to treatment. They analyze the contribution of ECG examination for detection of right ventricular hypertrophy and for monitoring the therapeutic success with the finding above all of repolarization changes in the right precordium. The patient had a transplantation of the lungs.

[Long-term electrocardiographic monitoring of patients after acute myocardial infarct]. / Dlhodobé elektrokardiografické sledovanie pacienta po akútnom infarkte myokardu.

The authors present an account on detailed electrocardiographic follow-up of a patient for 12 months after an inferior myocardial infarction. The patient died 14 months after the IM due to arrhythmia after previous remodelling of the left ventricle. The results assembled by means of superstandard methods of signal averaging electrocardiography (method of cumulative amplitudes, RMS signal and frequency analysis) and electrocardiographie body surface mapping (isointegral maps) are confronted with detailed clinical examinations and repeated echocardiographic investigations. The assembled results indicate that the applied superstandard methods make it possible to extract electrocardiographic parameters (presence of pathological high frequency peaks, raised values of partial cumulative amplitudes at the end of the QRS complex at higher frequencies, negative correlation coefficients from comparisons of integral maps with controls) which are a signal that the patient's life is threatened.

[Echocardiographic evaluation of asynergy of the left ventricle in the early stages of acute myocardial infarct and its value in predicting infarct complications]. / Echokardiografické hodnotenie asynergie lavej komory vo vcasnom stádiu akutného infarktu myokardu a jeho vyuzitie k predpovedi komplikácií infarktu.

The authors report on their experience with the semiquantitative echocardiographic evaluation of left ventricular asynergy (group of 36 patients examined by two-dimensional echocardiography, dividing the left ventricle into 20 segments) in the early stage of myocardial infarction and its application in the prediction of complications of infarction. The authors evaluated asynegry using two parameters: RA (range of asynergy and IA (asynergy index) which characterizes the grade of ventricular affection. They describe the calculation of these parameters. The authors revealed a significant correlation (p less than 0.005) between RA or IA and the incidence of decompensation or cardiogenic shock. RA and IA values (median values and scatter) in three groups of patients (non-complicated infarction, complicated infarction and infarction with cardiogenic shock and death) give the opportunity of early stratification of patients with acute infarction. RA above 50% and IA above 20 indicate that the patients is at high risk. On the other hand, RA lower than 25% and IA lower than 5 suggest a minor infarction and probably an uncomplicated course of the disease. In the investigated group anterior infarctions affected a greater mass of the left ventricle than diaphragmatic ones and the higher death rate in this group (20% vs. 14%) was consistent with this.