Increased level of morning surge in blood pressure in normotensives: a cross-sectional study from Pakistan

Objective: To determine the mean morning surge [MS] in blood pressure, the frequency of increased morning surge in normotensive subjects, and to compare those with morning surge with those without MS. Study Design: A cross-sectional, comparative study. Place and Duration of Study: The Department of Medicine, The Aga Khan University Hospital. Karachi, from April 2011 to March 2012

Methodology: Adult normotensive healthy volunteers aged 35 to 65 years were inducted. Their ambulatory blood pressure [ABP] was measured over a 24-hour period, using digital ambulatory blood pressure monitors. Morning surge was calculated as the average of four readings after waking minus the lowest three nocturnal readings. Increased morning surge was defined as > 11 mm Hg in systolic [SBP] or > 12 mm Hg in diastolic [DBP]. Dipping was defined as > 10% dipping in blood pressure

Results: Eighty-two healthy volunteers were recruited. Their mean age was 36.9 +/-1.2 years: 74.4 [61%] were men, and 58.5 [48%] woke up for morning prayers. Mean overall SBP was 113 +/-1.6 mm Hg, overall DBP was 73.9 +/-0.7 mm Hg, and overall heart rate was 75 [10] beats/minute. Mean morning surge was 17.6 +/-1.0 mm Hg in SBP and 16.0 +/-0.8 mm Hg in DBP. The frequency of increased morning surge was 66 [80.5%] in SBP, and 57 [69%] in DBP. On comparison of participants with normal morning surge and increased morning surge in SBP, there was a significant difference in non- dipping status [13.4% in normal vs. 18.3% in increased morning surge, p=0.001]

Conclusion: Mean morning surge in SBP and DBP are relatively higher in this subset population in a tertiary care center in Pakistan. These values are higher than those reported in the literature

Are BP readings taken after a patient-physician encounter in a real-world clinic scenario the lowest of all the readings in a clinic visit

To determine the difference in Blood Pressure [BP] readings taken before, during and after the clinic encounter. Descriptive study. Cardiology Clinic, The Aga Khan University Hospital, Karachi, from January to August 2013. Hypertensive and normotensive participants aged >/= 18 years were recruited. Pre-clinic BP was measured by a nurse and in-clinic BP by a physician. After 15 minutes, two post-clinic BP readings were taken at 1 minute interval. All readings were taken using Omron HEM7221-E. Out of 180 participants, males were 57% and 130 [71%] were hypertensive. Mean SBP [Systolic BP] taken preclinic, in-clinic, post-clinic 1 and post-clinic 2 were: 126 +/- 20 mmHg, 131 +/- 23 mmHg, 126 +/- 20 mmHg and 121 +/- 21 mmHg respectively [p < 0.001]. Mean DBP [Diastolic BP] taken pre-clinic, in-clinic, post-clinic 1 and post-clinic 2 were 77 +/- 12 mmHg, 81 +/- 13 mmHg, 79 +/- 12 mmHg and 79 +/- 11 mmHg respectively [p < 0.001]. BP taken in the post-clinic setting may significantly be the lowest reading in a clinic encounter, making in-clinic BP unreliable to diagnose or manage hypertension

Better physician-patient communication; an important milestone in control of hypertension, a multicenter study from Karachi, Pakistan

Control of hypertension is an important cornerstone in prevention of cardiovascular morbidity and mortality. This study was designed to compare physician encounter score in patients with controlled and uncontrolled hypertension. It was conducted at three tertiary care hospitals in Karachi. Patients were categorized into controlled and uncontrolled hypertension based on their initial blood pressure readings on presentation. Primary outcome variable was control of hypertension and physician encounter score [a composite score of 12 item question] was the main candidate variable. Higher scores reflected favorable encounter with physician. Mean age of participants was 57.7 +/- 12 years; 224 [50.1%] were men. Controlled hypertension was present in 72.3% [323] and uncontrolled hypertension was present in 27.4% [124]. Mean physician encounter score in uncontrolled hypertensive was 7.25 +/- 2.64 versus 7.83 +/- 2.22 [p=0.02] in controlled hypertensive. Patient-physician encounter is an important milestone in control of hypertension in hypertensive patients and directly translates into better adherence to antihypertensives in these patients

