Grossesse et cirrhose: aspects épidémiologiques et pronostiques à propos de 7 cas suivis au centre hospitalier universitaire de Libreville / Pregnancy and cirrhosis: epidemiological and prognostic aspects about 7 cases followed at the University Hospital of Libreville

Introduction : L'association cirrhose et grossesse est peu décrite en Afrique. Nous rapportons notre expérience à travers une série de femmes cirrhotiques régulièrement suivies.Patients et méthodes : Il s'agit d'une étude transversale, rétrospective et descriptive menée entre le 1er Juin 2016 et le 31 Décembre 2018 au centre hospitalier universitaire de Libreville. Nous avons inclus les dossiers des femmes cirrhotiques en âge de procréer, vivant en couple et ayant exprimé le désir de procréer. Nous avons analysé la fréquence des grossesses, le devenir de celle-ci, le type d'accouchements, les complications maternelles et obstétricales. L'analyse des données colligées a été réalisée par le logiciel SPSS 20.Résultats: Sept femmes ont présenté une grossesse parmi les 84 femmes cirrhotiques suivies soit 33 grossesses/1000 femmes/an. Leur âge moyen était de 26±6 ans. La cirrhose était classée Child-Pugh A, B et C respectivement pour 1, 3 et 3 patientes. L'étiologie de la cirrhose était l'hépatite B pour 3 patientes l'hépatite C pour 1 patiente, l'alcoolisme pour 1 patiente et l'hépatite auto-immune chez 2 patientes. Sur le plan obstétrical, 1 seule grossesse a été menée à terme sans incident. Il y a eu 1 avortement tardif, 1 accouchement prématuré et 4 morts foetales in utéro. La voie d'accouchement était la césarienne chez 2 patientes et la voie basse pour 5 patientes.Trois décès maternels ont été observés dans un contexte hémorragique.Conclusion : La grossesse au cours de la cirrhose est une situation à risque élevée pour la mère et l'enfant.

Introduction: The association of cirrhosis and pregnancy is poorly described in Africa. We report our experiencethrough a series of cirrhotic women regularly monitored. Patients and methods: This is a cross-sectional, retrospective and descriptive study conducted between June 1, 2016 and December 31, 2018 at the University Hospital of Libreville. We included women aged 15 to 35 years who had been followed for at least 12 months for cirrhosis and who had a pregnancy during the study period. We analysed the frequency of pregnancies, the fate of pregnancy, the type of delivery, maternal complications and fetal complications. The analysis of the collected data was carried out by the SPSS 20 software.Results: Seven women had a pregnancy among the 84 cirrhotic women followed or 33 pregnancies/ 1000women/year. Their average age was 26±6 years. Cirrhosis was classified as Child-Pugh A, B and C for 1, 3 and 3 patients respectively. The etiology of cirrhosis was chronic viral hepatitis B for 3 patients hepatitis C for 1 patient, alcohol for 1 patient and autoimmune hepatitis for 2 patients. Obstetrically, only 1 pregnancy was completed to term without incident. There was 1 late-term abortion, 1 preterm birth and 4 fetal deaths in utero.The delivery route was caesarean section for 2 patients and vaginal section for 5 patients. Three maternal deaths were observed in a hemorrhagic context. Conclusion: Pregnancy during cirrhosis is a high-risk situation for both mother and child.

Prevalence of Masked and White-Coat Hypertension in Pre-Hypertensive and Stage 1 Hypertensive patients with the use of TeleMRPA / Prevalência de Hipertensão Mascarada e do Avental Branco em Pré-Hipertensos e Hipertensos Estágio 1 com o uso da TeleMRPA

