24-hour Ambulatory Monitoring Research Articles

THE ROLE OF TYG INDEX AS PREDICTOR OF CARDIOVASCULAR EVENTS AMONG YOUNG TO-MIDDLE-AGE STAGE I HYPERTENSIVES

Objective: The triglyceride-glucose index (TYG), a surrogate marker of insulin resistance, was shown to be associated with an increased risk of cardiovascular events among people with diabetes or the metabolic syndrome, while its prognostic capacity among young hypertensives is less explored. The aim of the present study was to investigate the role of TYG as predictor of cardiovascular outcomes among young stage I hypertensives, untreated at baseline. Design and method: We investigated 1210 subjects from the HARVEST study, mean age 33.1±8.5 years, 72.8% males. TYG was calculated according to the usual formula. BP was measured with 24-hour ambulatory monitoring. For the analyses, patients were divided into TYG quartiles: 7.008-8.061, 8.063-8.423, 8.424-8.690, 8.691-10.678, respectively. The risk of major adverse cardiovascular events (MACE) was explored by means of survival Cox analyses adjusting for several confounders and risk factors, including lifestyle factors, 24-hour BP and cholesterol. Results: TYG was correlated with BMI (r=0.348, p<0.001), age (0.237, p<0.001), serum uric acid (r=0.349, p<0.001), total cholesterol (r=0.422, p<0.001) and HDL-cholesterol (-0.393, p<0.001), and diastolic BP (0.132, p<0.001). Subjects in the top TYG quartile had the highest percentage of smokers (p<0.001), coffee users (p=0.038) and alcohol drinkers (p=0.010). TYG was significantly correlated with left ventricle mass index (r=0.08, p=0.021), left ventricular septum thickness (r=0.15, p<0.001), and posterior wall thickness (r=0.17, p<0.001). During 17.4 years of follow-up, 108 MACE were accrued. In multivariate Cox analysis the risk of MACE was higher in the two highest TYG quartiles than in the bottom quartile. For the top quartile the hazard ratio was 2.46 (95%CI, 1.17-5.20, p=0.018). The association remained significant also when the lifestyle factors were included in the regression with a hazard ratio of 2.43 (95%CI, 1.14-5.17, p=0.022). This was driven mainly by the strong association found in men with a hazard ratio of 4.84 (95%CI, 1.63-14.39, p=0.004). Conclusions: TYG index is a surrogate marker of insulin resistance, easy to calculate, which significantly correlates with several other metabolic parameters and with left ventricular wall thickness and mass. It is a predictor of adverse cardiovascular outcomes especially in male individuals.

Evaluating Total Atherosclerosis Burden of Baroreceptor-Resident Arteries after Ischemic Cerebrovascular Disease for Identifying Patients with Heavy Coronary Atherosclerosis Burden.

The carotid sinuses and aortic arch are baroreceptor-resident arteries (BRAs) and atherosclerosis-susceptible sites of brain-supplying arteries, which would impair baroreflex-mediated blood pressure (BP) regulation and prompt coronary atherosclerosis. We sought to determine the relationship between total atherosclerosis burden (TAB) of BRAs and coronary atherosclerosis burden (AB) in patients with ischemic cerebrovascular disease (ICVD) and explore the potential contribution of BP profiles to this relationship. In this cross-sectional analysis of patients with ICVD who simultaneously undertook computed tomography angiography and 24-hour ambulatory BP monitoring, TAB of BRAs was scored based on the atherosclerotic vessel circumference ratio of the carotid sinuses and aortic arch, while the ABs of the intracranial, cervical, aortic, and coronary arteries were scored based on stenosis severity and plaque complexity as routine. Among the 230 patients analyzed, coronary AB was significantly correlated with TAB of BRAs, independently of, and more tightly than the ABs of the intracranial, cervical, and aortic arteries, and the stenosis- and complexity-based AB of BRA-located arteries (bilateral common and extracranial internal carotid arteries and aortic arch). Both coronary AB and TAB of BRAs were negatively associated with the night-to-day BP dipping ratios, which was quite different from the relationship between intracranial AB and 24-hour BP characteristics. These findings were also true for patients with ICVD without a history of coronary artery disease. Evaluating TAB of BRAs might provide a new link between atherosclerosis of brain- and heart-supplying arteries, connected partially by BP circadian rhythm. It might facilitate identifying patients with ICVD with heavy coronary AB and comprehensively managing vascular risk.

Characteristics Of Pathogenetic Links In Vascular Remodeling And Bone Tissue Destruction In Postmenopausal Women With Arterial Hypertension

