Background We aimed to assess the prevalence and degree of overlap of potential embolic sources (PES) in patients with embolic stroke of undetermined source (ESUS). Methods and Results In a pooled ...data set derived from 3 prospective stroke registries, patients were categorized in ≥1 groups according to the PES that was/were identified. We categorized PES as follows: atrial cardiopathy, atrial fibrillation diagnosed during follow-up, arterial disease, left ventricular disease, cardiac valvular disease, patent foramen ovale, and cancer. In 800 patients with ESUS (43.1% women; median age, 67.0 years), 3 most prevalent PES were left ventricular disease, arterial disease, and atrial cardiopathy, which were present in 54.4%, 48.5%, and 45.0% of patients, respectively. Most patients (65.5%) had >1 PES, whereas only 29.7% and 4.8% of patients had a single or no PES, respectively. In 31.1% of patients, there were ≥3 PES present. On average, each patient had 2 PES (median, 2). During a median follow-up of 3.7 years, stroke recurrence occurred in 101 (12.6%) of patients (23.3 recurrences per 100 patient-years). In multivariate analysis, the risk of stroke recurrence was higher in the atrial fibrillation group compared with other PES, but not statistically different between patients with 0 to 1, 2, or ≥3 PES. Conclusions There is major overlap of PES in patients with ESUS. This may possibly explain the negative results of the recent large randomized controlled trials of secondary prevention in patients with ESUS and offer a rationale for a randomized controlled trial of combination of anticoagulation and aspirin for the prevention of stroke recurrence in patients with ESUS. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02766205.
Increased blood pressure (BP) variability is associated with the development of target organ damage. However, the optimal type and index of BP variability (BPV) regarding their prognostic ...significance is unclear. The aim of our study was to compare the association of ambulatory and home BPV with the left ventricular mass index (LVMI) in patients with chronic kidney disease (CKD). From a total of 1560 consecutive subjects, 137 hypertensive patients with CKD underwent home and ambulatory BP monitoring and echocardiographic measurements. The variability of home BP monitoring was quantified by using the standard deviation (SD), coefficient of variation (CV), and morning minus evening BP values. Ambulatory BPV was quantified using the SD, CV, and the time rate (TR) of BP variation. The univariate analysis demonstrated that day-to-day systolic SD and the 24-h TR of systolic BP (SBP) variation were significantly associated with the LVMI. The multivariate linear regression analysis showed a significant and independent association of the LVMI with the 24-h TR of SBP variation (B = 9.204, 95% CI: 1.735-16.672; p = 0.016). A 0.1-mmHg/min increase in the 24-h TR of SBP variation was associated with an increment of 9.204 g/m
in the LVMI, even after adjustment for BP and other vascular risk factors. In conclusion, ambulatory BPV but not home BPV was associated with the LVMI in CKD patients. The 24-h TR of SBP variation was the only BPV index associated with the LVMI, independent of average BP values.
The ASTRAL score was externally validated showing remarkable consistency on 3-month outcome prognosis in patients with acute ischemic stroke. The present study aimed to evaluate ASTRAL score's ...prognostic accuracy to predict 5-year outcome.
All consecutive patients with acute ischemic stroke registered in the Athens Stroke Registry between January 1, 1998, and December 31, 2010, were included. Patients were excluded if admitted >24 hours after symptom onset or if any ASTRAL score component was missing. End points were 5-year unfavorable functional outcome, defined as modified Rankin Scale 3 to 6, and 5-year mortality. For each outcome, the area under the receiver operating characteristics curve was calculated; also, a multivariate Cox proportional hazards analysis was performed to investigate whether the ASTRAL score was an independent predictor of outcome. The Kaplan-Meier product limit method was used to estimate the probability of 5-year survival for each ASTRAL score quartile.
The area under the receiver operating characteristics curve of the score to predict 5-year unfavorable functional outcome was 0.89, 95% confidence interval 0.88 to 0.91. In multivariate Cox proportional hazards analysis, the ASTRAL score was independently associated with 5-year unfavorable functional outcome (hazard ratio, 1.09; 95% confidence interval, 1.08-1.10). The area under the receiver operating characteristics curve for the ASTRAL score's discriminatory power to predict 5-year mortality was 0.81 (95% confidence interval, 0.78-0.83). In multivariate analysis, the ASTRAL score was independently associated with 5-year mortality (hazard ratio, 1.09, 95% confidence interval, 1.08-1.10). During the 5-year follow-up, the probability of survival was significantly lower with increasing ASTRAL score quartiles (log-rank test <0.001).
The ASTRAL score reliably predicts 5-year functional outcome and mortality in patients with acute ischemic stroke.
