Differences In Blood Pressure Research Articles

Pharmacist interventions in the control of hypertension and adherence to anti-hypertensive treatment: A systematic review and meta-analysis of randomised controlled trials

Abstract Introduction Non-adherence to antihypertensive therapy is one of the major barriers for the achievement of blood pressure (BP) control and has a significant cost burden1. Non-adherence is also thought to be one of the leading factors leading to ethnic disparities in hypertension control in the UK2. Pharmacists have an important role in the management of hypertension and non-adherence due to their ideal position to promote optimal use of medication3. Many have advocated for pharmacist involvement in team-based hypertension management, however which pharmaceutical care interventions are most effective remains unclear. There have been many new studies in recent years exploring the effect of pharmacist interventions in hypertension and this meta-analysis provides an update of the current literature and quantification of the results. Aim This study aimed to systematically evaluate the efficacy of pharmacist-delivered interventions for adults with hypertension and examine the intervention characteristics associated with greater BP-lowering efficacy. The primary outcome was the change in BP and secondary outcomes were % achieving BP control. Methods Systematic review and meta-analysis of randomized controlled trials (RCTs). This review was registered on PROSPERO. Embase, CENTRAL, MedLine, Psychinfo and CINAHL were searched until February 2024. Eligible studies included adult patients with a diagnosis of essential hypertension where a pharmacist intervention (alone or collaborative care) targeting BP control was compared with control (usual care). Exclusion criteria included secondary hypertension, pregnancy, children and review articles/case studies. The risk of bias was assessed by the Cochrane risk-of-bias tool for RCTs. The primary outcome was change in BP. We extracted data on sample and intervention characteristics. Meta-analysis was performed using Comprehensive Meta-Analysis Software v4. Moderator analyses examined the association between intervention effects and intervention features. This study was a systematic review and meta-analysis of already completed trials and so ethical approval was not required. Results 2402 articles were retrieved. After removal of duplicates, 1538 were screened by title and abstract against the inclusion criteria. 88 studies with 25,516 participants were included. Mean intervention duration was 7.2 months (range 1-14 months). The overall pooled mean differences in systolic BP (SBP) and diastolic BP (DBP) between pharmacist intervention and control were -7.39 (-8.56, -6.23) mmHg and -3.99 (-4.61, -3.37) mmHg respectively, both P<0.001. With BP control, pharmacist interventions caused a significant increase in those achieving BP control compared to usual care (+21 (16.88, 25.27) %, P<0.001). Duration of intervention had no influence on change in SBP or DBP (both P>0.05). Discussion Pharmacists can make a significant impact in the management of hypertension in respect to increasing treatment adherence and improving BP control and this study highlights the importance of including them as part of the multidisciplinary team responsible for patient care. Limitations of the present study include the inability to extract individual patient data and stratification by ethnicity, socioeconomic status and gender. However, pharmacist interventions in hypertension significantly reduced SBP and DBP and improved BP control. Identifying the characteristics of the most effective interventions can lead to better treatment adherence and BP-lowering in patients with hypertension.

Effect of interdisciplinary obesity care on metabolic markers and body weight in people with type 2 diabetes in a rural setting: A randomised controlled trial

