[Prognostic value of QKD interval corrected by QRS duration in hypertensive patients]. / Valeur pronosfique de l'intervalle QKD: intérêt d'une correction par la largeur du QRS.

OBJECTIVES: The QKD interval is measured between the onset of QRS on the ECG and detection of last Korotkoff sound by a microphone placed on the brachial artery while measuring BP. It is the sum of preejection time and pulse transmission time and thus is correlated to pulse wave velocity (PWV). This interval is automatically monitored with BP and HR every 15 minutes during 24 h with an ambulatory blood pressure monitoring device (Diasys integra, Novacor, France). The 96 measurements obtained allow to automatically calculate the QKD(100-60), QKD value for 100 mmHg SBP and 60 bpm HR. This indice of arterial stiffness has been shown to be linked to future cardiovascular (CV) events, independently of 24 h BP. However this interval may be abnormally prolonged in case of left bundle branch blocks (LBBB). METHODS: We tested the effects of simply removing QRS duration from QKD(100-60) value on the prediction of CV events in a population of 412 hypertensives (247 males: age = 53 +/- 14 years; office BP = 158 +/- 19/97 +/- 11 mmHg; 24 h BP = 133 +/- 17/86 +/- 11 mmHg) followed prospectively. RESULTS: Mean follow up was 65 months, 32 pts were lost, 49 CV events occurred including 11 deaths. Cox model showed that baseline QKD(100-60) (m = 202 +/- 19; 142-254 ms) was significantly (p < 0.05) associated to events independently of age, 24h SBP and other traditional risk factors. Removing QRS duration (m = 85 +/- 10: 61-158 ms) improves the relation to events (monovariate khi2 = 38 vs 30). CONCLUSION: Removing QRS duration from QKD(100-60) improves its predictive value of future CV events and allows using this method in patients with LBBB.

[Biochemical detection of Conn's adenoma: definition of criteria and reference values]. / Dépistage biologique des adénomes de Conn: definition des critères et des seuils.

Primary hyperaldosteronism is a diagnosis which should be considered in refractory hypertension even in the absence of any hypokalaemia. Its detection relies above all on the levels of renin and aldosterone. The aldosterone/renin ratio has been proposed as the most sensitive criterium. The reference values used for the diagnosis of primary hyperaldosteronism are very variable in the literature, depending not only on the method used but also on the criteria used for their determination. In this study we evaluated the defined reference values prospectively by studying a population of patients with a Conn's adenoma treated surgically. The study included an initial retrospective period which allowed identification of 29 cases of Conn's adenoma treated surgically, and a 9 month prospective period during which 212 reports were collected. During this prospective period a further 9 cases of Conn's adenoma were detected, which were successfully treated with surgery. Analysis to discriminate the 38 Conn's adenomata from the rest showed that 3 parameters contributed significantly and independently to the diagnosis: supine plasma renin activity (ARPc), supine aldosteronaemia and the erect aldosterone/renin ratio, allowing correct classification in 88% of the cases. The reference ranges of these 3 parameters were calculated in order to give a sensitivity of 100% and the best possible specificity, therefore allowing a combined criterium involving all 3 parameters to be defined: ARPc < 0.45 ng/ml/h, supine aldosteronaemia >417 pmol/l, and erect aldosterone/renin >1180.

[Malignant hypertension. Case series of 42 patients]. / Hypertension artérielle maligne.

One could expect that malignant hypertension would belong to the history. Unfortunately, this complication has not been eradicated even though many physicians have already forgot it. The hypertension care units are still confronted to it, and even the arrival of the renin-angiotensin system blockers have changed the prognosis of those patients, an adequate management on emergency remains mandatory in order to avoid in particular the evolution to renal failure. By reporting a series of 42 patients included in a period of 7 years, we aimed to remind the presentation of this severe pattern of hypertension and the basics of its management.

[Is arterial hypertension in women different from that in men? Example of the relationship between arterial pressure and left ventricular mass]. / L'HTA de la femme est-elle différente de celle de l'homme? Exemple de la relation pression artérielle-masse ventriculaire gauche.

