Digital plethysmography and arginine metabolism in prehypertension: effect of nebivolol therapy.

Prehypertension is an important phenotype for cardiovascular risk and development of established hypertension. To better understand the early circulatory changes in this group, the authors studied 34 patients with prehypertension (blood pressure 120-139/80-89 mm Hg) using digital plethysmography for measurement of blood flow and reactive hyperemic index (RHI). Arterial augmentation index (AI) was also measured. Because prehypertension is associated with endothelial dysfunction and decreased availability of nitric oxide (NO), indices of arginine metabolism (l-arginine, asymmetric dimethylarginine (ADMA), symmetric dimethylarginine, and l-citrulline) were measured. Nebivolol (5 mg/d), a vasodilating ß1 -antagonist with ß3 -agonist activity, was studied in a double-blind fashion for 8 weeks. Nebivolol increases the bioavailability of NO. Prehypertension was associated with normal RHI and baseline digital blood flow. AI was abnormal and associated with diastolic blood pressure. ADMA concentration was increased at baseline. After 8 weeks of nebivolol therapy, RHI, ADMA, symmetric dimethylarginine, and AI showed no significant change, but digital blood flow and l-citrulline levels were significantly increased. Prehypertension is associated with increased ADMA and evidence of increased arterial stiffness and preserved RHI. Nebivolol therapy is associated with digital vasodilation and increased NO production, as depicted by increased levels of l-citruline and mean digital blood flow.

Pancreatic adenocarcinoma presenting as acute pancreatitis during pregnancy: clinical and radiologic manifestations.

Only seven cases of pancreatic adenocarcinoma diagnosed during pregnancy have been reported. In this article, we describe a case of pancreatic adenocarcinoma presenting clinically as acute pancreatitis in a pregnant patient. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) revealed a pancreatic mass with an inflammatory component and multiple hyperintense metastatic lesions in the liver. The patient was initially treated for biliary pancreatitis, and pancreatic cancer was not suspected given her young age and absence of risk factors. A diagnosis of pancreatic cancer in a pregnant patient requires a high index of suspicion, and pancreatitis can be a mode of presentation.

The effect of nebivolol versus metoprolol succinate extended release on asymmetric dimethylarginine in hypertension.

This study sought to determine if metoprolol succinate ER (MET), and nebivolol (NEB), a ß1-AR with increased bioavailability of nitric oxide (NO), would have differing effects on plasma asymmetric dimethylarginine concentration in hypertensives. It was hypothesized that NEB, a ß1-AR antagonist and ß3-AR agonist with NO-releasing properties, and MET, only a ß1-AR antagonist, would have different effects on plasma asymmetric dimethylarginine (ADMA) concentration. Forty-one hypertensive subjects randomly received either 50 mg of MET (n = 19) or 5 mg of NEB (n = 22) for 4 weeks followed by 100 mg MET and 10 mg NEB for 4 weeks. ADMA and insulin-like growth factor-1 (IGF-1) were measured by enzyme-linked immunosorbent assay kit; endothelial progenitor cells were estimated using fluorescein-labeled monoclonal antibody to KDR and CD133 receptors; arterial augmentation index was measured by radial tonometry. Baseline systolic/diastolic blood pressure was 155.1 ± 18.7/85.3 ± 12.5 mm Hg for MET subjects and 157.6 ± 20.7/87.1 ± 14.0 mm Hg for NEB subjects. Baseline ADMA was 0.32 ± 0.123 µmol/L in the MET group and 0.4035 ± 0.1378 in the NEB group. ADMA increased 44.78% and 72% in the MET group at weeks 4 and 8 (P < .05 for both), respectively, without increase in the NEB group. At week 8, augmentation index was increased in the MET group (P < .05). IGF-1 and endothelial progenitor cells were unchanged by treatment. Plasma ADMA and augmentation index are increased in a dose-dependent fashion by MET but not with NEB.

C-reactive protein is an independent predictor for carotid artery intima-media thickness progression in asymptomatic younger adults (from the Bogalusa Heart Study).

BACKGROUND: Conflicting information exists regarding the association between hsCRP and the progression of early stages of atherosclerosis. The purpose of the study was to investigate the association of high sensitiviy c-reactive protein (hsCRP) along with major cardiovascular (CV) risk factors on early carotid atherosclerosis progression in a large, population-based cohort study. METHODS: The study cohort included 839 young adults (aged 24 to 43 years, 70% white, 42% men) enrolled in Bogalusa Heart Study, who in 2001-2002 attended baseline examination with measurements of CV risk factors. Progression of carotid artery intima-media thickness (IMT) was assessed during a mean follow-up of 2.4 years. RESULTS: Carotid artery IMT progression rates were as follows: composite carotid artery = 9.2 ± 52 µm/y, common carotid artery = 0.0 ± 51 µm/y, carotid bulb = 8.8 ± 103 µm/y, and internal carotid artery = 18.9 ± 81 µm/y. Elevated baseline hsCRP, reflecting an inflammatory state, showed independent association with composite carotid artery IMT progression. Increased age, systolic blood pressure, fasting glucose, LDL cholesterol, and current smoking were other risk associates of carotid artery IMT progression in young adults, indicating an underlying burden on the CV system by multiple risk factors. CONCLUSION: In this population-based study, we observed independent categorical association of increased hsCRP with carotid artery IMT progression in young adults. This study underlines the importance of assesssing hsCRP levels along with smoking and traditional CV risk factor profiles in asymptomatic young adults.

Atorvastatin induced multiple organ failure.

A 71-year-old African American woman presented with a past medical history significant for diabetes mellitus, coronary artery disease, hypertension and hyperlipidemia. She was being treated with atorvastatin and verapamil in addition to a few other medications. She complained of nausea, vomiting, myalgia, generalized weakness and dark urine. Initial evaluation revealed clinical icterus and mild mental confusion. Admission laboratory results showed features of multiple organ dysfunction. Over the course of four to five days the patient deteriorated to multiple organ failure resulting in death. Extensive work up for the etiology for multiple organ failure was noncontributory. We presume the cause for multiple organ failure could be the result of drug-drug interaction, atorvastatin and verapamil, as verapamil is known to increase the serum concentration of atorvastatin significantly.

Dialysis disequilibrium syndrome presenting as a focal neurological deficit.

We report a patient suffering from chronic kidney disease who presented to us with severe pulmonary edema. His clinical, laboratory, and sonological parameters were suggestive of end-stage renal disease. Hemodialysis was initiated, and after 48 hours (3 sessions of hemodialysis) he became drowsy and a neurological examination revealed left upper limb monoplegia with left facial palsy. Urgent computerized tomography scan of the brain revealed diffuse hypodensity in the cerebral white matter bilaterally, and brain magnetic resonance imaging showed diffuse hyperintensity in the cerebral white matter bilaterally, right internal capsule and external capsule on fluid attenuated inversion recovery and T2 sequences (hypointense on T1 sequence). He made a gradual but complete neurological recovery and was discharged 2 weeks later with normal neurological status. A repeat brain magnetic resonance imaging on follow-up 6 weeks later revealed complete resolution of the white matter abnormalities.