Abstract Background: The diagnosis of arterial hypertension based on measurements of blood pressure in the office has low accuracy. Objective: To evaluate the prevalence of masked hypertension (MH) and white-coat hypertension through home blood pressure monitoring (HBPM) in pre-hypertensive and stage 1 hypertensive patients. Method: Retrospective study, of which sample consisted of individuals with BP ≥ 120/80 mmHg and < 160/100 mmHg at the medical office without the use of antihypertensive medication and who underwent exams on the HBPM platform by telemedicine (TeleMRPA) between May 2017 and September 2018. The four-day MRPA protocol was used, with 24 measurements, using automated, validated, calibrated equipment with a memory function. Results: The sample consisted of 1,273 participants, of which 739 (58.1%) were women. The mean age was 52.4 ± 14.9 years, mean body mass index (BMI) 28.4 ± 5.1 kg/m2. The casual BP was higher than the HBPM in 7.6 mmHg for systolic blood pressure (SBP) and 5.2 mmHg for diastolic blood pressure (DBP), both with statistical significance (p < 0.001). There were 558 (43.8%) normotensive individuals; 291 (22.9%) with sustained hypertension; 145 (11.4%) with MH and 279 (21.9%) with white-coat hypertension (WCH), with a diagnostic error by casual BP in the total sample in 424 (33.3%) patients. In stage 1 hypertensive individuals, the prevalence of WCH was 48.9%; in prehypertensive patients, the prevalence of MH was 20.6%. Conclusion: MH and WCH have a high prevalence rate in the adult population; however, in prehypertensive or stage 1 hypertensive patients, the prevalence is higher. Out-of-office BP measurements in these subgroups should be performed whenever possible to prevent misdiagnosis.

Resumo Fundamento: O diagnóstico de hipertensão arterial baseado nas medidas do consultório tem baixa acurácia. Objetivo: Avaliar a prevalência de hipertensão mascarada (HM) e do avental branco pela monitorização residencial da pressão arterial (MRPA) em pacientes pré-hipertensos e hipertensos estágio. Método: Estudo retrospectivo com amostra constituída de indivíduos com pressão arterial (PA) na clínica ≥ 120/80 mmHg e < 160/100 mmHg sem uso de medicação anti-hipertensiva e que realizaram exames na plataforma de MRPA por telemedicina (TeleMRPA) entre maio de 2017 e setembro de 2018. Foi utilizado o protocolo MRPA de quatro dias, com 24 medidas, com equipamentos automáticos, validados, calibrados e com memória. Resultados: A amostra foi constituída de 1.273 participantes, sendo 739 (58,1%) mulheres. A idade média foi 52,4 ± 14,9 anos, índice de massa corporal (IMC) médio 28,4 ± 5,1 kg/m2. A PA casual foi maior que a MRPA em 7,6 mmHg para pressão arterial sistólica (PAS) e 5,2 mmHg para a pressão arterial diastólica (PAD), ambas com significância estatística (p < 0,001). Foram diagnosticados 558 (43,8%) normotensos; 291 (22,9%) hipertensos sustentados; 145 (11,4%) com HM e 279 (21,9%) com hipertensão do avental branco (HAB), com erro diagnóstico pela PA casual na amostra total em 424 (33,3%) pacientes. Em hipertensos estágio 1, a prevalência de HAB foi de 48,9%; nos pré-hipertensos a prevalência de HM foi de 20,6%. Conclusão: HM e HAB têm elevada prevalência na população adulta; entretanto, na população de pré-hipertensos ou hipertensos estágio 1 a prevalência é maior. Medidas da PA fora do consultório, nestes subgrupos, devem ser realizadas sempre que possível para evitar erro diagnóstico.

Clinical Significance and Therapeutic Implication of Nocturnal Hypertension: Relationship between Nighttime Blood Pressure and Quality of Sleep

Recent global hypertension guidelines recommend an early, strict and 24-hour blood pressure (BP) control for the prevention of target organ damage and cardiovascular events. Out-of-office BP measurement such as ambulatory BP monitoring and home BP monitoring is now widely utilized to rule out white-coat hypertension, to detect masked hypertension, to evaluate the effects of antihypertensive medication, to analyze diurnal BP variation, and to increase drug adherence. Nocturnal hypertension has been neglected in the management of hypertension despite of its clinical significance. Nighttime BP and non-dipping patterns of BP are stronger risk predictors for the future cardiovascular mortality and morbidity than clinic or daytime BP. In addition to ambulatory or home daytime BP and 24-hour mean BP, nocturnal BP should be a new therapeutic target for the optimal treatment of hypertension to improve prognosis in hypertensive patients. This review will provide an overview of epidemiology, characteristics, and pathophysiology of nocturnal hypertension and clinical significance, therapeutic implication and future perspectives of nocturnal hypertension will be discussed.