In the Bordeaux cohort of never treated, uncomplicated hypertensive patients with office BP > 140/90 on at least 2 occasions, we selected those with good quality 24 H ambulatory BP measurement and LVM measured with M mode echo before any antihypertensive treatment. In this group, we studied the relationships between LVM and average 24 h systolic BP in males and females in univariate and multivariate analysis, taking into account age, weight and height. The population studied included 531 patients whose main characteristics are summarized in the table. The slope of the relationship between LVM and 24 h SBP is significantly steeper in males than in females (1.73 vs 0.58, p < 0.01). In multivariate analysis, the variable showing the higher correlation to LVM is 24 h SBP in males, weight in females. For a similar increase in BP, males hypertensive show a higher increase in LVM than females.

Successful laparoscopic operation of bilateral pheochromocytoma in a patient with Beckwith-Wiedemann syndrome.

We report the case of a 20-year-old female patient with Beckwith-Wiedemann syndrome presenting with high blood pressure and bilateral adrenal pheochromocytoma successfully removed with laparoscopy in the same time. To our knowledge, the present case is the first observation of a bilateral pheochromocytoma occurring in the Beckwith-Wiedemann syndrome. It provides further support for a genetic anomaly in this condition. Our case also indicates the interest of laparoscopy for the surgical treatment of adrenal pheochromocytoma, even in bilateral tumors.

[Sensitivity and specificity of criteria of left ventricular hypertrophy for predicting cardiovascular complications in the Bordeaux cohort of hypertensive patients]. / Sensibilité et spécificité des différents critères d'hypertrophie ventriculaire gauche pour la prédiction des complications cardiovasculaires dans une cohorte d'hypertendus bordelais.

Left ventricular hypertrophy (LVH) is associated with an increased risk of cardiovascular complications independently of other known risk factors. Since 1983, we have followed up a cohort of initially untreated hypertensive patients with echocardiographic measurements of left ventricular mass (LVM). We analyzed the data on 474 patients with more than five years' follow-up to assess the prognostic value of LVM and the sensitivity and specificity of the different ways to index for LVM through ROC curves. Forty patients were lost to follow-up. The mean follow-up period was 89 +/- 31 months. A cardiovascular complication was recorded in 40 individuals. There was a strong link between increased LVM and the occurrence of complications. Indexation by body surface area or height to the power 2.7 give the [table: see text] greatest area under the curve (AUC) to discriminate between patient with or without cardiovascular events. To get the same sensitivity in females and in males for the prediction of future events, lower cut-off must be used in females.

Ambulatory measurement of the QKD interval normalized to heart rate and systolic blood pressure to assess arterial distensibility--value of QKD(100-60).

BACKGROUND: Reduced distensibility of large arteries plays an important role in cardiovascular risk. Determination of the QKD interval during the ambulatory measurement of blood pressure enables calculation of an index of arterial distensibility. This index, the QKD(100-60), is the theoretical value of QKD at systolic blood pressure of 100mmHg and heart rate of 60bpm obtained from the linear bivariate relationship linking QKD, systolic blood pressure and heart rate on a hundred successive values measured over 24h. This study was designed to examine the relationship between QKD and QKD(100-60) on heart rate and systolic function of the left ventricle, the two parameters governing the pre-ejection time which is part of the QKD interval. METHODS AND RESULTS: In a population of 203 untreated hypertensive patients having benefited from an ambulatory measurement of blood pressure over 24h with QKD monitoring and an M-mode echocardiographic recording of the left ventricle, we found that although mean QKD was linked to heart rate and systolic function of the left ventricle, QKD(100-60) was not. It fell significantly with age, and to a greater extent in the sustained hypertensives than in white-coat hypertensives. CONCLUSION: QKD(100-60) constitutes an index of arterial distensibility independent of the pre-ejection time. As an adjunct to the ambulatory measurement of blood pressure, its determination is simple and completely automatic, thus eliminating observer bias.

Prognostic significance of blood pressure measured on rising.

