Previous studies have demonstrated that the time rate of blood pressure (BP) variation was associated with early carotid atherosclerosis, independent of peripheral and central BP levels. We evaluated ...the association between the rate of BP variation, derived from ambulatory BP monitoring (ABPM) data analysis, and the severity and topography of coronary artery lesion in a cohort of normotensive patients with suspected coronary artery disease.
ABPM and coronary angiography were performed in 162 normotensive patients with suspected coronary artery disease. The topography and severity of coronary artery lesions were assessed by Gensini score. The time rate of BP variation was defined as the first derivative of the BP values against time.
Patients with coronary artery disease (n = 123) presented significantly (P = 0.005) higher daytime rate of systolic BP variation than control patients (n = 39). Multiple linear regression models revealed independent determinants of Gensini score in the following rank order: diabetes mellitus (β: +0.286, P < 0.001), daytime rate of systolic BP variation (β: +0.277, P < 0.001), daytime systolic BP (β: +0.216, P = 0.002), smoking (β: +0.178, P = 0.008) and hypercholesterolemia (β: +0.158, P = 0.020). A 0.1 mmHg/min increase in the daytime rate of systolic BP variation correlated with an increment of 4.935 in the Gensini score (95% CI 2.432-7.438).
Steeper BP variations may produce a greater stress on the arterial wall and may have an additive role to vascular risk factors and BP parameters in the detection of the severity of coronary artery lesions in normotensive individuals with suspected coronary artery disease.
BACKGROUND AND PURPOSE—We aimed to assess if renal function can aid in risk stratification for ischemic stroke or transient ischemic attack (TIA) recurrence and death in patients with embolic stroke ...of undetermined source (ESUS).
METHODS—We pooled 12 ESUS datasets from Europe and America. Renal function was evaluated using the estimated glomerular filtration rate (eGFR) and analyzed in continuous, binary, and categorical way. Cox-regression analyses assessed if renal function was independently associated with the risk for ischemic stroke/TIA recurrence and death. The Kaplan-Meier product limit method estimated the cumulative probability of ischemic stroke/TIA recurrence and death.
RESULTS—In 1530 patients with ESUS followed for 3260 patient-years, there were 237 recurrences (15.9%) and 201 deaths (13.4%), corresponding to 7.3 ischemic stroke/TIA recurrences and 5.6 deaths per 100 patient-years, respectively. Renal function was not associated with the risk for ischemic stroke/TIA recurrence when forced into the final multivariate model, regardless if it was analyzed as continuous (hazard ratio, 1.00; 95% CI, 0.99–1.00 for every 1 mL/min), binary (hazard ratio, 1.27; 95% CI, 0.87–1.73) or categorical covariate (likelihood-ratio test 2.59, P=0.63 for stroke recurrence). The probability of ischemic stroke/TIA recurrence across stages of renal function was 11.9% for eGFR ≥90, 16.6% for eGFR 60–89, 21.7% for eGFR 45–59, 19.2% for eGFR 30–44, and 24.9% for eGFR <30 (likelihood-ratio test 2.59, P=0.63). The results were similar for the outcome of death.
CONCLUSIONS—The present study is the largest pooled individual patient-level ESUS dataset, and does not provide evidence that renal function can be used to stratify the risk of ischemic stroke/TIA recurrence or death in patients with ESUS.
Prehypertension has been recently introduced by JNC 7 as a new blood pressure (BP) category, associated with increased target-organ damage. Subclinical atherosclerosis by means of common artery ...intima-media thickness (CCA-IMT) has been incompletely investigated in prehypertensive patients. The aim of our study was to assess the extent of CCA-IMT and left ventricular mass (LVM) in prehypertensive adults in comparison to normotensive and untreated hypertensive subjects.
From a total of 5221 consecutive patients screened to our Hypertension Unit we selected 896 consecutive individuals according to prespecified inclusion criteria, who underwent 24-hour ambulatory BP monitoring, carotid artery ultrasonographic, and echocardiographic measurements. Patients who received antihypertensive treatment during the BP monitoring were excluded. According to the office BP levels, patients were divided into 3 subgroups: normotensives (office BP <120/80 mm Hg), prehypertensives (120/80 mm Hg<or=office BP<140/90 mm Hg), and hypertensives (office BP >or=140/90 mm Hg). Statistical analyses were performed by means of 1-way ANOVA, chi(2) test, and ANCOVA.