Prevalencia de hipertensión enmascarada en niños con factores de riesgo para el desarrollo de hipertensión arterial / Prevalence of masked hypertension among children with risk factors for arterial hypertension

Introducción. La hipertensión enmascarada (HE) en niños se define por registros de presión arterial normal en la consulta y elevados fuera de ella. El monitoreo ambulatorio de presión arterial de 24 horas (MAPA) permite su diagnóstico. Existe poca información sobre su prevalencia en nuestra población. Objetivo. Estimar la prevalencia de HE en niños con factores de riesgo para el desarrollo de hipertensión arterial. Material y método. Estudio prospectivo, observacional, corte transversal. Se incluyeron en forma consecutiva pacientes asistidos en el Hospital General de Niños P. de Elizalde entre 1/7/2015 y 1/12/2016, de 5 a 11 años, con presión arterial normal y, al menos, un factor de riesgo para hipertensión arterial. Se realizó MAPA durante 24 horas (SpaceLabs 90207/90217). Muestra estimada: 110 pacientes. Se contó con las aprobaciones pertinentes. Resultados. Se incluyeron 110 pacientes, edad de 8,7 ± 1,8 años, 60 mujeres. Tiempo de MAPA: 23,18 ± 1,8 horas. Tenían antecedentes neonatales 23 pacientes; todos tenían, al menos, un antecedente personal (los más frecuentes, ingesta aumentada de sal y obesidad); 101 tenían, al menos, un antecedente familiar. El MAPA permitió identificar a 10 pacientes con HE (9,1%; IC 95%: 5,1-15,9); 7 con hipertensión nocturna aislada (6,4%; IC 95%: 3,1-23,5) y 28, prehipertensión (25,4%; IC 95%: 18,2-34,3). Los 10 pacientes con HE fueron 7 varones, 9 obesos y con, al menos, un antecedente familiar. Conclusión. La prevalencia de HE en niños con factores de riesgo de desarrollar hipertensión arterial fue cercana al 10%.

Introduction. Masked hypertension (MH) in children is defined as normal office blood pressure values and high values outside the clinical setting. The 24-hour ambulatory blood pressure monitoring (ABPM) is helpful for diagnosis. There is little information on MH prevalence in our population. Objective. To estimate the prevalence of MH in children with risk factors for arterial hypertension. Material and method. Prospective, observational, cross-sectional study. Patients seen at Hospital General de Niños "P. de Elizalde" between July 1st, 2015 and December 1st, 2016, aged 5-11 years, with normal blood pressure and at least one risk factor for arterial hypertension were included in consecutive order. A 24-hour ABPM was done (SpaceLabs 90207/90217). Estimated sample: 110 patients. All relevant authorizations were obtained. Results. One hundred and ten patients aged 8.7 ± 1.8 years were included; 60 were girls. ABPM duration: 23.18 ± 1.8 hours. Twenty-three patients had neonatal history; all had at least one factor corresponding to personal history (the most common ones were increased salt intake and obesity); 101 had at least one factor corresponding to family history. ABPM helped to identify 10 patients with MH (9.1%; 95% confidence interval --1;CI--3;: 5.1-15.9); 7 had isolated nocturnal hypertension (6.4%; 95% CI: 3.1-23.5) and 28 had prehypertension (25.4%; 95% CI: 18.234.3). Among the 10 patients with MH, 7 were boys, 9 were obese and had at least one factor corresponding to family history. Conclusion. The prevalence of MH in children with risk factors for arterial hypertension was close to 10%.

A possible cause of epistaxis: increased masked hypertension prevalence in patients with epistaxis / Uma possível causa de epistaxe: maior prevalência de hipertensão mascarada em pacientes com epistaxe

Abstract Introduction Epistaxis and hypertension are frequent conditions in the adult population. Masked hypertension is defined as a clinical condition in which a patient's office blood pressure level is <140/90 mmHg, but the ambulatory or home blood pressure readings are in the hypertensive range. Many studies have proved that hypertension is one of the most important causes of epistaxis. The prevalence of this condition in patients with epistaxis is not well defined. Objective This study aimed to evaluate the prevalence of masked hypertension using the results of office blood pressure measurement compared with the results of ambulatory blood pressure monitoring. Methods Sixty patients with epistaxis and 60 control subjects were enrolled in the study. All patients with epistaxis and controls without history of hypertension underwent physical examination, including office blood pressure measurement, ambulatory or home blood pressure, and measurement of anthropometric parameters. Results Mean age was similar between the epistaxis group and the controls – 21–68 years (mean 42.9) for the epistaxis group and 18–71 years (mean 42.2) for the control group. A total of 20 patients (33.3%) in the epistaxis group and 7 patients (11.7%) in the control group (p = 0.004) had masked hypertension. Night-time systolic blood pressure was significantly higher in patients with epistaxis than in the control group (p < 0.005). However, no significant difference was found in daytime systolic blood pressure between the control group and the patients with epistaxis (p = 0.517). Conclusion This study demonstrates increased masked hypertension prevalence in patients with epistaxis. We suggest that all patients with epistaxis should undergo ambulatory or home blood pressure to detect masked hypertension, which could be a possible cause of epistaxis.