Previous works using ambulatory blood pressure (BP) monitoring demonstrated that independently of the mean level of BP, the variability in BP, or the day-night range, could have prognostic significance. We have also found that the value of BP on rising in the morning is strongly correlated with left ventricular mass of hypertensive individuals independently of the 24-h value. In the present study, we sought its predictive value for cardiovascular complications in a cohort of hypertensive patients. The population studied belongs to a cohort of initially untreated hypertensive patients recruited since 1983 and followed for more than 5 years. Patients were then treated and followed by their family doctor. At entry, all patients were equipped with a device to measure ambulatory BP. They were requested to trigger a measurement manually on rising in the morning (arising BP). The data on their outcome were collected by a physician unaware of the initial state of the patients. A total of 256 patients have been followed up for 5 years or more, 19 were lost to follow-up. The mean follow-up period was 84 +/- 29 months. Cardiovascular complications were recorded in 23 individuals. The arising systolic BP (SBP) was significantly higher in the group who presented a complication. In a stepwise discriminant analysis including age, office, fitting, arising and 24-h average SBPs only age and arising SBP entered the equation. In conclusion, the single BP value measured by an ambulatory device on rising in the morning seems more discriminant of future cardiovascular events than the value of BP measured on fitting the device or the average of three measurements taken under standardised conditions in the hospital or office.

Prognostic value of left ventricular mass and its evolution during treatment in the Bordeaux cohort of hypertensive patients.

Left ventricular hypertrophy (LVH) is associated with an increased risk of cardiovascular complications independently of other known risk factors, but so far the predictive value of its evolution under treatment has been studied relatively little. Since 1983 we have followed up a cohort of initially untreated hypertensive patients with echocardiographic measurements of left ventricular mass (LVM). We analyzed the data on 474 patients with more than 5 years of follow-up to assess the prognostic value of LVM and its evolution during treatment for high blood pressure. A total of 40 patients were lost to follow-up. The mean follow-up period was 89 +/- 31 months. A cardiovascular complication was recorded in 40 individuals. There was a strong link between increased LVM and the occurrence of complications (P < .001). At least a second determination of LVM was performed in 311 patients, and the last value before the occurrence of any complication (60 +/- 38 months after the initial examination) was retained. In this subgroup, 28 patients presented with a cardiovascular event. There was a trend toward a reduction of the incidence of events in the group with a regression of LVH as compared to the group with persistent LVH, but there was no difference when patients were split into quartiles according to LVM evolution between baseline and follow-up. Thus, the reduction of LVM on treatment was not a good marker of future cardiovascular events and its seems at least premature to say that LVM fulfils all conditions for a surrogate end point in the evaluation of morbidity/ mortality in the hypertensive.

Echocardiographic definition of left ventricular hypertrophy in the hypertensive: which method of indexation of left ventricular mass?

OBJECTIVES: It has been suggested that hypertensives at high risk of cardiovascular complications can be identified on the basis of their left ventricular mass as determined echographically. However, there is as yet a lack of consensus on the mode of indexation (body surface area, height, height 2.7) of left ventricular mass (LVM), and on the cut-off values for definition of left ventricular hypertrophy (LVH). The main objective of this study is to test the influence of the different modes of indexation for LVM on the prevalence of LVH in a population of never treated hypertensive patients on the basis of cut-offs for LVM based upon its relationship with ambulatory blood pressure (BP) measurement. METHODS: A population of 363 untreated hypertensives was investigated using a standardised procedure. The men and women were analysed separately. We studied the relationship between mean daytime ambulatory systolic BP and LVM and calculated the LVM cut-off for a BP of 135 mm Hg using three different methods of indexation. On the basis of these criteria, the population was divided into those with and those without LVH. RESULTS: The prevalence of LVH was found to be higher when LVM was indexed to height2.7 (50.4%) or height (50.1%). Prevalence was lowest when LVM was indexed to body surface area (48.2%), which tended to minimise the hypertrophy in obese individuals. Only indexation by height 2.7 fully compensates for relationships between height and ventricular mass in this population. CONCLUSIONS: Indexing LVM to height 2.7 thus appeared to give a more sensitive estimate of LVH by eliminating the influence of growth. Cut-offs of 47 g/m2.7 in women and 53 g/m2.7 in men corresponded to a cardiovascular risk indicated by a daytime systolic BP >/=135 mm Hg.

