Central systolic blood pressure (cSBP) to brachial systolic blood pressure (brachSBP) ratio reproducibility during antihypertensive therapy.

OBJECTIVES: Higher CSBP than brachial SBP in individual patient increases cardiovascular (CV) risk. For follow-up it is important to assess the reproducibility of such measurements. The aim of this study was to assess the reproducibility of these differences, expressed as a CSBP/BrachSBP ratios. SUBJECTS AND METHODS: Eighty-three patients on antihypertensive therapy were analysed for the reproducibility of such ratios after time interval of several month up to several years. For CSBP estimation, we used the Arteriograph (Tensiomed Ltd.), based on blood pressure measurements by cuff on oscillometric principle, using pulse wave analysis (PWA) for assessment of CSBP. RESULTS: The proportion of patients retained the same characteristics (either higher central or higher peripheral SBP) between the first and second measurement was 71.1 %. The association between 1st and 2nd measurement, was statistically significant, p < 0.001. CONCLUSION: In our study, a high proportion (60 %) of treated hypertensive patients had CSBP higher than brachial SBP, which may adversely influence their prognosis. This characteristic is highly reproducible. Taking into the account these differences may increase the exactness of CV risk estimation and may contribute to explanation of residual risk of individual patient (Tab. 3, Fig. 1, Ref. 28).

Central systolic blood pressure increases with aortic stiffness.

OBJECTIVES: Central systolic blood pressure (CSBP) is the pressure in the root of aorta, which directly influences organs such as brain, heart and kidneys and is related to organ damage. Its value increases with the aortic stiffness. The aim of this study was to analyze the relationships of CSBP to aortic stiffness parameters. METHODS: Central blood pressure (BP) and related parameters were measured by Arteriograph, working based on oscillometric principle, using pulse wave analysis (PWA) approach. We examined 123 patients (69 females, 54 males) with a primary hypertension. RESULTS: Using a linear correlation analysis, we found that CSBP was correlated to aortic pulse wave velocity (PWV), aortic and brachial pulse pressure (PP), aortic augmentation index, return time of reflected pressure wave (RT) and aortic and brachial augmentation indexes. Multivariate analysis defines the aortic pulse pressure (PPao) as the most powerful parameter influencing CSBP. By an individual analysis of BP in each patient separately, we defined two different types of central hemodynamics; those with a higher CSBP than brachial SBP occur in stiffer aorta. CONCLUSION: The CSBP increases with aortic PP, the most powerful stiffness parameter of aorta. Higher CSBP than brachial SBP usually accompanies a stiffer aorta (Tab. 5, Ref. 19).

Holter ECG findings in diabetics with medial arterial calcification.

OBJECTIVES: Medial arterial calcification (MAC) is a nonobstructive condition leading to reduced arterial compliance. The disease most commonly occurs in diabetes mellitus. Decreased ankle-brachial pressure index (ABI) is a well-known marker of increased cardiovascular mortality. However, also the values of ABI above 1.3, typical in MAC, are associated with increased mortality. METHODS: By means of Holter ECG monitoring, we investigated 41 patients (25 men, 16 women) with mean age of 59±8 years, suffering of type 2 diabetes mellitus and identified as having MAC, and Holter ECG monitoring with an average duration of recording 22.36 hours, was carried out by GE-Marquette MARS ECG Holter system. RESULTS: We found frequent incidence of cardiac arrhythmias and myocardial ischemia in 22 patients (53.7 %). Only 19 patients (46.3 %) had normal Holter ECG recordings. ABI values were significantly higher in patients with abnormal ECG Holter recordings. CONCLUSION: Our results confirm the importance of ABI estimation in clinical practice. As the central goal of therapy for patients with myocardial ischemia and/or complex forms of cardiac arrhythmias is the reduction or elimination of these episodes. Ambulatory Holter ECG monitoring plays an important role in the management of these patients (Tab. 7, Ref. 16).

The use of antiplatelet medication in hospitalised elderly patients.