SummaryManagement of type 2 diabetes includes medications that can unintentionally increase obesity and insulin resistance. This unblinded, single‐centre, randomised controlled trial focused on rural Australian adults with type 2 diabetes (aged 18–75 and body mass index [BMI] >30 kg/m2), measuring the effectiveness of a tailored interdisciplinary obesity care approach compared with usual diabetes care. Led by a nurse practitioner with allied health support (dietitian ± psychologist and physiotherapist), the bariatric treatment involved reducing weight‐gaining medications, a 500‐calories/day deficit, an unsupervised exercise program emphasising movement/strength and psychotherapy, 3‐monthly to 24‐months with support phone calls at weeks 2, 4, 8 and 10. Outcomes from the 224 (113 intervention/111 control) participants were differences in biomedical and physical markers within‐ and between‐groups estimated using multivariate mixed‐effects linear regression between recruitment and 6‐monthly follow‐ups. Greater change occurred in intervention compared with control groups at 12 and 24 months in mean: body weight (−5.9 kg [95% confidence interval, CI: −8.53, −3.23] and −9.0 kg [95% CI: −13.2, −4.77]); BMI (−2.03 kg/m2 [95% CI: −2.92, −1.15] and −3.51 kg/m2 [95% CI: −4.93, −2.08]); and glycated haemoglobin (−0.26% [95% CI: −0.69%, 0.18%] and −0.63% [95% CI: −1.17%, 0.08%]). The control group showed a significant increase in mean leptin level, resulting in a between‐group difference (−27.1 [95% CI: −42.7, −11.5]). Lipids and blood pressure differences were inconclusive, while exploratory analysis showed greater decline in estimated glomerular filtration rate in the control group. The interdisciplinary obesity approach, compared with usual diabetes care, resulted in sustained weight loss and improved diabetes control over 2 years. Trial registration number: ACTRN12622000240741.

Desprescribing antihypertensives in older people in primary care: subgroup analysis of the MINOR randomised clinical trial.

Polypharmacy is often required for older adults with hypertension, and excessive treatment is associated with a high risk of adverse reactions, including hypotension. To evaluate the deprescribing of antihypertensive medications guided by pharmacists using home blood pressure monitoring in older adults with hypotension. A subgroup of older adults with signs or symptoms of hypotension, included in the MINOR clinical trial, was analysed. In the MINOR procedures, each patient was provided with a device to conduct blood pressure measurement at home for 1week, following which a report was generated and shared with pharmacists (intervention group) or family physicians (control group). In the intervention group, a pharmacist suggested optimising pharmacotherapy; meanwhile, in the control group, a family physician alone determined the necessary treatment adjustments. Differences in mean blood pressure, the patients with symptoms/signs of hypotension, and the antihypertensive medication deprescribing between both groups were analysed. Seventy-two patients were evaluated (35, control group; 37, intervention group). The intervention group showed a significant reduction in medication prescriptions (- 28.6%; P < 0.001), especially beta-blockers (- 74.2%), loop diuretics (- 83.3%), and aldosterone antagonists (- 80%). The mean office blood pressure in the intervention group increased (14.1mmHg systolic and 6.9mmHg diastolic), remaining below the target range (140/90mmHg). The intervention group showed a significantly reduction in hypotensive symptoms than the control group (64.9% vs. 20%) (P < 0.001). The data highlight an important role for pharmacists in optimizing hypertension management in older people. Deprescribing antihypertensives can limit symptomatic hypotension. Registered on ClinicalTrials.gov under number NCT04861727.

Effects of integrated blood purification on haemodynamics and oxygen metabolism in children with severe sepsis

ObjectiveTo investigate the effects of integrated blood purification on haemodynamics and oxygen metabolism in children with severe sepsis.MethodsClinical data of 12 children with severe sepsis admitted to the pediatric intensive care unit of our hospital between October 2021 and June 2022 were retrospectively analyzed. All patients were treated with integrated blood purification, and changes in haemodynamic parameters, including heart rate, blood pressure, mean arterial pressure and cardiac output, and oxygen metabolism parameters (blood lactic acid, oxygen delivery, oxygen consumption and oxygen extraction rate) were observed before and after treatment.ResultsThe heart rate (134[106,160] vs 111[101,128], p = 0.037), central venous pressure (9[7,10] vs 8[7,9], p = 0.04), stroke output (28[18,43] vs 21[15,31], p = 0.01), blood lactate (3.3[2,4] vs 2.5[1.3,3.6], p = 0.015), oxygen consumption (165.99[121.44,230.31] vs 124.18[82.51,162.86], p = 0.041) and oxygen extraction rate (38.83[31.87,44.62] vs 28.67[21.05,32.72], p = 0.019) were decreased, whereas systolic blood pressure (97[83,104] vs 107[94,116], p = 0.033) and central venous oxygen pressure (32[29, 37] vs 39[34,46], p = 0.005) were increased in the children after treatment compared with before treatment. There were no statistically significant differences in diastolic blood pressure, mean arterial pressure, cardiac output, arterial oxygen pressure and oxygen delivery before and after treatment (all p &amp;gt; 0.05).ConclusionIntegrated blood purification can improve haemodynamic and oxygen metabolism parameters in children with severe sepsis, with a high value in clinical application.