Comparison of bisoprolol and verapamil in hypertension: influence on left ventricular mass and function--a pilot study.

The objective of this study was to test the influence of bisoprolol and verapamil on left ventricular filling in hypertensive patients in a 6 month randomized, double-blind trial in 54 hypertensive patients not previously treated with beta-blockers or calcium inhibitors. After administration of placebo for 14 days, an M echocardiogram of the left ventricle was recorded to determine left ventricular mass. Blood flow was evaluated by pulsed Doppler sonography. After randomization into two groups, one group received 10 mg of bisoprolol and the other 240 mg of verapamil LP in a single dose in the morning. After 2 months' treatment, the patients whose blood pressure was not well controlled were given a diuretic. Echo-Doppler was performed again by the same operator after 4-10 days on active treatment, after 6 months and after a subsequent 2 weeks of placebo for the patients treated with a single drug. The reduction in blood pressure was comparable in the two treated groups, but there was no significant decrease in left ventricular mass. Left ventricular filling was improved only in the patients receiving bisoprolol. The effect was observed immediately after the first administration and throughout the 6 months' treatment period declining slowly during the placebo wash-out. This effect appeared to be independent of any alteration in heart rate and was thought to be a specific action of this drug.

Left ventricular filling in the hypertensive patient: long-term course and influence of treatment.

BACKGROUND: Hypertension is accompanied by abnormalities in left ventricular filling; however, there is a lack of agreement on the extent of the influence of antihypertensive treatment on them. HYPOTHESIS: The present study was designed to evaluate the long-term course of these abnormalities in both treated and untreated hypertensive patients. METHODS: Left ventricular filling assessed by pulsed Doppler echocardiography of mitral flow was studied over a long follow-up period in both untreated and treated hypertensive patients. This retrospective study included 73 hypertensive patients who had not received any treatment. They had been followed up for at least 3 years and were divided a posteriori into two groups: Group 1 comprised the untreated patients, while Group 2 included the patients who had received antihypertensive treatment throughout the follow-up period. RESULTS: In the overall population, age and heart rate measured during the Doppler examination were the only parameters that correlated significantly with mitral flow. No significant changes in blood pressure or left ventricular mass were observed in Group 1 (14 patients) over the study period. There was a slight but nonsignificant decrease in E/A ratio of mitral flow. In the treated patients, there was a drop in heart rate-adjusted E/A ratio, despite a reduction in blood pressure and left ventricular mass, at mean follow-up of 5 years. CONCLUSION: Antihypertensive therapy did not arrest the long-term reduction in E/A ratio in hypertensive patients despite reduction in blood pressure and left ventricular mass.

Ambulatory measurement of the timing of Korotkoff sounds in a group of normal subjects: influence of age and height.

Ambulatory measurement of timing of Korotkoff sounds (QKD interval) gives an estimate of arterial distensibility derived from the velocity of the pulse wave over a vascular territory that includes the ascending aorta. The main advantages of the method are that it is entirely automatic, non-operator-dependent, and highly reproducible, and produces a measure independent of instantaneous blood pressure. This study of a group of 180 normal subjects aged between 10 and 78 years was designed to produce references values and to study the influence of height. The results confirmed the reduction with age of arterial distensibility in the whole population. However before the age of 30, QKD100-60 was positively correlated with height according to the relationship QKD100-60 = 0.73 height (cm) + 91, but not with age. This equation enables calculation of the theoretical value of QKD100-60 as a function of height for any patient to which the observed value can be expressed as a percentage. This effectively eliminates the influence of height, which reflects the length of the arterial segment under investigation.

Reduction in arterial distensibility in hypertensive patients as evaluated by ambulatory measurement of the QKD interval is correlated with concentric remodeling of the left ventricle.

