Predictive power of home blood pressure indices at baseline and during follow-up in hypertensive patients: HOMED-BP study.

We compared the predictive power for a major adverse cardiovascular event (MACE) of four home blood pressure (BP) indices (systolic BP, diastolic BP, mean BP, and pulse pressure (PP)) obtained at baseline before treatment and during the on-treatment follow-up period in 3147 patients with essential hypertension (women: 50.1%, mean age: 59.5 years). Associations between MACE and each index were determined using Cox proportional hazard models and the likelihood ratio (LR) test. During a median follow-up of 5.4 years, 46 patients experienced MACE, which was a composite of cardiovascular death, non-fatal stroke, and non-fatal myocardial infarction. The LR test showed that systolic, diastolic, and mean BP during follow-up was more closely associated with cardiovascular risk than the corresponding indices at baseline (LR χ2 for baseline versus follow-up: systolic BP, (6.0, P = 0.014) versus (11.3, P = 0.0008); diastolic BP, (0.4, P = 0.53) versus (12.4, P = 0.0004); mean BP, (3.2, P = 0.074) versus (15.0, P = 0.0001)), whereas neither PP at baseline nor that during follow-up was significantly associated with MACE risk. Among home BP indices during follow-up, mean BP further improved prediction models in which systolic or diastolic BP was already included (P ≤ 0.042), but neither systolic nor diastolic BP improved models with mean BP (P = 0.80). In addition to home systolic and diastolic BP, mean BP during follow-up period provides essential information in predicting future cardiovascular diseases, whereas its utilization should be further assessed by an intervention trial targeting mean BP levels.

Seasonal variation in self-measured home blood pressure among patients on antihypertensive medications: HOMED-BP study.

Seasonal variation of blood pressure (BP) has been reported in small populations or by BP levels captured at only a few points in a year, for example, summer and winter. We aimed to investigate the multiyear seasonal variation in self-measured home BP among hypertensive patients receiving antihypertensive medications. We selected 1649 eligible patients receiving antihypertensive drug treatment, and weekly averaged home BPs were analyzed throughout the follow-up period. Systolic and diastolic home BPs were fitted with the cosine function: 'Variation+Other Effects+Intercept', in which the 'Variation' was expressed by a cosine curve with three parameters representing: (1) maximum-minimum difference of home BP in one cycle of the cosine curve; (2) time required for one cycle of the cosine curve for home BP variation; and (3) time at which home BP reached the maximum point. Maximum-minimum differences in home BP were 6.7/2.9 mm Hg, and the highest home BPs were observed in mid-to-late January. In the multivariable-adjusted model, a large maximum-minimum difference in home BP was associated with lower body mass index and older age, and larger differences were observed in men compared with women. Summer-winter difference in home BP was essentially similar every year, though it was marginally reduced by 0.14/0.04 mm Hg per year, under long-term antihypertensive treatment. Records of daily home BP measurements enable us to capture long-term factors such as seasonal variation. Home BP should therefore be carefully monitored, particularly in patients with increased BP in winter, to mitigate cardiovascular risk.

Does Antihypertensive Drug Class Affect Day-to-Day Variability of Self-Measured Home Blood Pressure? The HOMED-BP Study.

BACKGROUND: Recent literature suggests that blood pressure variability (BPV) predicts outcome beyond blood pressure level (BPL) and that antihypertensive drug classes differentially influence BPV. We compared calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockade for effects on changes in self-measured home BPL and BPV and for their prognostic significance in newly treated hypertensive patients. METHODS AND RESULTS: We enrolled 2484 patients randomly allocated to first-line treatment with a calcium channel blocker (n=833), an angiotensin-converting enzyme inhibitor (n=821), or angiotensin receptor blockade (n=830). Home blood pressures in the morning and evening were measured for 5 days off treatment before randomization and for 5 days after 2 to 4 weeks of randomized drug treatment. We assessed BPL and BPV changes as estimated by variability independent of the mean and compared cardiovascular outcomes. Home BPL response in each group was significant (P≤0.0001) but small in the angiotensin-converting enzyme inhibitor group (systolic/diastolic: 4.6/2.8 mm Hg) compared with the groups treated with a calcium channel blocker (systolic/diastolic: 8.3/3.9 mm Hg) and angiotensin receptor blockade (systolic/diastolic: 8.2/4.5 mm Hg). In multivariable adjusted analyses, changes in home variability independent of the mean did not differ among the 3 drug classes (P≥0.054). Evening variability independent of the mean before treatment significantly predicted hard cardiovascular events independent of the corresponding home BPL (P≤0.022), whereas BPV did not predict any cardiovascular outcome based on the morning measurement (P≥0.056). Home BPV captured after monotherapy had no predictive power for cardiovascular outcome (P≥0.22). CONCLUSIONS: Self-measured home evening BPV estimated by variability independent of the mean had prognostic significance, whereas antihypertensive drug classes had no significant impact on BPV changes. Home BPL should remain the primary focus for risk stratification and treatment. CLINICAL TRIAL REGISTRATION: URL: http://www.umin.ac.jp/ctr/index.htm. Unique identifier: C000000137.