Resumo Introdução Epistaxe e hipertensão são condições frequentes na população adulta. Hipertensão mascarada é definida como uma condição clínica em que o nível da pressão arterial do paciente no consultório é < 140/90 mm Hg, mas as leituras da pressão arterial ambulatorial ou em casa se encontram na faixa hipertensiva. Muitos estudos demonstraram que a hipertensão é uma das causas mais importantes de epistaxe. Ainda não está devidamente definida a prevalência dessa condição em pacientes com epistaxe. Objetivo Avaliar a prevalência de HM com o uso dos resultados de mensurações da pressão arterial no consultório, em comparação com os resultados da MAPA. Método Foram recrutados 60 pacientes com epistaxe e 60 indivíduos para controle. Todos os pacientes com epistaxe e os controles sem histórico de hipertensão passaram por exame físico, inclusive determinação da pressão arterial no consultório, MAPA e mensuração dos parâmetros antropométricos. Resultados A média de idade foi similar entre o grupo com epistaxe e os controles: de 21 a 68 (média 42,9) anos para o grupo com epistaxe e de 18 a 71 (média 42,2) anos para o grupo controle. No total, 20 pacientes (33,3%) no grupo com epistaxe e sete (11,7%) no grupo controle (p = 0,004) apresentaram hipertensão mascarada. A pressão arterial sistólica noturna foi significantemente mais alta em pacientes com epistaxe, em comparação com o grupo controle (p < 0,005). No entanto, não foi observada diferença significante na pressão arterial sistólica obtida durante o dia entre o grupo controle e os pacientes com epistaxe (p = 0,517). Conclusão O presente estudo demonstra maior prevalência de hipertensão mascarada em pacientes com epistaxe. Sugerimos que todos os pacientes com epistaxe devam ser submetidos à monitoração da pressão arterial caseira ou em consultório com o objetivo de detectar hipertensão mascarada, que pode ser uma causa possível de epistaxe.

Discrepancies in Clinic and Ambulatory Blood Pressure in Korean Chronic Kidney Disease Patients

Blood pressure (BP) control is considered the most important treatment for preventing chronic kidney disease (CKD) progression and associated cardiovascular complications. However, clinic BP is insufficient to diagnose hypertension (HT) and to monitor overall BP control because it does not correlate well with ambulatory blood pressure monitoring (ABPM). We enrolled 387 hypertensive CKD patients (stages G1–G4, 58.4% male with median age 61 years) from 3 hospitals in Korea. HT of clinic BP and ABPM was classified as ≥ 140/90 and ≥ 130/80 mmHg, respectively. Clinic BP control rate was 60.2%. The median 24-hour systolic blood pressures (SBPs) of CKD G3b and CKD G4 were significantly higher than those of CKD G1–2 and CKD G3a. However, the median 24-hour SBPs were not different between CKD G1–2 and CKD G3a or between CKD G3b and CKD G4. Of all patients, 5.7%, 38.0%. 42.3%, and 14.0% were extreme-dippers, dippers, non-dippers, and reverse-dippers, respectively. Non-/reverse-dippers independently correlated with higher Ca × P product, higher intact parathyroid hormone (iPTH), and lower albumin. Normal BP was 33.3%, and sustained, masked, and white-coat HT were 29.7%, 26.9%, and 10.1%, respectively. White-coat HT independently correlated with age ≥ 61 years and masked HT independently correlated with CKD G3b/G4. In conclusion, ABPM revealed a high prevalence of non-/reverse-dippers and sustained/masked HT in Korean CKD patients. Clinicians should try to obtain a CKD patient's ABPM, especially among those who are older or who have advanced CKD as well as those with abnormal Ca × P product, iPTH, and albumin.