Music’s Influence on Cardiovascular Parameters During Cognitive Testing

BackgroundMozart’s music has been found to decrease stress and anxiety by decreasing blood pressure and heart rate in diverse populations. However, the influence on Mozart during cognitive tests remains unclear. Due to its proven anti-stress effects, Mozart’s music may be an effective tool for decreasing cardiovascular parameters during cognitive testing. MethodsThe cognitive test chosen was an untimed pattern-recognition Mensa test. The chosen song was Mozart’s Sonata K448. We included 10 adult participants who met the inclusion criteria. A matched pair study design was incorporated. All participants completed a diagnostic test that assessed relative cardiovascular sensitivities to the acute stress produced by the Mensa test. Participants were matched based on cardiovascular sensitivities, rating of momentary stress, and sex. Pairs were then randomly allocated to take the test again; one took the test while listening to Mozart’s Sonata K448, the other took it in silence. Post-test evaluations were then completed. ResultsIn both groups, the intervention did not induce significant changes in BP or HR, except for a significant decrease in SBP in the no music group (p=0.043). When comparing the difference in relative blood pressure and heart rate changes between the two groups, none were significantly different. There were significant decreases in perceived stress and increases in perceived relaxation in the music group (p=0.024 and p=0.039, respectively). ConclusionOur findings suggest that Mozart’s music does not decrease cardiovascular responses during cognitive testing. Additionally, perceived stress is independent of cardiovascular indicators of stress which has unknown implications.

Impact of Haemodialysis: Analysis of Haemoglobin Levels and Blood Pressure Control in Patients with End-Stage Renal Disease

Aims: To analyze the effect of hemodialysis on hemoglobin levels and blood pressure in patients with End Stage Renal Disease (ESRD). Method: The study used a one-group pretest-posttest design with 17 respondents. Data were collected using EDTA tubes, sphygmomanometers, and stethoscopes. A paired t-test and Wilcoxon signed-rank test were applied to analyze the significance of changes between pretest and posttest results Results: The mean hemoglobin level before hemodialysis was 7.92 g/dL and increased to 8.50 g/dL after hemodialysis (p = 0.001). The mean systolic blood pressure decreased from 136.6 mmHg before to 124.0 mmHg after hemodialysis (p = 0.003). However, there was no significant difference in diastolic blood pressure, with an average of 80.6 mmHg before and 78.6 mmHg after hemodialysis (p = 0.180). Conclusion: It can be concluded that hemodialysis significantly increases hemoglobin levels and reduces systolic blood pressure in ESRD patients, while diastolic blood pressure remains unchanged. Regular monitoring of hemoglobin and systolic blood pressure is crucial for managing patient health. Hemodialysis effectively raises hemoglobin levels and reduces systolic blood pressure in ESRD patients. Regular monitoring of both parameters is essential for effective patient management. While the findings highlight the benefits of hemodialysis, the limited sample size may restrict the generalizability of the results. Further studies with larger sample sizes are needed to confirm these findings and explore the long-term implications.