Relationships between ambulatory arterial pressure and arterial distensibility as assessed by ambulatory measure of the QKD interval and echocardiographic measurement of left ventricular mass and relative wall thickness were evaluated in a population of 163 untreated hypertensive patients. The height-corrected QKD100-60 interval was significantly correlated with left ventricular mass (LVM; r = -0.29, P<.001) and with relative wall thickness (r = -0.31, P<0.001). In a multivariate analysis, LVM was significantly correlated with mean arterial pressure, pulse pressure, and age, whereas the relative wall thickness was correlated with the QKD interval and the mean arterial pressure. The concentric character of the LVH of the hypertensive patient was thus linked to the reduction in arterial distensibility.

Relationship between left ventricular mass and serum cholesterol level in the untreated hypertensive.

OBJECTIVE: To study the relationship between serum cholesterol level and left ventricular mass for a population of untreated hypertensive patients. DESIGN: A cross-sectional study. PATIENTS: We studied 273 untreated hypertensive patients without associated diseases consecutively referred for evaluation of blood pressure. All patients underwent M-mode echocardiographic assessment of left ventricular mass, office blood pressure measurement and 24 h ambulatory blood pressure monitoring. Fasting plasma glucose and total cholesterol levels were measured on the same day. RESULTS: We found a weak but significant correlation (r = 0.20-0.26, P < 0.01) between serum cholesterol level and left ventricular wall thickness or left ventricular mass irrespective of the mode of indexation used (height, height2.7 and body surface area). In multivariate analysis this relation remained significant after introduction of sex, age, weight, height, blood pressure and blood glucose level. When data for men and women were analysed separately the relationship between left ventricular mass and cholesterol remained significant for men only. CONCLUSION: There is a significant and independent positive relationship between serum cholesterol level and left ventricular mass that could contribute to the prognostic value of left ventricular hypertrophy.

A short standardized protocol for measuring the QKD interval: comparison with 24 h monitoring and reproducibility.

BACKGROUND: Ambulatory measurement for the QKD interval is a new method for evaluation of the rigidity of large arterial trunks. Reliable indices of arterial rigidity can be distilled from the large number of measurements (usually around 100) obtained during 24 h monitoring. OBJECTIVE: To describe a shorter standardized protocol (4 h) including a 15 min effort test on an ergometric bicycle designed to reduce examination time and generate a wider range of heart rates and blood pressures, to test the equivalence of this short protocol with 24 h monitoring and to test its reproducibility. DESIGN: The results of the short protocol were compared with 24 h monitoring results for 15 subjects. The reproducibility of the short protocol for 15 subjects examined twice within 7 days was studied. RESULTS: We found a good correlation between the values obtained with this method and those from 24 h recordings, with comparable reproducibilities in the determination of QKD for systolic blood pressure 100 mmHg and heart rate 60 beats/min. CONCLUSION: A short (4 h) standardized protocol including an exercise test could replace 24 h ambulatory monitoring to assess arterial distensibility through QKD measurement.

[Echocardiographic measurement of left ventricular mass associating data of the M and 2D modes]. / Mesure échocardiographique de la masse ventriculaire gauche associant les données du mode M et du bidimensionnel.

Calculation of left ventricular mass by M mode echo is based on the assumption that the geometry of the left ventricle is an ellipsoid, the long axis of which is twice that of its short axis. The hypothesis in not always true and often leads to overestimation of the ventricular mass. The authors propose a method combining M mode data (end diastolic dimension, septal and posterior wall thickness) and 2D measurement of the left ventricular long axis: the left ventricular mass was measured by Devereux's and the authors' methods in 185 hypertensives. The 2D measurement of the long axis (mean: 84.7 mm) was much smaller than twice the short axis (mean: 52.3 mm) and the two measurements were poorly correlated. Measurement of the long axis was reproducible. The two methods of calculation were closely correlated (r = 0.95) but, on average, 23% lower with the authors' method. These results seem to be more closely related to ambulatory blood pressure than those of the classical method. The authors' combined method takes into account the true geometry of the left ventricle better than M mode method alone and avoids overestimation of left ventricular mass and the prevalence of excentric left ventricular hypertrophy in hypertensive patients.