Background There is increasing debate whether atrial fibrillation (AF) episodes during follow-up in patients with embolic stroke of undetermined source (ESUS) are causally associated with the event. ...AF-related strokes are more severe than strokes of other etiologies. In this context, we aimed to compare stroke severity between ESUS patients diagnosed with AF during follow-up and those who were not. We hypothesized that, if AF episodes detected during follow-up are indeed causally associated with the index event, stroke severity in the AF group should be higher than the non-AF group. Methods Dataset was derived from the Athens Stroke Registry. ESUS was defined by the Cryptogenic Stroke/ESUS International-Working-Group criteria. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS) score. Cumulative probabilities of recurrent stroke or peripheral embolism in the AF and non-AF ESUS groups were estimated by Kaplan–Meier analyses. Results Among 275 ESUS patients, AF was detected during follow-up in 80 (29.1%), either during repeated electrocardiogram monitoring (18.2%) or during hospitalization for stroke recurrence (10.9%). NIHSS score was similar between the two groups (5 2-13 versus 5 2-14, P = .998). More recurrent strokes or peripheral embolisms occurred in the AF group compared with the non-AF group (42.5% versus 13.3%, P = .001). Conclusions Stroke severity is similar between ESUS patients who were diagnosed with AF during follow-up and those who were not. Given that AF-related strokes are more severe than strokes of other etiologies, this finding challenges the assumption that the association between ESUS and AF detected during follow-up is as frequently causal as regarded.
The clinical importance of white‐coat hypertension (WCH) remains a controversial issue. The aim of this study was to evaluate the association of isolated systolic, isolated diastolic, and ...systolic/diastolic WCH with common carotid artery intima‐media thickness (CCA‐IMT) and to compare each subgroup of WCH against other blood pressure (BP) phenotypes in terms of CCA‐IMT values. A total of 1382 consecutive patients underwent 24‐hour ambulatory BP monitoring and carotid artery ultrasonographic measurements. According to the type of elevated office BP, WCH was divided into three groups: isolated systolic, isolated diastolic, and systolic/diastolic WCH. Patients with isolated systolic WCH (n=112) had significantly higher CCA‐IMT values (0.737 mm) than those with isolated diastolic WCH (n=66) (0.685 mm) and nonsignificantly greater compared with those with systolic/diastolic WCH (n=228) (0.708 mm). Patients with isolated systolic WCH had CCA‐IMT values similar to those with hypertension, patients with isolated diastolic WCH had similar values to those with normotension, and patients with systolic/diastolic WCH had an intermediate risk between normotension and hypertension.
Factors Influencing White-coat Effect Manios, Efstathios D.; Koroboki, Eleni A.; Tsivgoulis, Georgios K. ...
American journal of hypertension,
02/2008, Letnik:
21, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Background The transient blood pressure (BP) rise during clinical visits is usually referred to as white-coat effect (WCE). The aim of the present study was to investigate factors that may influence ...the WCE. Methods A total of 2004 subjects underwent office BP measurements and 24-h ambulatory BP monitoring (ABPM) on the same day. The WCE was estimated as the difference between office and average daytime ambulatory BP (ABP). According to the office and daytime BP values, the study population was divided into normotensives (NTs), white-coat hypertensives (WCHs), masked hypertensives (MHTs), and sustained hypertensives (SHTs). Statistical analyses were performed using one-way analysis of variance and multiple linear regression models. Results The mean systolic and diastolic WCE was 9 ± 16 and 7 ± 12 mm Hg, respectively. In the entire group of patients, multiple linear regression models revealed independent determinants of systolic WCE in the following rank order: office systolic BP (SBP) (β = 0.727; P < 0.001), female gender (β = 0.166; P < 0.001), daytime SBP variability (β = 0.128; P < 0.001), age (β = 0.039, P = 0.020), and smoking (β = 0.031, P = 0.048). A 1.0 mm Hg increase in daytime SBP variability correlated with an increment of 0.589 mm Hg (95% confidence intervals, 0.437–0.741) in the systolic WCE. The regression analyses for diastolic WCE revealed the same factors as independent determinants. A 1.0 mm Hg increase in daytime diastolic BP (DBP) variability was independently associated with an increment of 0.418 mm Hg (95% confidence intervals, 0.121–0.715) in the diastolic WCE. Conclusions Factors such as gender, age, smoking, office BPV and daytime BPV may exert an important influence on the magnitude of the WCE.
Interoceptive awareness in essential hypertension Koroboki, Eleni; Zakopoulos, Nikolaos; Manios, Efstathios ...
International journal of psychophysiology,
11/2010, Letnik:
78, Številka:
2
Journal Article
Recenzirano
Clinical practice and research provide evidence indicating the involvement of psychological factors in essential hypertension. Little is known about interoception (i.e. the ability of perceiving ...bodily signals) in essential hypertension. The present study focused on the assessment of interoceptive awareness in newly diagnosed-untreated hypertensives by means of ambulatory blood pressure monitoring (ABPM), a useful tool in the detection and evaluation of hypertension.
The study population consisted of 50 untreated newly diagnosed hypertensives (48.3
±
9.7
years) and 31 normotensives (49.5
±
14.2
years) matched regarding sex, BMI and prevalence of smoking. All participants underwent 24-hour ABPM (Spacelabs 90207). Cardiac interoceptive awareness was assessed by means of a heartbeat detection task.