Antihypertensive treatment of masked hypertension guided by ambulatory blood pressure monitoring: a double-blind, placebo-controlled trial

Abstract Background Masked hypertension, office normotension combined with out-of-office hypertension, is associated with target organ damage (TOD), but whether antihypertensive treatment guided by out-of-office blood pressure (BP) would reduce TOD is unproven. Purpose To assess TOD change on antihypertensive treatment guided by ambulatory BP monitoring. Methods We conducted a double-blind, placebo-controlled randomized trial at 15 Chinese hospitals. Enrolment started on February 14, 2017 and follow-up ended on October 31, 2021. Patients of either sex, aged 30-70 years, not on antihypertensive drugs were eligible, if at two screening visits 1-week apart office BP was &amp;lt;140/&amp;lt;90 mm Hg and the 24 hour, daytime or nighttime ambulatory BP was ≥130/≥80, ≥135/≥85, or ≥120/≥70 mm Hg, respectively. Patients had ≥1 sign of TOD: ECG left ventricular hypertrophy (LVH), brachial-ankle pulse wave velocity (baPWV) ≥1400 cm/s, or urinary albumin-to-creatinine ratio (ACR) ≥3.5 mg/mmol in women and ≥2.5 mg/mmol in men. Active antihypertensive treatment consisted of allisartan starting at 80 mg/day to be increased to 160 mg/day at month 2 and to be combined with amlodipine 2.5 mg/day at month 4, if the ambulatory BP remained uncontrolled. Matching placebos were used likewise in the control group. The primary endpoint included normalization of baPWV, ACR or LVH or ≥20% reduction in baPWV or ACR. Results Of 320 patients (43.1% women; mean age 54 years), 153 were randomized to active antihypertensive treatment and 167 to placebo. At baseline, office BP averaged 130/81 mm Hg and the 24 hour BP 136/84 mm Hg. The prevalence of elevated baPWV, ACR and LVH was 97.5%, 12.5%, and 7.8%. The 24-hour systolic/diastolic decreased by 9.0/5.6 mm Hg (95% CI: 7.5-10.5/4.8-6.5 mm Hg) on active treatment and by 1.4/1.0 mm Hg (-0.1-2.8/0.2-1.8 mm Hg) on placebo. Regression of TOD, the primary outcome, occurred more frequently in patients randomized to active treatment than in those assigned to placebo with 1 year rate of 45.8% (95% CI: 37.9-53.7%) and 25.8% (19.1-32.4%), respectively (P&amp;lt;.001 for between-group differences in BP and TOD). Per-protocol and subgroup analyses were confirmatory. Conclusions Masked hypertensive patients require antihypertensive treatment guided by out-of-office BP monitoring before subclinical TOD progresses to major cardiovascular complications.

Double arch technique - a novel surgical procedure for the hypoplastic aortic arch syndrome