BACKGROUND: The use of antiplatelet agents is strongly recommended for the secondary prevention of ischemic events such as myocardial infarction, stroke/transient ischemic attack (TIA). OBJECTIVES: The aim of our study was to analyse the use of antiplatelet medication in patients after myocardial infarction, stroke/TIA, and patients with both conditions and to identify patient-related characteristics, which determine the use of such drugs in elderly patients. METHODS: Study sample (n=372) was derived from 2,157 patients admitted to long-term care departments of three municipal hospitals. The study included patients aged ≥65 years after myocardial infarction, stroke/TIA or both. RESULTS: Antiplatelet medications were prescribed in 54.8 % and 68.5 % of patients at hospital admission and discharge, respectively. Hospitalisation led to a significant increase in the use of antiplatelet medication in patients after myocardial infarction and in those with the combination of both events. However, in patients after only stroke/TIA, we did not find any significant difference comparing the use of antiplatelet medication at the time of hospital admission and discharge, respectively. CONCLUSION: Our study revealed that physicians are more aware of the benefits of antiplatelet medication in elderly patients after myocardial infarction or those after both myocardial infarction and stroke/TIA in comparison with patients after only stroke/TIA (Tab. 3, Ref. 32).

Suboptimal use of gastroprotective medication in elderly antiplatelet users.

BACKGROUND: Use of acetylsalicylic acid (ASA) or thienopyridines in monotherapy or combination of both drugs is associated with increased risk of gastrointestinal (GI) bleeding. The administration of drugs inhibiting gastric acid production represents an effective way to avoid GI disorders associated with antiplatelet therapy. OBJECTIVES: The aim of our study was to evaluate the use of gastroprotective medication in elderly antiplatelet users in relation to risk factors for GI bleeding. METHODS: Patients (n = 428) aged ≥ 65 years who were prescribed low dose ASA or clopidogrel in monotherapy or combination at hospital discharge were enrolled in the study. RESULTS: Only 39.7 % of patients with 2 or more risk factors for GI bleeding were prescribed gastroprotective medication at hospital discharge. The probability of elderly antiplatelet drug user for prescription of gastroprotective medication was improved with following risk factors: age ≥ 85 years (OR = 2.99); history of peptic ulcer disease/ GI bleeding (OR = 15.79); other GI disorders (OR = 15.48); concomitant therapy with drugs increasing the risk of GI bleeding - systemic corticosteroids (OR = 29.03) and NSAIDs (OR = 4.79). CONCLUSION: Results of our study indicate the necessity to increase the awareness of GI bleeding risk in long-term antiplatelet users among prescribing physicians.

[Cardiorenal syndrome by heart failure]. / Kardiorenální syndrom u srdecního selhání

Cardiorenal (CR) syndrome is defined for the purposes of the following text mainly as primary cardiac dysfunction with a consequent failure of renal haemodynamics. Heart failure leads to a decrease in cardiac output and to the activation of vasoconstrictors; this gradually precipitates a decrease in the level of renal perfusion, the vasoconstriction of renal vessels and a decrease in glomerular filtration with a gradual development of renal failure. The following paper analyses the pathophysiological mechanisms, the characteristics of the patients, the role of medication during CR syndrome, the relationship between proteinuria and anaemia during CR syndrome and the application of bio-markers and pulmonary hypertension in the prognosis of patients with CR syndrome.

[Impact of aortic stiffness on central hemodynamics and cardiovascular system]. / Vplyv tuhosti aorty na centrálnu hemodynamiku a na kardiovaskulárny systém.

Arterial stiffness increases as a result of degenerative processes accelerated by aging and many risk factors, namely arterial hypertension. Basic clinical examination reveals increased pulse pressure as its hemodynamic manifestation. The most serious consequence of increased vascular stiffness, which cannot be revealed by clinical examination, is a change of central hemodynamics leading to increased load of left ventricle, left ventricular hypertrophy, diastolic dysfunction and to overall increase of cardiovascular risk. This review aimed to point at some patophysiological mechanisms taking part in the development of vascular stiffness, vascular remodeling and hemodynamic consequences of these changes. This work also gives an overview of noninvasive examination methods and their characteristics enabling to evaluate the local, regional and systemic arterial stiffness and central pulse wave analysis and their meaning for central hemodynamics and heart workload.

