Relationship between left ventricular mass and blood pressure in treated hypertension.

This study evaluated prospectively whether there is still a relationship between left ventricular mass and blood pressure once hypertension is treated and determined the relative importance of daytime vs night-time blood pressure, systolic vs diastolic blood pressure and office vs ambulatory blood pressure. A total of 649 patients (305 or 47% female) with essential hypertension, treated with antihypertensive drugs for at least 3 months, underwent office blood pressure measurement and both daytime and night-time ambulatory blood pressure measurement, electrocardiography and echocardiography. Correlations were made between blood pressure values and parameters of left ventricular mass. Electrocardiographic voltage criteria and even more so echocardiographic parameters correlate significantly albeit weakly (r < or = 0.28) with blood pressure in treated hypertension. Correlations are consistently higher when systolic blood pressure is considered. Overall, the best correlations are found between 24-h ambulatory systolic or night-time blood pressure and the Sokolow-Lyon voltage as well as the echocardiographic age and body mass index adjusted left ventricular mass. In conclusion, once hypertension is treated, the relationship between blood pressure and left ventricular mass is low. Nevertheless, in this the largest single centre study of its kind, echocardiographic parameters of left ventricular mass in treated hypertensive subjects correlate better with blood pressure than electrocardiographic parameters. Parameters of hypertrophy are more closely related to systolic blood pressure than to diastolic blood pressure. In accordance with the finding that dippers have a better prognosis than non-dippers, night-time blood pressure consistently correlates better with left ventricular mass than daytime blood pressure.

[Addition of beta blockers in chronic heart failure]. / Toediening van beta-blokkers bij chronisch hartfalen.

Chronic heart failure is an increasing cause of hospital admission in the Netherlands and Belgium. Despite numerous medical treatment modalities, the mortality remains high. Recent placebo-controlled randomized studies suggest that the addition of beta-blockers in stabilized, optimally pretreated patients with chronic heart failure using angiotensin converting enzyme (ACE) inhibitors, diuretics and digitalis, is accompanied by an additional absolute decrease in mortality by about 5% and a relative decrease in mortality by about 35%. Also the number hospitalization frequency decreases. Initially, the beneficial effects of beta-blockers on symptoms are only minor or absent. During the initiation period some clinical deterioration may occur which has to be treated accordingly; these patients are, however, difficult to identify. Initiation has to be done using low doses and should be restricted to stabilized, optimally treated patients. Doses should only be increased every 2 to 4 weeks until target doses are reached. These findings must not be extrapolated automatically to all cases of heart failure, since patients in the trials may differ considerably from those encountered in general practice.

Pacemaker lead infection: report of three cases and review of the literature.

Pacemaker lead infection is a rare condition, most often occurring when intervention is needed after pacemaker implantation. Diagnosis is by blood cultures and confirmation by transoesophageal echocardiography; transthoracic echocardiography is often inadequate. A literature review indicated the microorganism most responsible for late lead infection is Staphylococcus epidermidis (which can grow on plastic material). A retrospective analysis of patient files from the authors' institution (1993-97) yielded three patients with proven pacemaker lead endocarditis. The diagnosis of pacemaker endocarditis was by transoesophageal echocardiography. The endocarditis appeared after a long period and in two of the three patients there was S epidermidis infection. Thoracotomy with removal of the infected system was performed because of the large dimensions of the vegetations. A new pacemaker was implanted: in one patient with endocardial leads, in the other two with epicardial leads. All three patients recovered well and follow up was uneventful for at least one year.

Surgical treatment of impending paradoxical embolism through patent foramen ovale.

We describe the case of a patient with deep venous thrombosis who had cerebral and extremity paradoxical emboli and an intracardiac thrombus crossing a patent foramen ovale identified by echocardiography. He was treated successfully with immediate intracardiac embolectomy and closure of the patent foramen ovale.

Exercise performance and diastolic filling in essential hypertension.

OBJECTIVES: To investigate the relationship between arterial blood pressure, left ventricular mass, diastolic filling and maximal exercise capacity in patients with newly diagnosed essential hypertension. DESIGN: Asymptomatic untreated patients with office blood pressure > 140/90 mmHg were studied prospectively after exclusion of associated disease. METHODS: Twenty consecutive white patients (14 male, 6 female; age 43 +/- 12 years) with office blood pressure 164 +/- 23/103 +/- 10 mmHg, mean 24-h ambulatory blood pressure 142 +/- 25/89 +/- 15 mmHg and normal systolic cardiac function underwent an echocardiographic examination to determine left ventricular mass and diastolic filling parameters and performed a bicycle ergometer test to determine maximal voluntary exercise capacity. RESULTS: In single regression analysis exercise time and maximal oxygen uptake were related to sex and age. A multiple regression showed that only age was related to exercise capacity, however. On subgroup analysis of male patients between 30 and 50 years (n = 10), exercise time (659 +/- 134 s) was significantly inversely related to mean 24-h ambulatory diastolic blood pressure (92 +/- 11 mmHg) (r = -0.67; p = 0.03) and positively to diastolic filling expressed as ratio of peak early to peak atrial filling velocity (Emax/Amax ratio; 1.34 +/- 0.40) (r = 0.65; p = 0.04) or as ratio of velocity time integral (VTI) of early filling phase to VTI of atrial filling phase (VTIE/VTIA ratio; 1.94 +/- 0.72) (r = 0.02). Maximal oxygen consumption (22.3 +/- 4.1 ml/kg/min) was significantly inversely correlated with mean 24-h ambulatory diastolic blood pressure (r = -0.67; p = 0.03), mean 24-h ambulatory systolic blood pressure (147 +/- 25 mmHg) (r = -0.82; p < 0.01), left ventricular mass (312 +/- 143 g) (r = -0.86; p < 0.01), left ventricular mass index (135 +/- 41 g/m2) (r = -0.76, p = 0.01) and positively with diastolic filling expressed as Emax/Amax ratio (r = 0.71; p = 0.02) or as VTIE/VTIA ratio (r = 0.70; p = 0.02). CONCLUSION: This study shows the important interrelation between blood pressure, cardiac mass, diastolic filling and exercise capacity. High blood pressure entrains a larger cardiac mass but slows cardiac filling and decreases exercise capacity.

Influence of the breathing mode on the time course and amplitude of the cyclic inter-atrial pressure reversal in postoperative coronary bypass surgery patients.

The haemodynamic basis for paradoxical embolization in patients with stroke and decompression sickness has not yet been fully elucidated. Therefore right and left atrial pressures were measured simultaneously with peroperatively placed catheters after coronary artery bypass grafting in 17 patients with sinus rhythm and normal left ventricular function. Recordings were made both during spontaneous breathing and positive pressure ventilation. A cyclic pressure reversal in which right atrial pressure exceeded left atrial pressure was reproducibly recorded. It started on average 215 +/- 5 ms (mean +/- SEM) after the onset of the electrocardiographic P-wave, lasted on average 179 +/- 14 ms and had a maximal amplitude of on average 4.1 +/- 0.3 mmHg. During the expiration phase of spontaneous breathing and inspiration phase of positive pressure ventilation, the onset of the pressure reversal occurred later, its duration was shorter and its amplitude smaller. These observations demonstrate the presence of a cyclic inter-atrial pressure reversal and illustrate the importance of the breathing mode for the time course and amplitude of this reversal.