The significance of blood pressure variation and metabolic risk factors in patients with different stages of hypertension / 고신대학교의과대학학술지

OBJECTIVES: Blood pressure variation (BPV) and metabolic syndrome is an independent risk factor for cardiovascular events. Ambulatory blood Pressure (ABP) has been shown to be more closely related to cardiovascular events in hypertensive patients than conventional office BP (OBP). Using both OBP and ABP, 4 groups of patients were identified: (1) normotensive patients (NT); (2) white coat hypertensives (WCHT); (3) masked hypertensives (MHT); and (4) sustainedhypertensives (SHT). We investigated the significance of BPV and metabolic risks of these 4 groups. METHODS: This study is a retrospective analysis of patients between January 2008 and May 2013. Echocardiography and 24 hour ABP monitoring were performed. RESULTS: BMI was significantly higher in the MHT compared with the NT. There were progressive increases in fasting glucose level from NT to WCHT, MHT, and SHT.MHT and SHT had higher 24h and nighttime BPV than NT.MHT was significantly related with BMI (r = 0.139, P = 0.010), creatinine (r = 0.144, P = 0.018), fasting glucose (r = 0.128, P = 0.046), daytime systolic BPV (r = 0.130, P = 0.017), and daytime diastolic BPV (r = 0.130, P = 0.017). Dyslipidemia (r = 0.110, P = 0.043), nighttime systolic BPV (r = 0.241, P < 0.001) and nighttime diastolic BPV (r = 0.143, P = 0.009) shown correlation with SHT. In multivariate logistic regression, MHT was independently associated with Body mass index (OR 1.086, 95% CI 1.005–1.174, P = 0.038) and creatinine (OR 1.005, 95% CI 1.001–1.010, P = 0.045). CONCLUSIONS: BPV and metabolic risk factors were found to be greater in MHT and SHT compared with NT and WCHT. This suggests that BPV and metabolic risks may contribute to the elevated cardiovascular risk observed in patients with MHT and SHT.

Ambulatory Blood Pressure Monitoring: Five Decades of More Light and Less Shadows / Monitorização Ambulatorial da Pressão Arterial: Cinco Décadas de mais Luzes e Menos Sombras

Abstract Casual blood pressure measurements have been extensively questioned over the last five decades. A significant percentage of patients have different blood pressure readings when examined in the office or outside it. For this reason, a change in the paradigm of the best manner to assess blood pressure has been observed. The method that has been most widely used is the Ambulatory Blood Pressure Monitoring - ABPM. The method allows recording blood pressure measures in 24 hours and evaluating various parameters such as mean BP, pressure loads, areas under the curve, variations between daytime and nighttime, pulse pressure variability etc. Blood pressure measurements obtained by ABPM are better correlated, for example, with the risks of hypertension. The main indications for ABPM are: suspected white coat hypertension and masked hypertension, evaluation of the efficacy of the antihypertensive therapy in 24 hours, and evaluation of symptoms. There is increasing evidence that the use of ABPM has contributed to the assessment of blood pressure behaviors, establishment of diagnoses, prognosis and the efficacy of antihypertensive therapy. There is no doubt that the study of 24-hour blood pressure behavior and its variations by ABPM has brought more light and less darkness to the field, which justifies the title of this review.

Resumo Nas últimas cinco décadas muito têm sido questionadas as medidas casuais da pressão arterial (PA). Significativa porcentagem de pacientes apresenta PA muito diversa quando examinados na clínica ou fora dela. Por isso, é hoje observada uma mudança de paradigma com relação ao melhor modo de se avaliar a PA. O método que mais se consolidou é a Monitorização Ambulatorial da Pressão Arterial - MAPA. É possível obter-se o registro de medidas de PA durante 24 horas avaliando-se vários parâmetros como: médias de PA, cargas de pressão, áreas sob as curvas, variações entre vigília e sono, variabilidade de pressão de pulso etc. As medidas de PA obtidas pela MAPA são mais bem correlacionadas, por exemplo, com os riscos da hipertensão arterial. As principais indicações para a MAPA são: suspeita de hipertensão do avental branco e da hipertensão mascarada, avaliação da eficácia terapêutica nas 24 horas e avaliação de sintomas. Crescem as evidências de que o emprego da MAPA contribui para avaliar os comportamentos da PA, estabelecer diagnósticos, prognóstico e avaliar a eficácia terapêutica anti-hipertensiva. Sem dúvidas, o estudo do comportamento da PA e suas variações durante as 24 horas pela MAPA nos deixaram com menos sombras e mais luzes, e justifica o título desta revisão.