Background — Much attention is drawn to the role of the nonspecific immune inflammatory vascular response as a link of general pathogenetic mechanisms with changes in the elastic properties of arteries and the phenomena of destructive changes in bones. Objective — We aimed to study the role of nonspecific immune inflammatory markers, parathyroid hormone and female sex hormones as predictors of cardiovascular and degenerative bone changes in postmenopausal women with arterial hypertension (AH) and osteoporosis (OP). Methods — We examined 104 patients (mean age: 54.03±9.56 years) distributed among three groups: healthy women, females with AH and osteopenia, and women with AH and OP. The markers of immune inflammatory response, endothelial dysfunction, hormonal, mineral, and vitamin statuses were analyzed simultaneously with 24-hour ambulatory monitoring of blood pressure, and parameters of vascular wall stiffness and densitometry to elucidate the predictors of cardiovascular and degenerative bone changes in postmenopausal women. Results — For patients with AH and osteopenia, a significant parameter associated with the risk of OP was pulse wave velocity (PWV); its increase exceeding 12.05 m/s was associated with a 3.8-fold increase in the risk of OP. Levels of proinflammatory indicators, interleukins IL-6 and IL-8, tumor necrosis factor-α, high-sensitivity C-reactive protein, and parathyroid hormone were elevated, while levels of progesterone and IL-10 were decreased. Conclusion — Timely specialized multidirectional research of biochemical and instrumental parameters (PWV and densitometry) could become the basis for the development of a personalized strategy for the prevention and treatment of women in order to avoid dangerous cardiovascular and bone complications.

POSSIBLE PREDICTORS CONTRIBUTING TO ATRIAL FIBRILLATION OCCURRENCE IN HYPERTENSIVE PATIENTS

Objective: Arterial hypertension (HT) and atrial fibrillation (AF) are two important public health problems. Their prevalence is increasing worldwide, and often coexist in the same patient. HT and AF are strikingly related to an excess risk of cardiovascular disease and death. HT ultimately increases the risk of AF and several factors underlying the higher risk of AF in patients with HT are still incompletely known. HT is one of the main reasons for the remodeling process in and makes a significant contribution to the development of structural changes of the heart. The aim of this study is to identify possible predictors of paroxysmal/persistent AF occurrence and progression in hypertensive patients. Design and method: In this study where enrolled 219 hypertensive patients with non-valvular paroxysmal/persistent AF (mean age 63.6±7.4). As a control group 94 patients with HT and without AF were also examined. Echocardiography examination and 24-hour ambulatory Holter monitoring ECG were registered in each patient. The database consisting of 19 indicators that characterize the clinical, hemodynamic and structural-functional state of the heart, as well as markers of inflammation and fibrosis was created. Data were analyzed by SPSS 13 program using logistic analysis by odds ratio (OR). Results: The obtained results showed that in hypertensive patients with paroxysmal/persistent AF, OR of more episodes of hypertensive crises, deterioration of electrical remodeling and left ventricular (LV) diastolic function, as well as a significant increase in the levels of concentrations of inflammatory and fibrosis markers in comported with hypertensive patients without AF were detected. Conclusions: The multifactorial analysis revealed significant impact of LA and LV dysfunction, inflammation and fibrosis as well as hypertensive crises on the possible risk of AF occurrence and progression in hypertensive patients.

POSSIBLE PREDICTORS CONTRIBUTING TO AF OCCURRENCE IN HYPERTENSIVE PATIENTS

Objective: Arterial hypertension (AH) and atrial fibrillation (AF) are two important public health problems. Their prevalence is increasing worldwide, and often coexist in the same patient. AH and AF are strikingly related to an excess risk of cardiovascular disease and death. AH ultimately increases the risk of AF and several factors underlying the higher risk of AF in hypertensive patients are still incompletely known. AH is one of the main reasons for the remodeling process in these patients and makes a significant contribution to the development of structural changes. The aim of this study is to identify possible predictors of paroxysmal/persistent AF occurrence and progression in hypertensive patients Design and method: In this study where enrolled 219 hypertensive patients with non-valvular paroxysmal/persistent AF (mean age 63.6 ±7.4) who were hospitalized at Research Institute of Cardiology between 2016 and 2018 year. As a control group 94 hypertensive patients without AF were also examined. After the enrollment the echocardiography examination and 24-hour ambulatory Holter monitoring ECG were registered in each patient. We measured plasma indexes of inflammation (hsCRP, IL-6) and fibrosis marker TGF-beta1. The database consisting of 19 indicators that characterize the clinical, hemodynamic and structural-functional state of the heart, as well as markers of inflammation and fibrosis was created. All data were analyzed by SPSS 13 and EXCEL - 2013 programs using logistic analysis by odds ratio (OR). Results: The obtained results showed that in hypertensive patients with paroxysmal /persistent AF, OR of more episodes of hypertensive crises, deterioration of electrical remodeling and LV diastolic function, as well as a significant increase in the levels of concentrations of inflammatory and fibrosis markers in comported with hypertensive patients without AF were detected (tabl.1). Conclusions: The multifactorial analysis revealed significant impact of left atrial and ventricular dysfunction, inflammation and fibrosis as well as hypertensive crises on the possible risk of AF occurrence and progression in hypertensive patients