According to the office BP levels, the distribution of the study population was: normotensives (14.4%), prehypertensives (23.7%), and hypertensives (61.9%). Prehypertensive patients had higher CCA-IMT (P=0.038) and LVM (P=0.030) values than normotensive subjects, even after adjustment for baseline characteristics. Greater CCA-IMT values were observed in hypertensive patients in comparison to prehypertensives (P=0.002).
Prehypertensive patients had higher CCA-IMT and LVM than their normotensive counterparts. Prehypertension status is cross-sectionally associated with subclinical atherosclerosis and target-organ damage.
Non-traumatic convexity subarachnoid hemorrhage (cSAH) is a rarely reported condition with a wide spectrum of etiologies. Cerebral ischemia secondary to extracranial or intracranial atherosclerotic ...disease has been identified as a relatively uncommon cause of cSAH.
We report a case of cSAH caused by cardioembolic stroke. A 69-year old female patient developed suddenly left-sided face and body weakness and numbness and visual neglect on the left. She was newly detected with paroxysmal atrial fibrillation on the ground of thyrotoxicosis. Brain magnetic resonance imaging revealed ischemia of embolic pattern with cSAH. Further evaluation excluded other cause of hemorrhage. Dilation of leptomeningeal collateral vessels and rupture of pial vessels in distal cortical arteries may caused cSAH. Full anticoagulation was initiated. After one month, her condition improved significantly (NIHSS from 6 to 2).
cSAH may be a rare complication of cardioembolic stroke.
Ambulatory blood pressure monitoring provides a unique tool in the evaluation of night-time blood pressure (BP), having a critical role in the detection of a blunted nocturnal fall and of elevated ...night-time BP. Both nondipping status and nocturnal hypertension are associated with increased cardiovascular risk and target organ damage. The aim of our study was to investigate the impact of both nondipping status and nocturnal hypertension on left ventricular mass (LVM), assessed by means of echocardiography in a consecutive cohort of untreated participants.
A total of 937 individuals were assessed by means of ambulatory blood pressure monitoring and echocardiography. Participants were divided into dippers and nondippers with or without systolic nocturnal hypertension (SNH). SNH was defined as night-time systolic blood pressure of 120 mmHg or more, and nondipping status was defined as an average reduction in systolic blood pressure at night less than 10% compared with the daytime BP.
Dippers and nondippers with SNH presented significantly higher values of left ventricular mass index compared with dippers and nondippers without SNH, respectively. Multiple regression analysis revealed that age (β=0.182, P<0.001), male gender (β=0.168, P<0.001), body mass index (β=0.080, P=0.011), and nocturnal SBP (β=0.174, P=0.037) were significant and independent determinants of LVM. Nondipping status was not found as an independent factor associated with LVM (P=0.136).
Nocturnal hypertension rather than nondipping status seems to be an independent factor associated with left ventricular mass index. The concomitant presence of both nondipping status and nocturnal hypertension is associated with higher LVM, indicating an enhanced cardiovascular risk.
Masked hypertension (MH) is associated with advanced target organ damage. However, patients with MH constitute a group of individuals with heterogeneous characteristics concerning their ambulatory ...blood pressure (BP) status. The aim of this study was to evaluate the association of isolated systolic MH, isolated diastolic MH, and systolic/diastolic MH with carotid artery intima‐media thickness (CIMT). A total of 101 patients with MH underwent carotid artery ultrasonographic measurements. The patients were divided into three groups according to office and daytime BP values: isolated systolic MH, isolated diastolic MH, and systolic/diastolic MH. Patients with isolated systolic (n=36) (0.771 mm) and systolic/diastolic MH (n=37) (0.775 mm) had significantly (P<.05) higher CIMT values than those with isolated diastolic MH (n=28) (0.664 mm), even after adjustment for baseline characteristics and risk factors. Patients with isolated systolic and systolic/diastolic MH presented significantly higher CIMT values compared with patients with isolated diastolic MH.