Prevalence of Masked Hypertension: a Population-Based Survey in a Large City by Using 24-Hour Ambulatory Blood Pressure Monitoring

BACKGROUND AND OBJECTIVES: We estimated the prevalence of hypertension and hypertension subtypes in a large semi-urban city in Korea, using 24-hour ambulatory blood pressure monitoring (ABPM) in a randomly selected sample population. SUBJECTS AND METHODS: A random sample (aged 20-65 years) from a city with an adult population of approximately 600000 was selected by using a list-assisted random digit dialing method. The 24-hour ABPM and conventional blood pressure measurement (CBPM) of these individuals were obtained. RESULTS: Among the 496 participants, valid 24-hour ABPM and CBPM were obtained from 462 (93%) individuals. The estimated prevalence of hypertension in Goyang was 17.54% by CBPM and 32.70% by 24-hour ABPM (p<0.01). In the age stratified analysis, both CBPM and 24-hour ABPM showed increased prevalence of hypertension with age. The estimated prevalence of masked hypertension was 16.22% and that of white-coat hypertension was 1.08%. Men had a higher prevalence of masked hypertension than women (20.79% vs. 11.86%, p=0.0295). The estimated prevalence of masked hypertension was 17.5%, 20.58%, 24.34%, and 13.29% in the age categories of 30s, 40s, 50s, and 60s, respectively. The estimated prevalence of masked uncontrolled hypertension was 26.79% in patients with hypertension who were taking antihypertensive medications. CONCLUSION: The estimated prevalence of hypertension by 24-hour ABPM was higher than that by CBPM, revealing high prevalence of masked hypertension. The high prevalence of masked hypertension supports the adoption of ABPM in the national population survey and clinical practice to improve public health and reduce health care costs.

Higher Blood Pressure Variability in White Coat Hypertension; from the Korean Ambulatory Blood Pressure Monitoring Registry

BACKGROUND AND OBJECTIVES: Blood pressure variability (BPV) was recently shown to be a risk factor of stroke. White coat hypertension (WCH) used to be regarded as innocuous, but one long-term follow-up study reported that WCH increased stroke rate compared to normotension (NT). In this study, we aimed to evaluate the relationship between WCH and BPV. SUBJECTS AND METHODS: We analyzed 1398 subjects from the Korean Ambulatory Blood Pressure Registry, who were divided into NT (n=364), masked hypertension (n=122), white coat hypertension (n=254), and sustained hypertension (n=658) groups. RESULTS: Baseline characteristics were similar among groups. The average real variability (ARV), a highly sensitive BPV parameter, was highest in the WCH group, followed by the sustained hypertension, masked hypertension, and NT groups. The results persisted after being adjusted for covariates. The WCH vs. sustained hypertension results (adjusted mean±standard error) were as follows: 24-h systolic ARV, 22.9±0.8 vs. 19.4±0.6; 24-h diastolic ARV, 16.8±0.6 vs. 14.3±0.5; daytime systolic ARV, 21.8±0.8 vs. 16.8±0.6; and daytime diastolic ARV, 16.2±0.6 vs. 13.4±0.5 (p<0.001 for all comparisons). CONCLUSION: From the registry data, we found that subjects with WCH or masked hypertension had higher BPV than NT. However, long-term follow-up data assessing the clinical influences of WCH on stroke are needed.

Systemic Hemodynamic Atherothrombotic Syndrome and Resonance Hypothesis of Blood Pressure Variability: Triggering Cardiovascular Events

Blood pressure (BP) exhibits different variabilities and surges with different time phases, from the shortest beat-by-beat to longest yearly changes. We hypothesized that the synergistic resonance of these BP variabilites generates an extraordinarily large dynamic surge in BP and triggers cardiovascular events (the resonance hypothesis). The power of pulses is transmitted to the peripheral sites without attenuation by the large arteries, in individuals with stiffened arteries. Thus, the effect of a BP surge on cardiovascular risk would be especially exaggerated in high-risk patients with vascular disease. Based on this concept, our group recently proposed a new theory of systemic hemodynamic atherothromboltic syndrome (SHATS), a vicious cycle of hemodynamic stress and vascular disease that advances organ damage and triggers cardiovascular disease. Clinical phenotypes of SHATS are large-artery atherothombotic diseases such as stroke, coronary artery disease, and aortic and pheripheral artery disease; small-artery diseases, and microcirculation-related disease such as vascular cognitive dysfunction, heart failure, and chronic kidney disease. The careful consideration of BP variability and vascular diseases such as SHATS, and the early detection and management of SHATS, will achieve more effective individualized cardiovascular protection. In the near future, information and communication technology-based 'anticipation medicine' predicted by the changes of individual BP values could be a promising approach to achieving zero cardiovascular events.