CORRELATION BETWEEN BLOOD PRESSURE RESPONSE TO SUB MAXIMAL EXERCISE AND LEFT VENTRICULAR HYPERTROPHY

Objective: Currently, there is no common consent on what constitutes a normal increase in blood pressure (BP) during physical activity and, consequently, what constitutes an exaggerated increase in BP response to exercise. At this stage, the processes, and clinical consequences of hypertensive response to exercise (HRE) remain unknown. Even in those who do not have hypertension or other cardiovascular disorders, a hypertensive response to exercise (HRE) is common. An increased blood pressure response to exercise is a legitimate risk marker for future hypertension, as previous research has demonstrated. HRE has among its contributors the endothelial dysfunction and an increase in afterload. in terms of neurohormonal aspects Excess sympathetic nervous system activation and an increase in angiotensin II appear to be crucial mechanisms in HRE, according to studies. Design and method: Of the 84 eligible participants, men (n 46) women (n 38) with I and II degree hypertension (n 32) and pre hypertension (n 22). The study analysis included the subjects with an age range of 18-64 years (mean age 42.1±12.7 years) With or without left ventricular hypertrophy (LVH) described as normal, Concentric hypertrophy, Eccentric hypertrophy, concentric remodeling. Results: For most of the subjects on the initial evaluation, we discovered echocardiographic evidence of concentric hypertrophy. Among the resting and exercise BP indices, submaximal SBP was the strongest correlate of LV mass (r = 0.40, P<0.04). In multivariate analysis, maximal SBP was independently associated with LV mass and concentric LV hypertrophy, after adjustment for lean body mass and gender. Submaximal exercise SBP is a modest but still independent predictor of LV remodeling (grade and type of LV geometry) in population with prehypertension, I and II grade hypertension. Conclusions: More frequent clinical control of resting BP, an echocardiogram, a 24-hour BP ambulatory monitoring as a more dynamic test, and at least annual repetition of the exercise test, to follow up the same abnormal response, as more studies are needed and a consensus regarding the abnormal response of the BP during exercise. Our study can be of clinical importance to prevent future adverse events linked to hypertension induced organ damage.

ARTERIAL HYPERTENSION IN PREGNANCY - PULSE WAVE VELOCITY EVALUATION AS A PROGNOSTIC MARKER

Objective: In the general population, arterial stiffness is associated with a higher incidence of cardiovascular complications. Little is known whether this same trend is observed in pregnant women with hypertension. The authors presented in 2020, a series of 234 pregnant women complicated by arterial hypertension submitted to 24-hour ambulatory monitoring (ABPM). They concluded that the absence of nocturnal pressure drop, especially diastolic pressure, was associated with a worse maternal-fetal outcome. The aim of this work is to present preliminary results of PWV in pregnant women with hypertension, and its relationship with an aggravated maternal-fetal outcome, as well as its relationship with the findings previously obtained with ABPM. Design and method: Observational study of 22 pregnant women who underwent VOP (Complior Analyze) and ABPM (Spacelabs 90207), between July 2015 and July 2022. Event was defined by: maternal death, fetal or neonatal death, preeclampsia or eclampsia, gestational diabetes, prematurity, fetal growth retardation, or dystocia due to uncontrolled hypertension. Results: The mean age and BMI were 31.0 ± 6.0 years and 27.2 ± 4.3 kg/m2. PWV showed mean values of 6.2 ± 0.9 m/s, and ABPM values for the studied population, SBP 24h 117.8 ± 8.6mmHg; DBP 24h 73.3 ± 8.8 mmHg; daytime SBP 123.8 ± 8.5 mmHg; daytime DBP 78.4 ± 7.9 mmHg; nocturnal SBP 106.9 ± 9.7mmHg; Night DBP 63.4 ± 9.2 mmHg. Pearson's correlation coefficient was calculated to measure the linear correlation between the variables and a hypothesis test was performed to conclude on the hypothesis of correlation between the variables. Analysis with Pearson's correlation showed a negative correlation between PWV values and nocturnal DBP and SBP decreases in percentage, which infers that nocturnal decrease values decrease when PWV values increase. In the case of the correlation between PWV and nocturnal SBP decrease, the correlation coefficient was -0.495 (p = 0.016). In the case of the correlation between PWV and nocturnal fall in DBP, the correlation coefficient was -0.425 (p = 0.043). Conclusions: In line with what was previously demonstrated, the results suggest that a higher PWV, pathophysiological related to alterations in vessel elasticity, pro-inflammatory status

Added value of 12-lead 24-hour ambulatory ECG monitoring in the identification of a spontaneous type 1 Brugada pattern and its prognostic role. A sub-study of the BHF RASE Brugada project

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Background A spontaneous type 1 Brugada (spT1-BrS) pattern is a recognised marker of arrhythmic risk. However, its fluctuations may underestimate the risk in subjects with concealed T1-BrS at presentation. Aim To investigate the yield of repeat resting and high-lead 12-lead ECG and the additional role of 12-lead 24-hour Holter monitoring with leads V1 and V2 in standard and high precordial ECG positions (12-HPL Holter), and evaluate the prognostic role of spT1-BrS in a large, single-centre, cohort of BrS patients. Methods Three-hundred and eighty-one subjects with BrS enrolled in our Registry from 2008 to December 2021 and with at least 3 months follow-up data were included in this study. Seventy-seven had spT1-BrS pattern at presentation (Group 1), and 304 did not (Group 2). All received lifestyle recommendations and had regular follow-up appointments with 12-lead ECG; the majority of them were also screened with 12-HPL Holter. Medical notes and tracings were reviewed to identify a dynamic spT1-BrS and events at f-up (SCD/appropriate ICD shock). Results The mean age at presentation was 44±15 years; 52% of participants were males. All had at least 2 resting ECGs recorded; in 281 subjects at least one 12-HPL Holter was available (total 643, median 2, range 1-8). Over a median follow-up of 66 months (IQR 75), 37 subjects in Group 2 showed a spT1-BrS at least once: 10 during a repeat resting ECG, 2 during/after exercise tolerance test, 25 at 12-HPL Holter. The average time at spT1 appearance during follow-up was 23 months (range 1- 225). Those with a newly detected spT1-BrS were more frequently males and less likely to have a familial history of sudden cardiac death (Table 1). Excluding subjects with previous aCA/documented VT, 6 events occurred at f-up, all in subjects with spT1 (Figure 1). Univariate models showed that the presence of a spT1-BrS pattern was consistently associated with increased risk of events (at presentation: HR 10, 95% C.I. 1.8-54; at follow-up: HR 5.3, 95% C.I. 1.6-17). Conclusions A spontaneous T1-BrS can be detected in up to 12% of subjects with concealed BrS at presentation using 12-HPL Holter monitoring. Its presence is consistently associated with arrhythmic risk at f-up up, regardless of the time at detection. Prolonged ambulatory ECG monitoring is fundamental for risk stratification in this population.