Abstract Background The hypoplastic aortic arch syndrome was defined as a combination of hypoplastic aortic arch and complex proximal descending aortic anomalies (such as aortic aneurysm, aortic coarctation, aortic tortuosity, or aortic dissection). In this study, we proposed a novel 'double arch' technique as a simple surgical procedure to treat the hypoplastic aortic arch syndrome, which could eliminate the requirement for cardiopulmonary bypass. Purpose This study aimed to investigate the surgical outcomes of patients who underwent the 'double arch' technique, and further evaluate the effectiveness and safety of this novel technique. Methods Briefly, J-shaped mini-sternotomy and left posterolateral thoracotomy were both performed in this technique. The ascending aorta, aortic arch, and proximal descending aorta were dissociated. After that, the ascending aorta was occluded using a side-biting clamp, followed by an end-to-side anastomosis between the proximal end of vascular graft and the ascending aorta. Similarly, the thoracic descending aorta was occluded with two aortic clamps beyond the opening of the left subclavian artery, and was then transected between the clamps, followed by an end-to-end anastomosis between the distal end of vascular graft and the distal descending aorta, while the proximal descending aorta was closed with sutures. The transection site of the aorta could be adjusted according to the extent of the lesions, and the vascular graft was placed in the left thoracic cavity. The operation was performed at room temperature. The primary endpoint was early mortality, which referred to in-hospital death and/or death within 30 days after surgery (including intraoperative death), whichever is longer. Critical secondary endpoints included aortic reoperation, newly developed aneurysms, and the blood pressure difference between the upper and lower extremities. Results Twelve patients with hypoplastic aortic arch syndrome were enrolled from December 2015 to February 2022. Patients were diagnosed using computed tomography. The median age (interquartile range, IQR) was 26.5 (17.0, 39.0) years (ranging from 12.0 to 55.0), and 8 patients were female (66.7%). The median operation time (IQR) was 4.7 (3.8, 5.5) hours (ranging from 2.8 to 7.3). All patients survived to discharge and completed the follow-up. The median follow-up time (IQR) was 5.42 (3.25, 5.97) years (ranging from 0.02 to 6.25). During the follow-up, no patient died or was required for reoperation. In addition, no newly developed aneurysm was found, and no severe adverse event was recorded. The median blood pressure difference (IQR) between the upper and lower extremities was 9 (4, 17) mmHg (ranging from 3 to 27). Conclusions The 'double arch' technique is a viable alternative surgical treatment for the hypoplastic aortic arch syndrome. This technique is expected to significantly simplify the surgical procedure and improve the long-term prognosis of patients.Diagram of the 'double arch' techniqueCT scans of pre- and post-operation

Efficacy of online japanese intensive cardiac rehabilitation for secondary prevention for coronary artery disease: a comprehensive program including exercise, nutrition, mindfulness, and group support

Abstract Background/Introduction While comprehensive programs for cardiac rehabilitation are recommended for patients with coronary artery disease (CAD), systematic programs including nutrition, stress-management, and behavior change have not been clearly established. Purpose To comprehensively change the lifestyle of patients with CAD as secondary prevention, we developed an online based educational program "intensive cardiac rehabilitation for Japanese patients with CAD (J-ICR)" modifying ICR, a regimen covered by health insurance in the United States, to the program that has affinity with Japanese. Methods Online J-ICR program is set up as sessions for maintenance-phase CAD patients using an online application. J-ICR has 12 sessions held weekly for 3 hours per session, total 36 hours, aimed to integrate 4 components: 1) exercise guidance based on exercise prescription which contain aerobic exercise, resistance training, and multi-component exercise through online platforms, 2) dietary education focusing on "the Japan Diet", 3) stress management utilizing mindfulness, and 4) group support to enhance patient and medical-staff interaction. Twenty-two participants were randomly separated to Early Phase group and Late phase group. For verification of the efficacy of this program, we survey the adherence to the program and compared the changes in risk factor of CAD at 3 months defining Early phase group as intervention group and Late phase group as control. (Fig.1). Results After excluding 3 participants who withdrawn to participate, the remaining 19 participants were conducted the evaluation and 10 participants were in intervention group and 9 participants in control group, respectively. As for patient characteristics, the mean age was 66 years old, and all participants were male. History of CVD was comprising 8 cases of myocardial infarction and 15 cases of angina pectoris. As for the risk factors of CVD, there were not significant differences in mean low density lipoprotein (LDL) cholesterol (Intervention group 71.5mg/dl vs Control group 83.4mg/dl; p=0.12) or systolic blood pressure (SBP) (126mmHg vs 130mmHg; p=0.40) at base line between two groups. The average participating rate in program was 93.8% and there was no dropped out participant during the program in investigation group. After 3months, LDL cholesterol was not significantly decreased in both groups (mean reduction of Intervention group -0.3mg/dl, p=0.93 and control group -3.8mg/dl, p=0.43, respectively). However, there was significant reduction of SBP in intervention group (mean reduction 5.6mmHg, p=0.02) but in control group (mean reduction 2.4mmHg, p=0.42). (Fig.2). Conclusions This randomized controlled study showed the good adherence of J-ICR program and it suggested that J-ICR program has the effect on lowering systolic blood pressure at 3 months. Longer follow up data and the results of more participants are warranted to clarify the efficacy in real world prevention of CVD.