Impaired Higher-Level Functional Capacity as a Predictor of Stroke in Community-Dwelling Older Adults: The Ohasama Study.

BACKGROUND AND PURPOSE: Functional capacity is a predictor, as well as a consequence, of stroke. However, little research has been done to examine whether higher-level functional capacity above basic activities of daily living is a predictor of stroke. METHODS: We followed 1493 Japanese community-dwelling adults aged ≥60 years (mean age, 70.1 years) who were independent in basic activities of daily living and had no history of stroke. Baseline data were collected using a self-administered questionnaire. Higher-level functional capacity was measured using the total score and 3 subscales (instrumental activities of daily living, intellectual activity, and social role) derived from the Tokyo Metropolitan Institute of Gerontology Index of Competence. Adjusted hazard ratios and 95% confidence intervals were calculated by the Cox proportional hazards model. RESULTS: During a mean follow-up of 10.4 years, 191 participants developed a first stroke. Impaired higher-level functional capacity based on total score of the Tokyo Metropolitan Institute of Gerontology Index of Competence was significantly associated with stroke (hazard ratio, 1.64; 95% confidence interval, 1.15-2.33). Among the 3 subscales, only intellectual activity was significantly associated with stroke (hazard ratio, 1.64; 95% confidence interval, 1.21-2.22). Social role was significantly associated with stroke only among those aged ≥75 years (hazard ratio, 1.78; 95% confidence interval, 1.07-2.98). CONCLUSIONS: Impaired higher-level functional capacity, especially in the domain of intellectual activity, was a predictor of stroke, even among community-dwelling older adults with independent basic activities of daily living at baseline. Monitoring of higher-level functional capacity might be useful to detect those at higher risk of developing stroke in the future.

Long-Term Stroke Risk Due to Partial White-Coat or Masked Hypertension Based on Home and Ambulatory Blood Pressure Measurements: The Ohasama Study.

The prognostic significance of white-coat hypertension (WCHT) is controversial, and different findings on self-measured home measurements and 24-h ambulatory monitoring make identifying WCHT difficult. We examined whether individuals with partially or completely defined WCHT, as well as masked hypertension, as determined by different out-of-office blood pressure measurements, have a distinct long-term stroke risk. We followed 1464 participants (31.8% men; mean age, 60.6±10.8 years) in the general population of Ohasama, Japan, for a median of 17.1 years. A first stroke occurred in 212 subjects. Using sustained normal blood pressure (events/n=61/776) as a reference, adjusted hazard ratios for stroke (95% confidence intervals; events/n) were 1.38 (0.82-2.32; 19/137) for complete WCHT (isolated office hypertension), 2.16 (1.36-3.43; 29/117) for partial WCHT (either home or ambulatory normotension with office hypertension), 2.05 (1.24-3.41; 23/100) for complete masked hypertension (both home and ambulatory hypertension with office normotension), 2.08 (1.37-3.16; 38/180) for partial masked hypertension (either home or ambulatory hypertension with office normotension), and 2.46 (1.61-3.77; 42/154) for sustained hypertension. When partial WCHT and partial masked hypertension groups were further divided into participants only with home hypertension and those only with ambulatory hypertension, all subgroups had a significantly higher stroke risk (adjusted hazard ratio ≥1.84, P≤0.04). In conclusion, impacts of partial WCHT as well as partial masked hypertension for long-term stroke risk were comparable to those of complete masked hypertension or sustained hypertension. We need both home and 24-h ambulatory blood pressure measurements to evaluate stroke risk accurately.

Evaluating home blood pressure in treated hypertensives in comparison with the referential value of casual screening of blood pressure: the Ohasama study.