Twenty-four hour ambulatory blood pressure monitoring in patients with stable heart failure. Prevalence and associated factors

Introduction and objectivesHypertension is highly common in heart failure (HF). However, there is limited information on its prevalence, circadian variation, and relationship with the various HF phenotypes. The objective of this study was to describe the prevalence of hypertension and its patterns in HF. MethodsThis was a cross-sectional observational study of patients with optimized stable chronic HF. The patients underwent blood pressure (BP) measurement in the office and 24-hour ambulatory monitoring. We estimated the prevalence of hypertension, and its diurnal (controlled, uncontrolled, white coat, and masked) and nocturnal (dipper, nondipper, and reverse dipper) patterns. We also analyzed the factors associated with the different patterns and HF phenotypes. ResultsFrom 2017 to 2021, 266 patients were included in the study (mean age, 72±12 years, 67% male, 46% with reduced ejection fraction). Hypertension was present in 83%: controlled in 68%, uncontrolled in 10%, white coat in 10%, and masked in 11%. Among patients with high office BP, 51% had white coat hypertension. Among those with normal office BP, 14% had masked hypertension. The prevalence of dipper, nondipper, and reverse dipper patterns was 31%, 43%, and 26%, respectively. Systolic BP was lower in HF with reduced ejection fraction than in HF with preserved ejection fraction (P <.001). ConclusionsAmbulatory BP monitoring in HF identified white coat hypertension in more than half of patients with high office BP and masked hypertension in a relevant percentage of patients. The distribution of daytime patterns was similar to that of the population without HF in the literature, but most of the study patients had a pathological nocturnal pattern.

Patrones de presión arterial de 24 horas en pacientes con insuficiencia cardiaca estable. Prevalencia y factores asociados

Introduction and objectivesHypertension is highly common in heart failure (HF). However, there is limited information on its prevalence, circadian variation, and relationship with the various HF phenotypes. The objective of this study was to describe the prevalence of hypertension and its patterns in HF. MethodsThis was a cross-sectional observational study of patients with optimized stable chronic HF. The patients underwent blood pressure (BP) measurement in the office and 24-hour ambulatory monitoring. We estimated the prevalence of hypertension, and its diurnal (controlled, uncontrolled, white coat, and masked) and nocturnal (dipper, nondipper, and reverse dipper) patterns. We also analyzed the factors associated with the different patterns and HF phenotypes. ResultsFrom 2017 to 2021, 266 patients were included in the study (mean age, 72±12 years, 67% male, 46% with reduced ejection fraction). Hypertension was present in 83%: controlled in 68%, uncontrolled in 10%, white coat in 10%, and masked in 11%. Among patients with high office BP, 51% had white coat hypertension. Among those with normal office BP, 14% had masked hypertension. The prevalence of dipper, nondipper, and reverse dipper patterns was 31%, 43%, and 26%, respectively. Systolic BP was lower in HF with reduced ejection fraction than in HF with preserved ejection fraction (P <.001). ConclusionsAmbulatory BP monitoring in HF identified white coat hypertension in more than half of patients with high office BP and masked hypertension in a relevant percentage of patients. The distribution of daytime patterns was similar to that of the population without HF in the literature, but most of the study patients had a pathological nocturnal pattern.

The Relationship Between the Dipping Pattern and Coronary Artery Disease Severity Assessed by the SYNTAX Score in Patients With Hypertension.

Background The morbidity and mortality rates related to hypertension (HT) are still high despite the developments in this area. Nondipper hypertension (NDHT) is related to worse clinical outcomes. But the dipping pattern of HT is not still used for treatment targets. In this study, we investigated the effect of dipping patterns on coronary artery disease (CAD) complexity evaluated by the SYNTAX score (SS). Methodology Patients with stable CAD and HT were included in the study. All patients were monitored with 24-hour ambulatory monitoring, and dipping patterns were evaluated. Coronary artery complexity was determined by SS for all patients and compared along with different dipping patterns. Results A total of 331 patients with HT and stable CAD were evaluated in the study. The mean age of the patients was 62.6 ± 9.9 years, and 172 (52%) were male. The number and percentage of patients with dipper HT (DHT), NDHT, over-dipper HT (ODHT), and reverse-dipper HT (RDHT) were 89 (26%), 143 (43%), 11 (3%), and 88 (26%), respectively. When the groups were compared according to SS, the SS of the patients with RDHT were significantly higher (the SS were 6.33, 4.99, 3.09, and 2.7 for RDHT, ODHT, NDHT, and DHT, respectively, P = 0.003). The mean SS between the DHT group and the NDHT group (P = 0.03) and between the DHT group and the RDHT group (P = 0.01) was significantly different. The less decrease or increase in mean blood pressure (MnBP) values was significantly correlated with high SS. Conclusions NDHT, especially the reverse dipping pattern, is closely related to complex CAD. Meticulous consideration of dipping patterns can identify high-risk patients and improve clinical outcomes.