Evaluation of renal functional reserve in patients with preserved renal function and coronary microvascular disease

Abstract Background/introduction Renal Functional Reserve (RFR) stands as a subject of significant scientific discussion,holding promise as a diagnostic tool for early detection of subclinical renal disorders. Literature establishes a link between chronic kidney disease &amp; cardiovascular disease (CVD). Purpose This study aims to assess RFR in patients with coronary microvascular dysfunction (CMD), while maintaining preserved renal function (eGFR≥60ml/min/1.73m2 by CKD-EPI criteria)&amp;proteinuria&amp;lt;400mg/24hr. The investigation seeks to provide insights into the nuanced relationship between renal function&amp;CMD, offering potential early indicators of CVD. Methods This is a single-center, prospective study enrolling patients with CMD. In the absence of significant coronary artery disease, functional coronary circulation assessment was performed. Coronary flow reserve (CFR) &amp; index of microvascular resistance (IMR) were measured invasively with bolus thermodilution technique. In all participants, RFR was estimated by endogenous creatinine clearance after oral protein load (cooked meal, 1.2gr/kg). Normal RFR was defined as≥30 ml/min/1.73m2. Also, patients with CMD were offered 24-hour Ambulatory Blood Pressure Monitoring (ABPM). Results A total of 25 participants have been enrolled so far in study: 11 without CMD - control group [7 female, 64%, mean age: 52.9±8.8 years) &amp; 14 with CMD – CMD group (11 female, 79%, mean age: 53.5±10,3 years). CMD patients were classified into 2 groups, structural &amp; functional endotype (CFR&amp;lt;2.5 &amp; IMR≥25 were considered abnormal). The RFR value for CMD &amp; control group is 7.4±6.3 vs 36.3±5.8 ml/min/1.73m2 respectively (p&amp;lt;0.05). This difference between groups remained statistically significant after controlling for confounding factors. It was found that RFR value for functional &amp; structural CMD endotype was 3.8±2.6 &amp; 9.6±7,2 ml/min/1.73m2 respectively (p=0.06). Furthermore, no statistical significance was found between RFR and IMR, CFR indices. According to data from ABPM, there were no significant differences in ambulatory blood pressure (both systolic and diastolic) between the two endotypes of CMD, as well as no relationship with RFR was observed. However, the proportion of non-dipping BP pattern was significantly higher in functional CMD endotype (p&amp;lt;0.05). It was not found correlation between RFR &amp; non-dipping phenotype. Conclusions Impaired RFR is evident across all individuals experiencing microvascular angina. Furthermore, those with functional CMD exhibit a diminished RFR when compared with their counterparts with structural CMD. RFR does not exhibit a correlation with blood pressure levels or the absence of a nocturnal dipping pattern. In light of the hypothesis asserting that appraising renal functional reserve serves as an early diagnostic measure for subclinical renal disorders, promptly recognizing individuals with distinct phenotypes could facilitate tailoring therapeutic interventions on an individual basis.Functional Coronary AngiogramCMD group baseline characteristics

Clinical Implications of NT-proBNP trajectory following Sacubitril/Valsartan initiation