Systemic Hemodynamic Atherothrombotic Syndrome and Resonance Hypothesis of Blood Pressure Variability: Triggering Cardiovascular Events

Blood pressure (BP) exhibits different variabilities and surges with different time phases, from the shortest beat-by-beat to longest yearly changes. We hypothesized that the synergistic resonance of these BP variabilites generates an extraordinarily large dynamic surge in BP and triggers cardiovascular events (the resonance hypothesis). The power of pulses is transmitted to the peripheral sites without attenuation by the large arteries, in individuals with stiffened arteries. Thus, the effect of a BP surge on cardiovascular risk would be especially exaggerated in high-risk patients with vascular disease. Based on this concept, our group recently proposed a new theory of systemic hemodynamic atherothromboltic syndrome (SHATS), a vicious cycle of hemodynamic stress and vascular disease that advances organ damage and triggers cardiovascular disease. Clinical phenotypes of SHATS are large-artery atherothombotic diseases such as stroke, coronary artery disease, and aortic and pheripheral artery disease; small-artery diseases, and microcirculation-related disease such as vascular cognitive dysfunction, heart failure, and chronic kidney disease. The careful consideration of BP variability and vascular diseases such as SHATS, and the early detection and management of SHATS, will achieve more effective individualized cardiovascular protection. In the near future, information and communication technology-based 'anticipation medicine' predicted by the changes of individual BP values could be a promising approach to achieving zero cardiovascular events.

Associação entre valores de carga pressórica noturna na MAPA com o diagnóstico de apneia do sono / Association between sleep load pressure values with sleep apnea diagnosis

Fundamentos: A apneia do sono é fator de risco para várias condições cardiovasculares e, sendo assim, o seudiagnóstico é essencial.Objetivo: Verificar em pacientes portadores de hipertensão arterial sistêmica e apneia do sono, se há associaçãoentre esses diagnósticos.Métodos: Estudo retrospectivo, realizado com pacientes adultos, de ambos os sexos, provenientes do banco dedados da Clínica Paulista de Doenças Cardiovasculares, diagnosticados com hipertensão arterial sistêmica eapneia do sono, no período de janeiro de 2011 a janeiro de 2015. Utilizados dados da monitorização ambulatorialda pressão arterial (MAPA) e da polissonografia associados para verificar a presença de aumento da cargapressórica e ausência de descenso durante o sono e a presença de episódios obstrutivos que diagnosticaram apneiado sono. Os pacientes também foram avaliados em relação aos fatores de risco cardiovascular: sedentarismo,obesidade, tabagismo, nível glicêmico e perfil lipídico.Resultados: Foram avaliados 59 pacientes, sendo que 32 (54,2%) pacientes apresentaram na MAPA manutençãoou aumento da carga pressórica com ausência de descenso durante o sono, quando comparados à vigília. Dessespacientes, 31 (96,9%) apresentaram apneia do sono na polissonografia, mostrando uma associação de 97,0%.Conclusão: Neste estudo, observou-se forte associação entre hipertensão arterial sistêmica e apneia do sono.

Background: Sleep apnea is a risk factor for many cardiovascular conditions, therefore, its diagnosis is essential.Objective: To check in patients with systemic arterial hypertension and sleep apnea whether there is an association between thesediagnoses.Methods: Retrospective study with adult patients of both sexes from the database of Clínica Paulista de Doenças Cardiovascularesdiagnosed with systemic arterial hypertension and sleep apnea from January 2011 to January 2015. Data from ambulatory bloodpressure monitoring (ABPM) and polysomnography associated for the presence of increased pressure load and no pressure decreaseduring sleep and the presence of obstructive episodes that diagnosed sleep apnea. Patients were also evaluated for cardiovascularrisk factors: physical inactivity, obesity, smoking, glucose level and lipid profile.Results: Altogether, 59 patients have been evaluated, 32 of which (54.2%) presented, during ABPM, stable or increased pressureload with no decline during sleep compared to wakefulness. Of these patients, 31 (96.9%) had sleep apnea in polysomnography,showing an association of 97.0%.Conclusion: In this study, we observed a strong association between systemic arterial hypertension and sleep apnea.