Odnos varijabilnosti arterijskog pritiska iz ambulatornog 24-časovnog monitoringa arterijskog pritiska sa ehokardiografskim parametrima u bolesnika pod antihipertenzivnom terapijom

Introduction: Variability of systolic daytime arterial pressure was until recently a controversial parameter but is now recognized as an independent prognostic risk factor for stroke in hypertensive patients. Blood pressure variability is a quantitative index of spontaneous daily and nocturnal variations in systolic and diastolic arterial blood pressure and has been proposed as a risk factor for inducing subclinical damage to target organs in arterial hypertension. Besides varying degrees of left ventricular myocardial hypertrophy (LVH), patients with hypertension also exhibit accompanying diastolic dysfunction of the left ventricle as an early sign of hypertensive damage, even when myocardial hypertrophy does not develop. The variability of pressure over 24 hours in Ambulatory Blood Pressure Monitoring (ABPM) has not been sufficiently studied in terms of correlation with echocardiographic parameters in controlled hypertension. Methods: A total of 196 adequately treated patients with stage 2 hypertension, with a target of achieving normotension less than 140/90, were examined. The total of 196 patients, 109 males and 87 females, with a mean age of 49.3 ± 8.4 years, untreated or inadequately treated patients with stage 2 hypertension (mean BP before treatment 167/106 mmHg) were divided into three groups according to blood pressure variability parameters. Alongside standard methods: medical history, clinical examination, and electrocardiogram (ECG), 24-hour ambulatory arterial pressure monitoring (ABPM, so-called blood pressure holter) was performed with 24-hour, daytime, and nighttime variability of systolic and diastolic blood pressure as well as Color and Tissue Doppler echocardiography after adequate treatment. Results: Elevated blood pressure variability was observed in 66/196 patients (34%) in group V despite good pressure regulation, while 130/169 (66%) had normal variability - group C (control). A subgroup ExtV was particularly highlighted within group V with extreme variability of daytime systolic BP (SD&gt;20 mmHg) - 15/66 patients (8%). Evaluation of left ventricular myocardial mass index (LVMI) showed no difference in the degree of LVH between groups C and V. In the subgroup ExtV (from group V with extreme blood pressure variability), comprising 15/66 patients (8%), a significant difference in the degree of left ventricular myocardial hypertrophy was found between groups C and V regarding extreme variability (p&lt;0.01). There was no difference concerning gender and age structure. Statistical analysis of investigated 24-hour blood pressure parameters and echocardiographic parameters did not show significant correlation through calculation of the linear correlation coefficient between mean arterial pressure measured by 24-hour ambulatory pressure monitoring and standard deviations of daytime and nighttime pressure and the degree of left ventricular myocardial hypertrophy (linear correlation coefficients r &lt;0.20), as expected. However, there is a moderate but significant correlation between the best echocardiographic parameter of diastolic function, E/E' ratio, and variability of daytime systolic pressure: r= 0.41. Only the subgroup with extreme variability ExtV in terms of daytime systolic pressure has a statistically significant correlation with the degree of LVMI myocardial hypertrophy, r=0.51. Conclusion: One-third of the examined patients, 66/196 patients (34%) in group V, had elevated blood pressure variability despite good pressure regulation. There was no significant difference in the degree of left ventricular myocardial hypertrophy between the investigated parameters of 24-hour blood pressure and echocardiographic indices, except in extreme variability ExtV (P&lt;0.01). However, there is a moderate but significant correlation between the best echocardiographic parameter of diastolic function, E/E' ratio, and variability of daytime systolic pressure: r= 0.41. Only the subgroup with extreme variability ExtV in terms of daytime systolic pressure has a statistically significant correlation with the degree of LVMI myocardial hypertrophy, r=0.51.