Diuretic induced hyponatremia in hypertensive patients

Diuretics are the recommended antihypertensive by several international guidelines. This study was designed to determine the association of hyponatremia in hypertensive patients on diuretic therapy. This was a case control study conducted at the Aga Khan University Hospital, Karachi in adult inpatients [> 18 years] who were known hypertensive. Cases were defined as hypertensives with hyponatremia and controls were defined as hypertensives without hyponatremia. Outcome was hyponatremia. Exposed were those using diuretics. Out of 1800 hypertensive patients sampled by the ICD-9-Coding; 1191 [66%] fulfilled the inclusion criteria. Cases n [%] were 553 [46.4] and controls were 638 [53.5]. Among 553 cases [%] 180 [32.5] were exposed [on diuretics] and in controls 189 [29.6] were exposed [on diuretics] p=0.15. The association of hyponatremia with diuretic use was not significant with OR=1.11 [95% CI=0.86 - 1.45, p=0.40], after adjusting for chronic kidney disease, ischemic heart disease and chronic liver disease, in the final model. Diuretics were not associated with hyponatremia in hypertensive adult patients in this study

Multifocal venous thrombosis in Behcet's disease

Behcet's disease is a multisystem inflammatory vascular disorder with a chronic course characterized by recurrent oral and genital ulcers, eye lesion, arthritis and skin lesions. It has a typically waxing and waning course. The cause and pathogenesis of the disease are unclear and specific treatment is not available. A 39 years old man presented with rash, ocular manifestation and left leg swelling. He was found to have deep venous thrombosis of left leg along with recurrent cerebral venous thrombosis. He was a known case of Behcet's disease since 3 years and had been on anticoagulants since then

Emergency evaluation of acute chest pain

To determine the sensitivity and specificity of initial clinical assessment about the diagnosis of acute coronary syndrome [ACS] in patients presenting with acute chest pain by a cardiology resident in the emergency room and assess the 30-day outcome of patients with ACS and non ACS. Cohort study. The study was conducted in the emergency department and cardiac care units of the Aga Khan University in 2006-07. A total of 202 patients, who presented to the emergency room with chest pain, were given an initial ECG and troponin check. Patients were assigned to initial ACS and non-ACS groups by the cardiology resident. After cardiac workup, patients were assigned to final ACS/final non ACS group. They were followed for outcome after 30 days of initial presentation. Sensitivity and specificity, if initial workup was determined, keeping final assessment after cardiac workup as the gold standard. Out of the 202 patients, 61.9% were males. Their mean age was 54.05 +/- 13 years. Sixty eight percent were placed in the initial ACS group and 30.7% were placed in the initial non ACS group. After workup, 36% were placed in the final ACS group and 28.7% in the final non-ACS group and 35% were undecided. The sensitivity of initial assessment of ACS by the cardiology resident was 100%. However, the specificity was 54.2%. In the 30-day outcome, one patient [1.3%] died in the ACS group due to myocardial ischemia while no patient died from the non ACS group. Initial assessment about ACS by cardiology resident based on character of chest pain, ECG and troponin I is highly sensitive. However, the specificity is low

Beta-hemolytic streptococcus group A endocarditis: a rare clinical presentation

A case report of an elderly gentleman is reported herein, who presented with one week history of fever, drowsiness and left lower limb weakness. Examination revealed left lower limb weakness with power of grade 3/5. His workup showed evidence of infection and multiple cerebral infarcts on the right side. Blood culture grew Streptococcus pyogens. Echocardiogram showed two vegetations on the aortic valve. Fever was the main presenting feature in this case but it was the presentation of patient with multiple cerebral infarcts that lead to the diagnosis of infective endocarditis. The organism causing Infective Endocarditis [IE] in this patient was a rare one