OBJECTIVE: The target home blood pressure (BP) levels for antihypertensive treatment have not been fully investigated. We estimated home BP values that corresponded to the referential values of casual screening of BP using reduced major axis (RMA) regression for data from untreated and treated individuals in a general population. METHODS: The study included 2651 participants (778 treated) aged 20 years or above. The relationships between casual BP and home BP were examined using RMA regression to consider measurement errors. We calculated estimated home BP values that corresponded to casual BP using the regression equations. RESULTS: Although casual BPs and home BPs were significantly correlated (all: P<0.0001), the coefficients of determination in multiple regression were higher in untreated individuals than those in treated ones. When RMA regression was applied between casual BP (x) and morning home BP (y), the equations were expressed as y=0.78x+26.55 (systolic BP) and y=0.84x+14.34 (diastolic BP) in treated individuals and y=0.79x+19.29 (systolic BP) and y=0.85x+9.94 (diastolic BP) in untreated ones. The estimated home BPs corresponded to 140/90 mmHg of casual BP: 135.8/89.8 mmHg (morning), 132.2/86.6 mmHg (evening), and 133.9/87.8 mmHg (average) in treated individuals and 129.2/86.7 mmHg (morning), 127.8/84.8 mmHg (evening), and 128.2/85.2 mmHg (average) in untreated individuals. CONCLUSION: We estimated the referential values of home BP in treated hypertensives using a regression model; however, further intervention studies on home BP are needed to clarify the target treatment goals of home BP.

A case of asthma-complicated influenza myocarditis.

A 36-year-old man with a history of asthma visited an outpatient clinic complaining of high fever and general fatigue, and was diagnosed as having influenza type A by influenza antigen test. Laboratory findings revealed mild inflammation, mild acidemia, and hypercapnea with radiologic infiltrations in the right lung, and remarkable wheezes in both lungs were heard on auscultation. He was diagnosed with asthma exacerbation and having influenza pneumonia, and was referred to us. Therapy was begun with oseltamivir for influenza infection and intravenous infusions of betamethasone and aminophylline with non-invasive pulmonary ventilation for asthma exacerbation and acute respiratory failure. Although he was weaned from mechanical ventilation and his general condition became good, electrocardiogram showed sinus bradycardia and negative T waves in V1-4 without any symptoms. Blood test and echocardiography showed almost normal findings except for slight elevation of LDH and AST. Influenza A antigen was already confirmed and he was diagnosed as having influenza myocarditis clinically. Although it is well known that influenza can cause asthma exacerbation and encephalopathy, influenza myocarditis is regarded as rare by physicians. In fact, the number of case reports about influenza myocarditis is few. Myocarditis may not appear to be serious, but could cause fatal arrhythmia and heart failure. All clinicians should be aware of the overall clinical picture and the possibility of severe complications of myocarditis caused by flu infection.

[Prognostic lung abscess factors].

BACKGROUND: Lung abscess, although curable when caught early and treated appropriately, still may recur repeatedly or require surgery. We retrospectively assessed prognostic lung abscess factors and predictive recurrence factors. We evaluated comorbidity using the Charson comorbidity index (CCI). METHODS: Subjects numbered 44 hospitalized for lung abscesses between June 2004 and May 2009 and classified as; elderly (over 65 years) or non-elderly and cured treatment failed. RESULTS: Mean age and the CCI of failed treatment were statistically higher than in cures at 80.8 years and 3.25 vs 64.1 years and 1.25 (p < 0.05). Abscess location, smoking habits, symptoms, white blood cell count and C-reactive protein did not differ on day 1. The causative organism, fistula presence at 65.6% vs 45.5% (p = 0.30) and lesion size at 59.8 mm vs 71.6 mm (p = 0.14) did not differ between groups, but the degree of lesion size reduction in treatment failures was lower than cures at 24.9% vs 69.1% (p < 0.05). CONCLUSIONS: Lung abscess prognosis is thus adversely affected by age and comorbidity. In Japan, subjects having multiple comorbidities are expected to increase with aging. The degree of lesion size reduction appears to be a predictive factor in recurrence, underscoring the importance of follow-up in imaging, including chest computed tomography.

Stroke risk in treated hypertension based on home blood pressure: the Ohasama study.

BACKGROUND: Several observational studies have shown that treated hypertensives are characterized as having worse prognosis than nonhypertensives. However, there is little evidence based on home blood pressure (home BP) measurement. We compare the risk of stroke between untreated individuals and those taking antihypertensive medication based on home BP and casual-screening BP (casual BP) in the general population. METHODS: The study included 1,690 untreated and 700 treated subjects aged >or=35 years. We measured home BP and casual BP at the beginning of the study. The risk of first stroke was examined by using the Cox proportional hazards model. RESULTS: During 11.9 years of follow-up, we observed 242 first-time stroke cases. Treated subjects had significantly higher risk for stroke than untreated subjects based on home BP (relative hazard (RH) = 1.48) as well as on casual BP (RH = 1.78), adjusted for systolic BP values and characteristics. When subjects were classified into six categories based on BP (optimal, normal, high normal, and grade 1-3 hypertension), RHs in treated hypertensives linearly increased (trend P < 0.01) based on home BP. However, there was no consistent association for casual BP (trend P: not significant) in treated subjects. Stroke risk was linearly increased regardless of the BP information source in untreated subjects (home BP: trend P < 0.01, casual BP: trend P < 0.01). CONCLUSION: The results suggest a strong association between elevated home BP and increased risk of stroke. Home BP is a better tool to assess stroke risk, especially in treated hypertensives.