Hypertensives exhibited higher office blood pressure (BP) and heart rate (HR) levels (clinic systolic BP: 152
±
20 vs 140
±
17;
p
=
0.01, clinic diastolic BP: 95
±
10 vs 89
±
11;
p
=
0.008, clinic HR: 82
±
13 vs 74
±
11;
p
=
0.04) as well as ambulatory measurements (systolic BP24: 137
±
11 vs 119
±
7;
p
<
0.001, diastolic BP24: 87
±
7 vs 73
±
5;
p
<
0.001, HR24: 79
±
9 vs 71
±
10;
p
<
0.01) compared to normotensives. Moreover, the analysis revealed an increased interoceptive awareness in hypertensives as compared to normotensives. A comparison within the hypertensive group between subjects with and without interoceptive awareness revealed that subjects with increased interoceptive awareness had higher office systolic and diastolic blood pressure values, as well as mean ambulatory HR.
These findings give credence to the idea that interoceptive awareness may represent an enhanced cardiovascular reactivity involved in essential hypertension, even in its early stages. The cross-sectional nature of this study precludes causal inference, but provides valuable directions for future prospective investigations.
►Newly diagnosed unttreated hypertensives exhibited higher office blood pressure (BP) and heart rate (HR) levels as well as ambulatory measurements compared to normotensives.►Moreover, the analysis revealed an increased interoceptive awareness in hypertensives as compared to normotensives.►A comparisons within the hypertensive group between subjects with and without interoceptive awareness revealed revealed that subjects with increased interoceptive awareness had higher office systolic and diastolic blood pressure values, as well as mean ambulatory HR.
This study aims to compare automatic oscillometric blood pressure recordings with simultaneous direct intra-arterial blood pressure measurements in hyperacute stroke patients to test the accuracy of ...oscillometric readings.
A total of 51 first-ever stroke patients underwent simultaneous noninvasive automatic oscillometric and intra-arterial blood pressure monitoring within 3 h of ictus. Casual blood pressure was measured in both arms using a standard mercury sphygmomanometer on hospital admission. Patients who received antihypertensive medication during the blood pressure monitoring were excluded.
The estimation of systolic blood pressure (SBP) using oscillometric recordings underestimated direct radial artery SBP by 9.7 mmHg (95% confidence interval: 6.5-13.0, P<0.001). In contrast, an upward bias of 5.6 mmHg (95% confidence interval: 3.5-7.7, P<0.001) was documented when noninvasive diastolic blood pressure (DBP) recordings were compared with intra-arterial DBP recordings. For SBP and DBP, the Pearson correlation coefficients between noninvasive and intra-arterial recordings were 0.854 and 0.832, respectively. When the study population was stratified according to SBP bands (group A: SBP<or=160 mmHg; group B: SBP>160 mmHg and SBP<or=180 mmHg, group C: SBP>180 mmHg), higher mean DeltaSBP (intra-arterial SBP-oscillometric SBP) levels were documented in group C (+19.8 mmHg, 95% confidence intervals: 12.2-27.4) when compared with groups B (+8.5 mmHg, 95% confidence intervals: 2.7-14.5; P=0.025) and A (+5.9 mmHg, 95% confidence intervals: 1.8-9.9; P=0.002).
Noninvasive automatic oscillometric BP measurements underestimate direct SBP recordings and overestimate direct DBP readings in acute stroke. The magnitude of the discrepancy between intra-arterial and oscillometric SBP recordings is even more prominent in patients with critically elevated SBP levels.
Abstract Background Recent studies have reported that prehypertension is associated with increased values of common carotid artery intima–media thickness (CCA-IMT). The aim of this study was to ...assess the impact of daytime ambulatory blood pressure (BP) levels on the association of prehypertension with CCA intima–media thickening in prehypertensive subjects. Methods A total of 807 subjects with office systolic BP < 140 and diastolic BP < 90 mmHg, underwent 24 h ambulatory BP (ABP) monitoring and carotid artery ultrasonographic measurements. The study population was divided into 3 groups according to office and daytime ABP levels: (1) normotensives: subjects with office BP < 120/80 mmHg and daytime ambulatory BP values within the normal range, (2) actual prehypertensives: individuals with office SBP (120–139 mmHg) and/or DBP (80–89 mmHg) and daytime ambulatory BP values within the normal range and (3) prehypertensives with masked hypertension (MH): patients with office SBP (120–139 mmHg) and/or DBP (80–89 mmHg) and elevated daytime ambulatory BP values. Results Prehypertensive patients with MH had higher ( p < 0.01) CCA-IMT values (0.712 mm; 95%CI: 0.698–0.725) than actual prehypertensives (0.649 mm; 95%CI: 0.641–0.656) and normotensives (0.655 mm; 95%CI: 0.641–0.670) even after adjustment for baseline characteristics. Normotensives and actual prehypertensives did not differ significantly regarding CCA-IMT values ( p > 0.05). After adjusting for potential confounders, (including demographic characteristics, vascular risk factors, and office BP) prehypertension with MH was independently ( p < 0.01) associated with a 0.06 mm increment in CCA-IMT (95%CI: 0.03–0.09). Conclusions Patients with office BP levels in the prehypertensive range, who also have elevated daytime ABP levels, had higher CCA-IMT values than patients with prehypertension with normal daytime ABP values and normotensive individuals.
PDF