S-37-2: CIRCADIAN RHYTHM OF PERIPHERAL AND CENTRAL ARTERIAL BLOOD PRESSURES IN RELATION TO ALL-CAUSE MORTALITY

Objective: Brachial blood pressure (BP) presents a circadian rhythm. Abnormal rhythms are associated with adverse outcomes. However, it is not clear about the circadian rhythm of central BP and its predictive value. Methods: The study participants were patients referred to the outpatient clinic of Ruijin Hospital for 24-hour ambulatory BP monitoring from the year 2017 to 2020. The 24-hour brachial and central ambulatory BP monitoring were performed with the use of the Mobil-O-Graph (Germany) monitors. Dipping, non-dipping, reverse dipping and extreme dipping were defined as a night-to-day systolic BP ratio of 0.8–0.9, 0.9–1.0, &gt; 1.0, and &lt; 0.8, respectively. In cross-classification analysis of brachial and central dipping status, extreme dipping and reverse dipping were grouped with dipping and non-dipping, respectively. The vital status of patients until Dec 2020 was ascertained according to the vital statistics of the Shanghai Center for Disease Prevention and Control. Results: In 26,023 enrolled patients (men 47.4%, average age 53.0 years) followed up for a median of 1.8 years, 120 deaths occurred. The prevalence of non-dipping (46.7% vs. 43.7%, respectively) and reverse dipping (16.0% vs. 13.1%) was significantly (P &lt; 0.001) higher for central than for brachial BP. The hazard ratios (95% confidence intervals, [CI]) for all-cause mortality were statistically significant for reverse dipping (1.95 [1.18–3.23] and 2.37 [1.43–3.94], respectively), but not other dipping status, versus dipping in brachial and central BP, respectively. In the brachial and central cross-classification analysis, the prevalence of consistent dipping, consistent non-dipping, isolated central non-dipping, and isolated brachial non-dipping was 34.7%, 54.2%, 8.6%, and 2.5%, respectively. Taking the consistent dipping as reference, the hazard ratios (95% CI) for all-cause mortality were 1.83 (0.77–4.31), 1.34 (0.46–3.95), and 1.94 (1.20–3.15) for isolated central, isolated brachial and consistent non-dipping, respectively. Furthermore, cross-classification significantly improved the risk prediction of all-cause mortality with a net reclassification improvement index (95% CI) of 0.193 (0.069–0.304). Conclusions: Non-dipping and reverse dipping were more common for central than for brachial BP, and were associated with a higher mortality risk irrespective of brachial or central BP. Cross-classification of brachial and central dipping status further improved risk stratification.

Pediatric Cardiology Consultation at Long-Term Video EEG Monitoring

Objective: In children, a broad range of paroxysmal events, including syncope and arrhythmias, may mimic true epileptic seizures. When a definitive diagnosis could not be established, long-term video electroencephalogram monitoring (LTVEM) should be taken into consideration. Furthermore, epilepsy patients have a higher rate of cardiac comorbidities. The purpose of this study is to evaluate the rationale and results of the pediatric cardiology consultations in patients admitted to the LTVEM unit. Methods: We retrospectively analyzed the files of children who were admitted to LTVEM unit and consulted with the pediatric cardiology department between January 2006 and May 2014. The patients who had both echocardiography and 24-hour ambulatory electrocardiogram monitoring were included. Results: Among 70 children, 74.3% (n: 52) were classified as having epilepsy, 21.4%. (n: 15) with nonepileptic events, and 4.3% (n: 3) could not be classified. In epilepsy group, 21 children (40.4%) were consulted with pediatric cardiology due to rhythm disturbances detected during LTVEM, the remaining consultations (59.6%) were due to history of known cardiac diagnosis (arrythmias n: 2, structural/congenital heart disease: 5), tuberosclerosis (n: 6), drop attacks (n: 5), murmur (n: 5), and other reasons. The cardiac evaluation revealed previously undetected arrhythmia (n:3) and mitral valve prolapse (n:1) in four patients with epilepsy. In addition to the pre-existing long QT syndrome, one child experienced his typical attack, subsequently he was diagnosed as epilepsy. The remaining group consisted of 18 children, with syncope being the most common diagnosis for consultation (n: 10, 55.5%). Conclusion: Our study revealed that a subgroup of children with epilepsy had cardiovascular comorbidities. Additionally, epilepsy was confirmed in some patients who already had cardiac problems. Pediatricians should be aware of potential mimickers of epilepsy and note that epilepsy and cardiac problems may also co-exist. Correct diagnosis and appropriate treatment are crucial in this patient group.

1102 ARRYTHMOGENIC CARDIOMYOPATHY: LESSONS FROM A LARGE FAMILY

Abstract Background Arrhythmogenic cardiomyopathy is a genetically-inherited cardiomyopathy. PKP2 mutations are the most common cause of the disease, associated with conventional ARVC phenotype. Case presentation We presented a 14 years old sportswoman admitted to our emergency department for cardiac arrest-related to ventricular fibrillation. The patient was asymptomatic leading up to cardiac arrest. At admission, she met the diagnosis of AC with bi-ventricular involvement (T negative waves in V1-V6 and inferior leads; severe biventricular dysfunction with fibrofatty replacement involving both ventricles). Family history revealed that her cousin, a 15 years competitive athlete, received a recent diagnosis of ARVC, wherein pathogenetic variant p.Tyr857_Lys859 in heterozygosity in the PKP2 gene was found. As expected, the index case presented the same mutations in PKP2 gene, and no other mutations were found. Implanted cardioverter defibrillator (ICD) and strength follow-up, including heart failure management, was performed. Cascade screening of family members allowed us to identify 19 mutations carriers. Of these, 5 patients were identified to have disease expression. The first to be studied was her 9 years old sister, who involved in high level of sport activities. She presented abnormal ECG with negative T waves in V2-V4, significance burden of premature ventricular complex (PVC &amp;gt;500/24 h) with mild right ventricle dilatation. Of others family members, four patients presented early signs of myocardial disease and significant arrhythmias burden. Except for one patient, all these members were involved in amateur sport activities. Two members had signs of left ventricle (LV) involvement (inverted T waves in leads V4–V6 and inferior leads, LV wall motion abnormalities and late enhancement), whereas one patient (P3) showed a fulfilled ARVD. Three patients presented significant PVC on 24-hour ambulatory ECG monitoring (PVC &amp;gt;500/24 h) (P2, P3 and P5). The arrhythmic burden was more pronounced in two young patients having a sports activity (P2 and P3). This trend was also confirmed at exercise testing. Except for one patient, these findings appear to be related to sport activity, even if this is no high-intensity activity. Among other carriers of pathogenic mutation, three patients showed ECG abnormalities in infero-lateral leads and significance PVC at 24-hour ECG monitoring in absence of other findings related-cardiomyopathy. All family members carried PKP2 mutation were restricted in sports activities, and, in patients presented early disease and arrhythmogenic burden, treatment with beta-blockers was started. Conclusion In this family presenting PKP2 mutation, heterogenicity of disease expression and a close relationship with sport activity was found. This large family case encourages future ACM studies to better understand disease expression and their relationship with sports activity across the entire ACM phenotypic spectrum and ages. Also, this case underscores the importance of early familiar screening, including children involved high-level of sports activity.