Alcoholic cardiomyopathy and cardiovascular events - an insight from the Liptov region.

AIM: This study was conducted to study the association between alcohol consumption and cardiovascular events and echocardiographical parameters in 100 consumers with the average daily dose <120 g and ≥120 g of alcohol per day during a 4-year follow-up. METHODS: 100 patients/heavy alcohol consumers (on average ≥ 80 g daily), with no cardiovascular disease, divided into 2 groups, underwent a baseline echocardiographic and clinical evaluation and were followed-up for cardiovascular events, biochemical analysis and rhythm disorder for 4 years. RESULTS: Data regarding the dose and duration of alcohol consumption showed a low correlation and nonlinear character between the duration of alcohol consumption and monitored parameters. There were no differences between the groups in the echo-parameters ejection fraction EF (p=0.43), in the diameter of left atrium LA (p=0.51). Left chamber - LVEDD - was slightly bigger in the group with a heavier drinking pattern (p=0.09). There were no differences in biochemical parameters between the groups. When comparing these two groups of consumers the percentage of diabetes mellitus (p=0.283), episodes of heart failure (p=0.308), atrial fibrillation (p=0.652), cerebral vascular accident (p=0.722) and delirium (p=0.559) were not significantly different; only 2 subjects suffered from myocardial infarction during the follow-up. CONCLUSION: We conclude, that no significant differences (p<0.05) between the two groups of heavy alcohol consumers were observed in echo parameters, biochemical values and cardiovascular events (Tab. 4, Ref. 28).

The opposite polarity of the PQ segment compared to the P wave isointegral maps.

The aim of our work was to study the opposite polarity of the PQ segment to the P wave body surface potential maps in different groups of patients. We constructed isointegral maps (IIM) in 26 healthy controls (C), 16 hypertensives (HT), 26 patients with arterial hypertension and left ventricular hypertrophy (LVH) and 15 patients with myocardial infarction (MI). We analyzed values and positions of map extrema and compared the polarity of maps using the correlation coefficient. The IIM P maxima appeared mainly over the precordium, the minima mainly in the right subclavicular area. The highest maxima were in the MI group, being significantly higher than in the HT and LVH groups. No differences concerning any values of other extrema were significant. The IIM PQ maxima were distributed over the upper half of the chest; the minima mainly over the middle sternum. A statistically significant opposite polarity between the IIM P and IIM PQ was found in 80 % of cases. The opposite polarity of the P wave and the PQ segment was proved in isointegral body surface maps. The extrema occurred in areas not examined by the standard chest leads. This has to be considered for diagnostic purposes.

[Left ventricular end-systolic wall stress during antihypertensive treatment]. / Systolický wall stress l'avej komory srdca pri antihypertenzívnej liecbe.

INTRODUCTION: The mechanical load of left the ventricular wall by blood pressure generated during systole causes a strain associated with the impedance to ventricular emptying. Among several indices, the circumferential systolic wall stress is used to describe this load. The calculated stress depends on systolic blood pressure, wall thickness and ventricular cavity dimension. Methods enabling noninvasive quantification of those indices are based on echocardiographic examinations and blood pressure measurements. Left ventricular hypertrophy in hypertension is considered as a compensatory mechanism allowing the heart to withstand the hemodynamic strain associated with increased arterial pressure. SUBJECTS AND METHODS: In the group of 25 female patients with treated arterial hypertension with suboptimal blood pressure levels in the initial evaluation, we realized echocardiographic examination and calculated left ventricular mean circumferential systolic wall stress. The re-evaluation was done after achieving the target blood pressure levels (below 140/90 mm Hg) in the time interval of 6 month to 2 years. RESULTS: The statistically significant decrease of systolic wall stress was mainly due to lowering of blood pressure. The next favourable factor was diminishing of the left ventricular end-diastolic diameter, though the difference was not statically significant. By the multiple regression analysis we found that the final significant lowering of systolic wall stress was influenced also by favourable geometrical remodelling of the left ventricle by the tendency of diminishing of left ventricular diastolic diameter and the increase of relative wall thickness. CONCLUSION: We considered repeated echocardiographic examination and the systolic wall stress calculation (which integrates the ventricular geometry with the blood pressure values achieved) as an appropriate parameter for evaluation of the effect of antihypertensive therapy in the long-term management of hypertensive patients.