[Splenic metastasis of lung cancer].

A 71-year-old man was referred for a chest x-ray of the right upper lobe lung mass in August 2005. Bronchoscopy and transbronchial biopsy revealed squamous cell carcinoma. A routine metastatic workup revealed his clinical stage to be IIIA (cT2N2M0). We treated him with chemotherapy and radiotherapy. However, an abdominal CT scan showed an 8 cm nodule in the spleen in June 2006. Splenic metastasis from lung cancer is rare. Only 13 cases have been reported from 1990 to 2008. Four of 6 cases (67%) who did not have splenectomy reported splenic rupture and had poor outcomes. Therefore, we considered that splenectomy could possibly improve the prognosis of this patient with isolated splenic metastasis. We report a case with a brief review of the literature and summarize the 13 reported cases.

Repeated evening home blood pressure measurement improves prognostic significance for stroke: a 12-year follow-up of the Ohasama study.

OBJECTIVE: To compare the predictive power of home blood pressure (HBP) measured in the evening (E-HBP) and that of casual screening BP (CBP) for stroke risk in relation to the number of E-HBP measurements. METHODS: We obtained E-HBP (measured once in the evening just before going to bed for 4 weeks) and CBP (measured twice during the health checkup) from 2234 Japanese participants aged >or=35 years who had no history of a previous stroke. The participants were followed-up for a median duration of 11.9 years. The multivariate adjusted relative hazard (RH) and 95% confidence intervals (CI) for each 10 mmHg (systolic) or 5 mmHg (diastolic) increase in BP was determined by Cox regression model. RESULTS: There were 226 incidences of stroke. Even the initial E-HBP values significantly predicted future stroke events (systolic RH=1.19, 95% CI=1.11-1.28; diastolic RH=1.12, 95% CI=1.06-1.19), and the predictive power of E-HBP increased progressively with the increased number of measurements. When initial systolic E-HBP and systolic CBP values were simultaneously included into the Cox model, only initial E-HBP was significantly related with stroke risk (E-HBP RH=1.17, 95% CI=1.08-1.26; CBP RH=1.07, 95% CI=0.99-1.15). CONCLUSION: E-HBP has a stronger predictive power than CBP regardless of the number of measurements. Our findings emphasize the important clinical significance of E-HBP over CBP, even though the measurement conditions of E-HBP are generally less strict than that of morning HBP measurements.

The association between masked hypertension and waist circumference as an obesity-related anthropometric index for metabolic syndrome: the Ohasama study.

Masked hypertension has been proven to be associated with an increased risk for cardiovascular diseases. The purpose of this study was to examine the direct associations of obesity-related anthropometric indices, including waist circumference, with masked hypertension. Participants in this population-based survey included 395 residents (> or = 35 years) of Ohasama, a rural Japanese community. They measured blood pressure at home (HBP) and underwent an oral glucose-tolerance test. Participants were classified into four groups on the basis of their HBP and casual-screening blood pressure (CBP) values: sustained normotension, white-coat hypertension, masked hypertension or sustained hypertension. The relationships between the obesity-related anthropometric indices and the four blood pressure groups were examined using multivariate analysis adjusted for confounding factors. The mean waist circumference in men was significantly higher in individuals with masked hypertension (87.3 cm) than in those with sustained normotension (81.0 cm) and white-coat hypertension (79.3 cm), whereas the mean waist circumference in women was significantly higher in individuals with sustained hypertension (79.5 cm) than in those with sustained normotension (75.0 cm). In the multivariate analysis, waist circumference, body mass index (BMI) and waist-to-hip ratio were significantly associated with masked hypertension, particularly in individuals with normal CBP. Our results suggest that HBP measurements might be particularly important in abdominally obese people for the early detection of masked hypertension.

[Cryptococcemia with a severe bronchial asthma: case report and review of the literature].