Arterial stiffness in hypertensive patients with peripheral artery disease

Objective. To identify features of arterial stiffness, to establish relationships with indicators of the daily blood pressure profile and peripheral artery disease in patients with hypertension (HTN) in combination with subclinical and manifested atherosclerotic lesions of the arteries of the lower extremities. Design and methods. 120 patients were divided into 3 groups: group 1-46 patients with HTN and clinically manifested AALE, group 2-39 patients with HTN and asymptomatic AALE, group 3-35 HTN patients without AALE. All patients underwent general clinical laboratory and instrumental research methods, including 24-hour blood pressure ambulatory monitoring (24h-ABPM) with the assessment of 24-hour blood pressure profile and arterial stiffness parameters, ultrasonic triplex scanning (USTS) of the arteries of the lower extremities. Statistical data processing was carried out using Microsoft Office Excel 16 (2015, Microsoft, USA), Statistica 10.0 (StatSoft, USA), IBM SPSS Statistica 26.0 (IBM, USA). Results. Higher values of pulse wave velocity (PWVao), augmentation index (AIx) and ambulatory arterial stiffness index (AASI) were found in the 1st group in comparison to the 2nd and 3rd groups (p &lt; 0,05). Lower reflected wave transit time (RWTT) (119,5 [112;127] ms) was found in the 1st group (128 [122;132], p = 0,001 and 126 [121;129] ms, p = 0,03 in the 2nd and and 3rd groups, respectively) groups. The maximum rate of blood pressure increase (dP/dtmax) in patients of the 1st (550 [466;666] mm Hg/s) and 2nd (634 [511;695] mm Hg/s) groups was significantly lower than in patients of the 3rd group (655 [526;806] mm Hg/s, p &lt; 0,05). A direct correlation was found between AASI values and SBP (r = 0,291, p = 0,049) and its variability (r = 0,301, p = 0,042), AASI and PBP (r = 0,518, p &lt; 0,001), its variability (r = 0,596, r &lt; 0,001) in group 1, as well as AASI and PBP (r = 0,514, p &lt; 0,001) and PBP variability (r = 0,632, p &lt; 0,001) in group 2. A correlation between AIx and the degree of stenosis (%) of the arteries of the lower extremities was found in patients with AH and AALE of varying severity (r = 0,310, p = 0,004). Conclusions. In patients with subclinical course of AALE, lower values of dP/dtmax in comparison with HTN patients without AALE indicate an increase in arterial stiffness at the initial stages of peripheral atherosclerosis. Clinically manifested atherosclerotic lesions of the arteries of the lower extremities in HTN patients are associated with a more pronounced increase in arterial stiffness, which contributes to a higher cardiovascular risk.

The Effects of Modifying Amount and Type of Dietary Carbohydrate on Esophageal Acid Exposure Time and Esophageal Reflux Symptoms: A Randomized Controlled Trial.

INTRODUCTION:This is the first randomized controlled diet intervention trial to investigate both the amount and type of carbohydrate on symptomatic gastroesophageal reflux disease (GERD).METHODS:Ninety-eight veterans with symptomatic GERD were randomly assigned to high total/high simple, high total/low simple, low total/high simple, or low total/low simple carbohydrate diet for 9 weeks. The primary outcomes were esophageal acid exposure time (AET) and total number of reflux episodes derived from 24-hour ambulatory pH monitoring. Secondary outcomes were esophageal reflux symptoms rated using the Gastroesophageal Reflux Disease Questionnaire (GERDQ) and GERD Symptom Assessment Scale (GSAS).RESULTS:Half of the subjects were White and half African American (mean age, 60.0 ± 12.5 years; mean body mass index, 32.7 ± 5.4 kg/m2). There was a significant main effect of diet treatment on AET (P = 0.001) and on the total number of reflux episodes (P = 0.003). The change in AET in the high total/low simple group (−4.3% ± 3.8%) differed significantly from the high total/high simple control group (+3.1% ± 3.7%), (P = 0.04). The reduction in simple sugar intake averaged 62 g less per day. Subjects' ratings of symptoms improved in all carbohydrate modification groups, including significant reductions in heartburn frequency, heartburn severity, acid taste in the mouth, lump/pain in the throat or chest, and sleep disturbance.DISCUSSION:A modification of dietary carbohydrate intake that targeted a substantial reduction in the intakes of simple sugars improved pH monitoring outcomes and symptoms of GERD that profoundly affect daily life. These findings provide a feasible and clinically applicable contribution to the limited objective data existing for efficacious dietary recommendations in the routine treatment and management of GERD.