[Alcoholic cardiomyopathy--still a topical diagnosis]. / Alkoholová kardiomyopatia--diagnóza stále aktuálna.

Even though extensive experimental as well as clinical evidence exists for adverse cardiac effects of alcohol, pathogenesis and incidence of alcoholic cardiomyopathy is not fully understood. From the genetic level and understanding of the pathogenesis of the toxic effects of alcohol on the heart we come to discuss the diagnosis and treatment of the disease that, in the context of co-morbidities and complications (hypertension, diabetes, arrhythmias, heart failure), continues to represent an significant clinical entity with an important impact on patient prognosis.

[Metabolic syndrome and aortic stiffness]. / Metabolický syndróm a tuhost' aorty.

INTRODUCTION: The metabolic syndrome (MS) is a cluster of risk factors that move the patient into higher level of risk category of cardiovascular disease and the probability of type 2 diabetes mellitus manifestation. Definition of MS is s based on the presence of selected risk factors as: abdominal obesity (lager waist circumpherence), atherogenic dyslipidemia (low value of HDL-cholesterol and increased level of triglycerides), increased fasting blood glucose (or type 2 DM diagnosis), higher blood pressure or antihypertensive therapy. In 2009 there were created harmonizing criteria for MS definition; the condition for assignment of MS is the presence of any 3 criteria of 5 mentioned above. The underlying disorder of MS is an insulin resistance or prediabetes. The patients with MS more frequently have subclinical (preclinical) target organ disease (TOD) which is the early sings of atherosclerosis. Increased aortic stiffness is one of the preclinical diseases and is defined by pathologically increased carotidofemoral pulse wave velocity in aorta (PWV Ao). With the aim to assess the influence of MS on aortic stiffness we examined the group of women with arterial hypertension and MS and compare them with the group of women without MS. PATIENT AND METHODS: The aortic stiffness was examined by Arteriograph--Tensiomed, the equipment working on the oscillometric principle in detection of pulsations of brachial artery. This method determines the global aortic stiffness based on the analysis of the shape of pulse curve of brachial artery. RESULTS: From the cohort of 49 pts 31 had MS, the subgroups did not differ in age or blood pressure level. The mean number of risk factors per person in MS was 3.7 comparing with 1.7 in those without MS. In the MS group there was more frequently abdominal obesity present (87% vs 44%), increased fasting blood glucose (81% vs 22%) and low HDL-cholesterol level. The pulse wave velocity in aorta, PWV Ao, was significantly higher in patients with MS (mean value 10,19 m/s vs 8,96 m/s without MS). CONCLUSION: The higher PWV Ao indicates a higher aortic stiffness in patients with MS and more severe subclinical target organ damage of cardiovascular system.

Do we need new quality markers for chronic heart failure?

Guidelines are not cookbook medicine. Medical decisions for the treatment of chronic heart failure (CHF) are more determined by patient's characteristics than by knowledge of physicians or drug patterns. New quality markers are more favourable, because they have qualitative attributes (are more flexible and adaptable for each CHF patient due to considering objective reasons for deviation from guidelines) (Ref. 44).

[Risk profile of hypertensive patients]. / Rizikový profil hypertonika.

INTRODUCTION: Arterial hypertension is an important component of global cardiovascular risk profile of an individual patient. Estimation of global cardiovascular risk besides the blood pressure level incorporates all risk factors (RF), preclinical cardiovascular diseases (hypertension--induced target organ disease--TOD) and associated clinical conditions, and it should influence the therapy and long-term patient management. A group of metabolic risk factors comprizes several modifyable risk factors, detection of which influences the antihypertensive drug selection. The main goal of antihypertensive therapy is to achieve maximum reduction in the long-term total risk of cardiovascular disease, treating all modifyable risk factors in hypertensive patients. PATIENTS AND METHODS: In this work we present the results of group of 60 hypertensive patients examined for different risk factors detection and subsequent total cardiovascular risk estimation. RESULTS: The mean number of risk factors per patient was 4,1 (3% of patients had two RF, 22% of patients had three RF, 37% patients had four factors and 38% patients had five RF present). The ischaemic heart disease was found more frequently among hypertensives with higher number of RF. Metabolic syndrom (MS) was present in 53% of patients. Hypertensives with MS have higher rate of RF (4.9 per person) comparing to thouse without MS (3.6 RF per person). CONCLUSION: We found a quite high number of RF per individual hypertensive patient; the serious unfavourable consequence of this finding was the increased rate of coronary heart disease with the increasing number of risk factors found.