A 64-year old hospitalized male for severe bronchial asthma began to complain fatigue and appetite loss. His asthma had been treated with oral bethamethasone. The Chest CT at this time revealed a bilateral consolidation of the lower lung. Despite a week of treatment with antibiotics and anti-fungals, the patient expired from DIC progression. His premortem sputum and blood culture grew Cryptococcus Neoformans. We concluded his diagnosis as cryptococcal pneumonia and sepsis. Sepsis by Cryptococcus neoformans is a rare clinical event, and only 20 cases have been reported in Japan. Although 16 of the 20 had preexisting medical conditions, a case with underlying bronchial asthma has never been reported. A comparison of the reported cases of the US and Europe to that of Japan revealed differences in the patients' underlying conditions. We report a case with a brief review of the literature and summarize the 20 cases that have been reported in Japan.

Proposal of a risk-stratification system for the Japanese population based on blood pressure levels: the Ohasama study.

The aim of the present study was to propose a risk-stratification system based on self-measurement of home blood pressure (HBP) as well as casual-screening BP (CBP) in relation to Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2004). For 4 weeks, the subjects measured their HBP while seated every morning within 1 h after awaking, after having rested for at least 2 min. The subjects included 2,368 Ohasama residents aged > or = 35 years, with no history of stroke. CBP was measured twice consecutively at baseline. Among all subjects, there were 174 incidences of stroke or transient ischemic attack (TIA) observed during 9.4 years (interquartile 7.0-12.4) of follow-up. The analysis revealed statistically significant linear increases in stroke or TIA risk in both the CBP-based and HBP-based classifications. The risk for high-normal blood pressure (BP) was not significantly high according to the CBP-based classification (relative hazard [RH] 1.52; 95% confidence interval [CI] 0.89-2.60), whereas it was significantly high by the HBP-based classification (RH 1.91; 95% CI 1.04-3.51). On the basis of the data in the absolute risk table, the risks of first stroke or TIA for the 4 groups in the CBP-based and HBP-based classifications were proposed. Stroke or TIA risk increased linearly with the increase in the stage of stratified risk, regardless of BP information (trend p < 0.0001). Risks for non-hypertensive individuals should be assessed in the next version of the Japanese BP guidelines. Furthermore, the importance of HBP should be emphasized in order to accurately evaluate BP risks for individuals.

[The efficacy of influenza vaccine for acute exacerbation of chronic obstructive lung disease in elderly patients].

OBJECTIVE: Acute exacerbations adversely affect the quality of life and prognosis of patients with chronic obstructive lung disease (COPD). Prevention of future exacerbations is extremely important, especially for elderly patients. In this study, we evaluated the efficacy of influenza vaccine for acute exacerbation of COPD in elderly patients. METHODS: A prospective cohort study was conducted among 289 patients over 65 years of age with COPD (FEV1/FCV<0.70) during the 2001-2002 influenza season. Background data, outpatient visits for wheezing and hospitalizations were compared between the vaccinated group (n = 189) and the unvaccinated group (n = 100). RESULTS: The number of patients who visited hospital for wheezing was 11 of 189 (5.8%) in the vaccinated group and 23 of 100 (23%) in the unvaccinated group (RRR: relative risk reduction 74.7%, 95% CI: confidence interval 0.51-0.87). The number of hospitalizations for pneumonia was 8 of 189 (4.2%) in the vaccinated group and 14 of 100 (14%) in the unvaccinated group (RRR 69.8%, 95% CI: 0.32-0.87). The costs of hospitalization were lower in the vaccinated group with direct savings of 91,525 yen per patient. CONCLUSIONS: For elderly COPD patients, influenza vaccine decreases acute exacerbation due to pneumonia and bronchoconstriction, and also may minimize the costs of hospitalization.

[Effectiveness of inhaled corticosteroids (ics) combination therapy; the addition of qvar to flutide].

PURPOSE: We recently reported treatment of asthmatic patients with a combination of FP-DPI 800 microg/day and BDP-HFA 400 microg/day. This regimen induced significant improvement in subjective symptoms and pulmonary function tests. This led us to study the additive effect of BDP-HFA 400 microg/day for seven unstable severe persistent bronchial asthma patients. RESULTS: PEF improved, daily (circadian) variation was minimized and FVC and FEV1.0 testing showed slight improvement. V25/height also revealed significant improvement. The more peripheral the airways are, the greater improvement was observed. The annual emergency admission rate of 4.6 times per patient decreased to 2.1 times after the addition of BDP-HFA 400 microg/day. All the three cases dependent on oral steroid medication could be removed from the drug and 6 out of 7 cases were able to lower the dose of anti-asthmatic drugs. CONCLUSIONS: The effectiveness of inhaled corticosteroids (ICS) differs based on the site reached in the bronchi and depending on the inhalation devices used. Addition of a second ICS has the potential to further alleviate symptoms of unstable asthmatics on conventional therapy with ICS and other drugs.