The effect of regular physical training on heart rate variability in healthy male volunteers

Abstract Funding Acknowledgements Type of funding sources: None. Background The autonomic nervous system's responses are reflected in heart rate variability (HRV). They have a significant role in accompanying the training process, however, assessment of long-term daily HRV indices dynamics is not widely used in sports cardiology. Purpose To determine if there are variations in long-term responses of autonomic regulation of cardiac activity to regular systematic training. Methods In this prospective study, we included 28 healthy men aged 18-19 years who had a repeated 24-hour Ambulatory ECG monitoring between February 2018 and December 2019 (Figure 1). The subjects were in similar working and living conditions. The training regimen consisted of moderate to vigorous physical activity for 270 (SD 40) minutes per week (total 100 weeks of follow-up). The subjects were divided into groups according to the median of changes in assessment results for various types of physical training (Table 1): with the maximum and minimum positive dynamics of physical fitness in endurance (3000m race), speed (100m race), strength (pull-ups on the horizontal bar). 24-hour Holter was performed using a wearable ECG device. HRV parameters at the beginning and at the end of the study in groups with the maximum positive physical fitness dynamics were compared. To assess HRV, the following daily time-domain indices were used: RMSSD (root mean square of successive RR interval differences), pNN50% (percentage of successive RR intervals that differ by more than 50 ms) and SDANN (standard deviation of the averages of the NN intervals in all 5 min segments of the entire recording). Results The initial mean heart rate in groups 1-6 did not differ significantly across repeated heart rate monitoring (Table 1). In group 1, the improvement in endurance exercise performance directly correlated with changes in RMSSD (rs = 0.297, p &amp;lt;0.05) and pNN50% (rs = 0.448, p &amp;lt;0.05). In group 3, increased fitness in short distance running was accompanied by a decrease in the values of the RMSSD (rs = –0.211, p &amp;lt;0.05) and pNN50% (rs = –0.539, p &amp;lt;0.05) and an increase in the values of the SDANN (rs = 0.352, p &amp;lt; 0.05). In group 5, increased fitness in strength exercises was accompanied by a balanced increase in pNN50% (rs = 0.371, p &amp;lt;0.05), RMSSD (rs = 0.347, p &amp;lt;0.05), as well as SDANN (rs = 0.440, p &amp;lt;0,05). In groups 2, 4, 6, there were similar but weaker associations. Conclusion Systematic training is associated with significant changes in the autonomic regulation of heart rate. An increase in fitness in sprint distance running results in a decrease in daily parasympathetic and an increase in sympathetic activity on the heart. Increased fitness in strength exercises is associated with increase in both sympathetic and parasympathetic activity. While an increase in endurance is accompanied by an increase in the activity of the parasympathetic limb of the autonomic nervous system.

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time &gt; 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Study the effect of Bilateral Nasal Packing on Systemic Blood Pressure and Prevalence of Complications Associated with Nasal Packing in Patients who had Undergone Septoplasty

Aim: The main objective of this study was to determine the effect of bilateral nasal packing on systemic blood pressure in patients treated with septoplasty surgical procedure. Study Design: Retrospective study. Place and Duration: This study was conducted at the department of ENT/ Head &amp; Neck Surgery, Lady Reading Hospital MTI, Peshawar and Chaudhary Muhammad Akram Teaching and Research Hospital, Lahore for duration of one year from October 2020 to September 2021. Methods: One hundred and two men and women who had undergone nasal septoplasty following a clinical assessment were included in this research. From 18 to 48 years of age, the patients comprised this group. Detailed information about each patient, such as age, gender, and place of residence, was gathered after informed consent was obtained from each patient. Group C had no nasal packing placed, whereas typical anterior nasal packing was used in Group D. Both groups were evenly split. A 24-hour ambulatory monitoring of blood pressure was performed on all patients before to and during septoplasty. SPSS 23.0 was used to do statistical analysis on all of the data. Results: 60 (58.8%) of the 102 patients were male, and 42 (41.2%) of the patients were female. A total of 41 (40.2 percent) patients were under the age of 30, 35 (34.3 percent) were between the ages of 31 and 40, and 26 (25.5 percent) were above the age of 40. Rural residents comprised 52% of the patients. Study participants in Group D were found to have higher mean blood pressure (p-Value 0.05) following septoplasty therapy than those in Group C (P-Value &gt;0.05). Group D patients had bleeding, vestibulitis, and septal perforations as a result of their nasal packing procedure. Conclusion: It is determined that bilateral nasal packing was associated with an elevation in either systolic or diastolic blood pressure in individuals who had septoplasty treatment. Patient who did not get nasal packing showed no statistically significant change from the rest of the group. Keywords: Septoplasty, Bilateral Nasal Packing, Systemic blood pressure