Complementary therapy in diabetic patients with chronic complications: a pilot study.

BACKGROUND: Oxidative stress and dysregulation of antioxidant function play a pivotal role in the diabetic complications. METHODS: Fifty-nine patients with diabetes were randomly assigned into three groups. 1) PL group (n = 19): Polarized light (PL) was applied to neuropathic ulcers of diabetic foot twice daily for ten minutes in pulse regimen during three months. 2) QALA group (n = 20): Antioxidants (60 mg hydrosoluble CoQ10, 100 mg alpha-lipoic acid (ALA) and 200 mg vitamin E) were used in two daily doses for three months. 3) QALAPL group (n = 20): Patients used antioxidants along with PL applications. To test for differences in means, paired Student's t-test (before and after three months) was used. RESULTS: Three months application of PL significantly increased plasma concentrations of coenzyme Q10, alpha-tocopherol, tau-tocopherol and beta-carotene, and decreased lactate dehydrogenase (LDH) activity. Supplementation with antioxidants decreased plasma lipid peroxides, increased concentration of CoQ10 and improved echocardiographic parameters. Simultaneous application of PL and antioxidants significantly stimulated plasma CoQ10 and alpha-tocopherol concentrations, decreased LDH activity and contributed to improvement in heart left ventricular function in diabetics. CONCLUSION: Thus the data show that supportive therapy with PL along with the antioxidants hydrosoluble CoQ10, alpha-lipoic acid and vitamin E is an effective way of controlling the complications of type 2 diabetes (Tab. 7, Fig. 2, Ref. 44).

[Gender differences in non-pharmacological treatment of chronic heart failure]. / Rozdiely medzi pohlaviami v nefarmakologickej liecbe chronického srdcového zlyhávania.

Prior studies demonstrated sex-related differences in many aspects of chronic heart failure (HF), and in the appropriate use, individual response or complication rates with non-pharmacological treatment, too. There is seasonal variability in morbidity and mortality of HF with significant gender differences, partially due to respiratory diseases, which may be potentionally preventable by vaccination. Quitting smoking is associated with substantial decrease in morbidity and mortality in HF patients which is similar in magnitude to the effect of an appropriate beta-blocker use. Yet little emphasis has been placed on smoking cessation strategies in women with HF and should be adopted as vigorously as proven medical therapy. Complications of catheter ablation for atrial fibrillation were more frequent in females. Gender disparity exists in the use of implantable cardioverter-defibrillators and cardiac resynchronization therapy, although they are beneficial for both women and men. Smaller women have limited access to left ventricular assist device (LVAD) because these devices require a minimum body surface to fit properly. Women were more likely than men to develop severe right ventricular failure after implantation of LVAD. Lower cut-off level of peak oxygen consumption was suggested for women to determine optimal timing for heart transplantation. Disease management programs probably narrows gender differences in quality of care and survival among HF patients. Women with HF have less access to cardiologists, although this consultation is associated with better quality of care, particularly for women. Despite these known sex differences, recommendations for HF are the same for women and men, because prospective sex-specific clinical trials have not been performed.

[Diabetes and vascular diabetic disease]. / Diabetes a vaskulárne poskodenie.

The prevalence of type 2 diabetes mellitus is growing. Vascular disease is here the main cause of morbidity and mortality, and accelerated atherosclerosis is responsible for about 80% of mortality and for about 75% of hospitalizations. In diabetics there is 2-4 times greater risk of ischemic heart disease in comparison to non-diabetics, and this risk is even greater in diabetic-females. Authors put greater attention to pathophysiology of diabetic vascular disease (inflammation and adipose tissue, metabolic and other--AGEs, ADMA--abnormalities, their contribution to endothelial dysfunction). The main concern is devoted to the treatment possibilities of diabetic vascular disease.