White coat hypertension and masked hypertension among Omani patients attending a tertiary hospital for ambulatory blood pressure monitoring

Our study aimed to estimate the rate of white coat hypertension [WCH] and effect, and masked hypertension in patients attending a tertiary care hospital for 24 hour ambulatory blood pressure monitoring [24-h ABPM]. A total of 231 adult patients were referred to the Department of Clinical Physiology at Sultan Qaboos University Hospital, Muscat, for ABPM, between January 2010 and June 2012. The following data were gathered and analyzed: demographic data, clinic blood pressure [BP] measurements, and 24-h BP profile from ABPM. Thirty-two patients were excluded and the final analysis included 199 patients. There were 105 [52.8%] women and 94 [47.2%] men studied. The mean age of patients was 46 +/- 15 years and most patients were overweight with a mean BMI of 29.6 +/- 5 kg/m[2]. Around half of patients [53.8%] were on one or more antihypertensive medications. WCH was found in 10.6% and white coat effect was found in 16% of patients. The majority of patients [57%] with WCH were aged 40 years or above. Masked hypertension was present in 6% of patients and masked uncontrolled hypertension in 8.5% of patients. Our study showed that WCH and effect, and masked hypertension are common in hypertensive patients. Identifying these patients will have an impact on their management. However, the results of the study should be interpreted within the context of its limitations. Prospective randomized community and hospital-based studies should be conducted to estimate the true prevalence in the general population as well as in hypertensive patients

Discordance between ambulatory versus clinic blood pressure according to global cardiovascular risk group

BACKGROUND/AIMS: The detection of white coat hypertension (WCH), treated normalized hypertension, and masked hypertension (MH) is important to improve the effectiveness of hypertension management. However, whether global cardiovascular risk (GCR) profile has any effect on the discordance between ambulatory blood pressure (ABP) and clinic blood pressure (CBP) is unknown. METHODS: Data from 1,916 subjects, taken from the Korean Multicenter Registry for ABP monitoring, were grouped according to diagnostic and therapeutic thresholds for CBP and ABP (140/90 and 135/85 mmHg, respectively). GCR was assessed using European Society of Hypertension 2007 guidelines. RESULTS: The mean subject age was 54.1 ± 14.9 years, and 48.9% of patients were female. The discordancy rate between ABP and CBP in the untreated and treated patients was 32.5% and 26.5%, respectively (p = 0.02). The prevalence of WCH or treated normalized hypertension and MH was 14.4% and 16.0%, respectively. Discordance between ABP and CBP was lower in the very high added-risk group compared to the moderate added-risk group (odds ratio [OR], 0.649; 95% confidence interval [CI], 0.487 to 0.863; p = 0.003). The prevalence of WCH or treated normalized hypertension was also lower in the very high added-risk group (OR, 0.451; 95% CI, 0.311 to 0.655). CONCLUSIONS: Discordance between ABP and CBP was observed more frequently in untreated subjects than in treated subjects, and less frequently in the very high added-risk group, which was due mainly to the lower prevalence of WCH or treated normalized hypertension.

Hipertensão mascarada: diagnóstico e tratamento / Masked hypertension: diagnosis and treatment

A elevação da pressão arterial (PA) aumenta o risco cardiovascular. A medida da PA obtida no consultóriotem sido o padrão-ouro para o acompanhamento desses pacientes. O advento da monitorização ambulatorialda PA (MAPA) e das medidas domiciliares da PA,entretanto, trouxe novos paradigmas nos conceitos,na classificação e no manejo desses pacientes. A hipertensão mascarada (HM) se caracteriza por PAnormal no consultório acompanhada de elevação da PA na MAPA ou nas medidas domiciliares. Esses pacientes são semelhantes aos hipertensos sustentados em risco cardiovascular. Nesta publicação os autores discutem o diagnóstico e o tratamento da HM.

High blood pressure (BP) steps up cardiovascular risk, with in-office BP measurements long the gold standardfor monitoring these patients. However, the advent of Ambulatory BP Monitoring (ABPM) and in-home BP measurements has ushered in new paradigms forconcepts, classifications and management of these patients. Masked hypertension (MH) is characterizedby normal BP during appointments with rising BP during ABPM or in-home BP measurements. In terms of cardiovascular risk, these patients aresimilar to those with sustained hypertension. In this paper, the authors discuss MH diagnosis and treatment.