Several studies have shown that blood pressure (BP) variability derived from ambulatory blood pressure monitoring (ABPM) is associated with target organ damage development. However, the use of ...discontinuous ABPM to assess rapid BP changes is unavoidably limited by the long frequency at which automated measures are scheduled. The aim of our study was to identify whether ABPM-derived variability or short-term beat-to-beat BP variability is better associated with common carotid artery intima-media thickness (CCA-IMT) in untreated hypertensive patients.
A total of 85 individuals underwent 24-h ABPM and carotid artery ultrasonographic measurements. Three 5-min recordings of noninvasive beat-to-beat BP were made under standardized conditions. The time rate (TR) of BP variation was defined as the first derivative of the BP values against time. The study population was divided into normotensive and hypertensive participants according to 24-h BP values (130/80 mmHg).
Hypertensive patients (n=45) presented significantly higher TR of 24-h BP variation (P<0.05) and beat-to-beat TR of systolic BP variation (P<0.05) than their normotensive counterparts (n=40). The multivariate linear regression analyses in hypertensive patients showed significant and independent associations of CCA-IMT with the following factors: 24-h systolic blood pressure (SBP) (B=0.065, 95% confidence interval: 0.006-0.124; P=0.033) and TR of beat-to-beat SBP (B=0.013, 95% confidence interval: 0.005-0.020; P=0.002). A 10 mmHg/min increase in the TR beat-to-beat SBP variation correlated to an increase of 0.013 mm in the CCA-IMT values.
Short-term beat-to-beat TR of BP variation is associated independently with CCA-IMT values and presents a better predictor of target organ damage involvement than BP variability indexes derived from ABPM.
Background
The accurate knowledge of secular trends in prevalence, characteristics and outcomes of patients with ischemic stroke and atrial fibrillation allows better projections into the future.
Aim
...We aimed to report the overall, age- and sex-specific secular trends of characteristics and outcomes of patients with acute ischemic stroke (AIS) and atrial fibrillation between 1993 and 2012 in the Athens Stroke Registry.
Methods
We used Joinpoint regression analysis to calculate the average annual percent changes and 95% confidence intervals.
Results
Among 3314 stroke patients, 1044 (31.5%) had atrial fibrillation. Between 1993 and 2012, there was an average annual reduction of 0.8% (95% CI: −1.5%; 0.0%) in the proportion of atrial fibrillation patients among all AIS patients, whereas the proportion of newly diagnosed atrial fibrillation patients among all atrial fibrillation patients increased annually by an average of 7.1% (95% CI: 5.4%;8.9%). Among all atrial fibrillation patients, there was an average annual reduction of 2.9% (95% CI: −2.7; −3.2%) in the proportion of previously known atrial fibrillation patients, followed by an annual average reduction of 2.4% (95% CI: −1.2; −3.6%) in the proportion of previously known atrial fibrillation patients not receiving any antithrombotic treatment at admission. During that period, there was an increase in the average annual proportion of previously known atrial fibrillation patients treated with anticoagulants (6.4%, 95% CI: 1.2;11.9%) and aspirin (2.3%, 95% CI: −0.4;5.0%) at admission; an average annual increase in the proportion of atrial fibrillation patients who were prescribed anticoagulant was apparent both for patients with mRS<4 (3.5%) and mRS: 4–5 (7.2%), while the proportion of atrial fibrillation patients who were prescribed aspirin or no antithrombotic at discharge was annually reduced (5.8% for mRS<4; 1.6% for mRS: 4–5 and 7.1% for mRS<4;5.3% for mRS: 4–5 respectively). Stroke recurrences were annually reduced by an average of 5.8% (95% CI: −8.6; −3.0%), along with cardiovascular events (6.5%, 95% CI: −8.3; −4.7%) and deaths (7.9%, 95% CI: −9.2; −6.5%).
Conclusions
Between 1993 and 2012, the proportion of atrial fibrillation patients on proper antithrombotic treatment and the rate of newly diagnosed atrial fibrillation increased significantly. Rates of stroke recurrence, cardiovascular events, and mortality reduced significantly.
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