[Gender differences in pharmacotherapy of chronic heart failure]. / Rozdiely medzi pohlaviami vo farmakoterapii chronického srdcového zlyhávania.

At this point, guidelines recommend the same care for patients with chronic heart failure (HF), regardless of gender. In the future, however, HF care may need to be tailored by sex, as the best way to optimize outcomes for both men and women. Because prior studies demonstrated sex-related differences in many aspects of HF care (in the appropriate use and dosing of evidence-based therapy and in the individual response to pharmacological treatment between women and men with HF). In general, benefit of beta-blockers, ACE inhibitors, angiotensin II receptor blockers (ARBs) and spironolactone in clinical trials was similar, regardless ofgender. Women with HF appear to have significantly lower mortality rates on ARBs than on the more standard HF therapy (ACE inhibitors), but there was no difference in survival in men prescribed ARBs compared to ACE inhibitors. In a post hoc subgroup analysis digoxin was associated with a increased risk of death from any cause among women with HF, but not men. ACE inhibitor-induced cough was more frequent among women. The risk ofhyperkalemia was increased with male gender in HF patients treated with candesartan. The use ofspironolactone was inversely associated with fractures in men with CHF. Previous studies have suggested that female with HF are less likely received guideline-recommended therapies (in appropriate doses). Female patients with HF were less likely to receive certain guideline-recommended evidence-based treatments, but the influence of patient sex on delivery of these therapies was disappeared when the objective reasons for non-using of these therapies were taken into account. These sex differences could have potential widespread implications for routine heart failure care.

Antithrombotic treatment in patients with atrial fibrillation as a risk factor of stroke.

For over two decades, valuable insights have been accumulated from epidemiologic studies and randomized trials about the risks and prevention of atrial fibrillation. Atrial fibrillation (AF) substantially raises the risk of stroke, most likely through an atrio-embolic mechanism. Warfarin and other members of its class of oral anticoagulants targeted at an international normalized ratio (INR) of 2.5 can abrogate the risk of stroke attributable to AF effectively and fairly safely. High-quality management of anticoagulation can be achieved in usual clinical care. These insights have important implications for the care of individual patients and more generally for public health. Future research is needed to specify the risk of stroke and hemorrhage among patients with AF better, particularly among older individuals, to optimize use of antithrombotic agents, and to define the role of recently developed antithrombotic drugs and invasive nondrug approaches (Tab. 3, Ref. 20). Full Text (Free, PDF) www.bmj.sk.

Electrocardiography in two models of isoproterenol-induced left ventricular remodeling.

We studied the ability of the ECG to detect pathological changes in isoproterenol-induced remodeling of rat heart. Myocardial hypertrophy in rats was induced by repeated injections of isoproterenol (5 mg/kg s.c. 7 days, Iso5, n=7). Single overdose of isoproterenol (150 mg/kg s.c., Iso150, n=7) evoked myocardial infarction followed with ventricular remodeling. The electrocardiograms were recorded in anesthetized animals (thiopenthal 45 mg/kg i.p.) and myocardial contractile performance was analyzed in isolated hearts perfused according to Langendorff. The hypertrophic hearts were characterized by increased heart and left ventricular (LV) weight as well as by thicker LV free wall and interventricular septum. Mean values of LV contraction did not significantly differ from controls. Longer QT interval, QRS complex, negative Q and S waves, higher R amplitude were typical characteristics for Iso5 rats. Iso150 animals showed tendency to decreased systolic blood pressure and heart frequency. Decrease in the thickness of LV compared to Iso5 as well as impaired LV function were related to the dilated left ventricle. Iso150 ECG showed longer QRS and QT, deepened negativity of S wave and mild decrease of R(II) compared to Iso5. Voltage criteria showed that Sokolow-Lyon index is a good predictor of left ventricular hypertrophy in isoproterenol-induced cardiac remodeling without systemic hypertension.