Left ventricular mass is better correlated with arising blood pressure than with office or occasional blood pressure.

The peak incidence of cardiovascular complications in the morning points to a possible role of the abrupt increase in blood pressure on arising. However, there is as yet no firm evidence linking the extent of the elevation in blood pressure on arising and the risk of cardiovascular complications. We sought a correlation between blood pressure on arising and left ventricular mass in a population of 181 previously untreated hypertensive patients. Ambulatory blood pressure was measured over a 24-h period, and each patient was requested to trigger a blood pressure determination immediately after standing on arising in the morning. Left ventricular mass was measured with M-mode echocardiography and indexed for height, height(2.7), and body surface area. The systolic blood pressure on arising was significantly (P <.01) better correlated than office blood pressure with left ventricular mass index and wall thickness. On multivariate analysis, the values of systolic blood pressure on arising and mean 24-h systolic blood pressure contributed significantly and independently to the correlation with left ventricular mass and wall thickness. These observations point to the significance of the arising blood pressure. A marked abrupt daily elevation in blood pressure on arising, then maintained for a certain time, could contribute to the development of left ventricular hypertrophy and may constitute a trigger for cardiovascular complications.

Prognostic value of ambulatory measurement of the timing of Korotkoff sounds in elderly hypertensives: a pilot study.

Alteration in the physical properties of the large arteries is probably an important contributory factor in morbidity and mortality in the elderly as well as in patients with hypertension or diabetes. We have developed a simple method based on the ambulatory measurement of the timing of Korotkoff sounds (QKD interval), together with blood pressure, to assess these properties. We report its prognostic value in a retrospective survey of elderly hypertensives. We included in this study 134 hypertensive patients over 45 years of age with no cardiovascular complications, either receiving placebo or prior to treatment with antihypertensive medication and seen between January 1992 and July 1993. In June 1995, a survey was carried out to determine outcome by contacting the patients themselves and their family physicians. Data on outcome were obtained for 111 patients with a mean follow-up period of 30 +/- 8 months. At least one cardiovascular complication was recorded during the follow-up period in 14 patients. From the Cox model, data obtained from QKD monitoring, namely the QKD(100-60), was the best predictor of complications and remained significant (P < .01) even after introduction of age, mean 24 h SBP, gender, and smoking into the model. A QKD(100-60) below 187 msec was accompanied by a relative hazard of cardiovascular complications adjusted for age and mean 24 h BP of 7.3 (95% confidence interval: 2.9 to 11.7). The indices provided by the ambulatory measurement of QKD interval are significant predictors of cardiovascular complications independently of age and BP. This new method seems to add useful information to classic ambulatory blood pressure monitoring. However this will require confirmation in a large prospective study.

Ambulatory blood pressure and left ventricular hypertrophy.

The relation between ambulatory blood pressure and left ventricular mass has been studied with three main aims. The first aim was to validate this new technique for measuring blood pressure. Most studies have shown that the left ventricular mass is correlated more closely to the ambulatory blood pressure than it is to the office blood pressure. The second aim was to define the parameters of most interest in ambulatory recordings. Although the mean 24 h blood pressure has emerged as the parameter of most clinical interest, other parameters, such as the blood pressure measured during activity, the difference between daytime and night-time values and the blood pressure measured when the subject arises in the morning, may also be of value. The interest of these parameters awaits confirmation in prospective studies. Random peak pressures and the variability as determined by discontinuous measurements using non-invasive methods appear to be of little value. The third aim was to assess the value of ambulatory monitoring in identifying the role played by mechanical as opposed to genetic, humoural and hormonal factors in the development of left ventricular hypertrophy in the hypertensive patient. Ambulatory blood pressure monitoring might prove of particular value in assessing the true impact of blood pressure reduction by antihypertensive therapy on left ventricular hypertrophy.