Abstract Introduction Serum N-terminal pro–B-type natriuretic peptide (NT-proBNP) values after initiating Sacubitril/Valsartan is considered as a favorable prognostic factor, and widely used for risk stratification in patients with heart failure (HF). However, the relationship between the trajectory of serially measured NT-proBNP values and cardiovascular events in patients with HF who are treated with Sacubitril/Valsartan remains uncertain. Purpose This study aimed to reveal the prognostic association of an NT-proBNP trajectory after initiating Sacubitril/Valsartan and subsequent cardiovascular outcomes. Methods and Results A Japanese nationwide multicenter study was conducted on HF patients who initiated Sacubitril/Valsartan. Out of the 995 patients enrolled, we excluded 561 patients who were undergoing assessment of BNP or who lacked a complete set of NT-proBNP measurement. Finally, 434 patients included this study, and were divided into three groups based on NT-proBNP trajectory as follows; the ‘sustained-responder’ group (n = 129, 30%) : which exhibited a reduction of NT-proBNP by ≥10% at 1 month and further reduction of ≥10% at 3 months; and the ‘transient-responder’ group (n = 161, 37%), with ≥10% reduction at 1 month but not at 3 months; and the ‘non-responder’ group (n = 144, 33%), which did not achieve ≥10% reduction at 1 month. The mean age was 68 years, with females comprising 29%. In the ‘sustained-responder’ group, the age was significantly younger, and the duration of heart failure was significantly shorter. There were no significant differences in the mean systolic blood pressure, mean Sacubitril/Valsartan dose at each measurement points among the 3 groups. During follow-up of 456 (IQR, 371-549) days, the primary endpoint, which was either cardiovascular death or hospitalization of HF occurred in 78 of 434 patients (18%). The Kaplan-Meier analysis showed that the ‘sustained responder’ group experienced significantly lower event rate among the 3 groups (Log-rank p&amp;lt;.001). Additionally, an analysis that set a landmark time at 3 months post-initiation of Sacubitril/Valsartan showed that the ‘sustained-responder’ group experienced significantly fewer events than the ‘transient-responder’ group (Log-rank p=0.039) (Figure.1). Also, the ‘sustained responder’ was observed to have a better prognosis in a subgroup with LVEF&amp;lt;50%, but not in patients with LVEF ≥50%. (p value for interaction=0.035) (Figure.2). Conclusions This study revealed that sustained reduction of NT-proBNP was associated with a reduced risk of cardiovascular death or hospitalization for HF. The periodic NT-proBNP monitoring and the patterns of NT-proBNP during treatment with Sacubitril/Valsartan may be helpful in optimizing HF therapy and understanding the prognosis of HF.Figure.1Figure.2

Prevention of dementia using mobile phone applications (PRODEMOS): a multinational randomised controlled effectiveness-implementation trial

Abstract Background The expected increase of dementia prevalence in the coming decades will mainly be within low-and middle-income countries and those with low socioeconomic status (SES) in high income countries. Forty percent of dementia is associated with modifiable, lifestyle-related cardiovascular risk factors. Mobile health interventions with remote coaching can help reach underserved high-risk populations globally. Methods This open label, blinded endpoint, hybrid effectiveness-implementation randomised controlled trial (RCT) investigated whether a coach-supported mHealth intervention can reduce dementia risk in persons aged 55-75 years of low SES in UK or from the general population in China with at least two dementia risk factors. The primary effectiveness outcome was change in CAIDE dementia risk score (including age, education, sex, systolic blood pressure, total cholesterol, BMI, physical exercise) after 12-18 months of intervention. Main implementation outcomes were coverage, acceptability, appropriateness, adoption, feasibility, sustainability, fidelity, and costs using a mixed methods approach. Findings Between 15th January 2021 and 18th April 2023, 1,488 persons were included and randomised (734 intervention, 754 control), with 1,229 (82·6%) available for analysis of the primary effectiveness outcome. After a mean follow-up of 16 months, the mean CAIDE score improved by 0·16 points in the intervention group vs. 0·01 in the control group (Mean Difference (MD) 0·16, 95% Confidence Interval (CI) 0·03-0·29). The effect was larger in those who adhered to the intervention (MD 0·27, 95%CI 0·12-0·44) and those planning to change lifestyle (MD 0·33, 95%CI 0·10-0·57). Ten percent of those invited participated; of these, 81% adopted the intervention and 50% continued active participation throughout the study. For the individual components of the CAIDE score, there were no statistically significant differences for systolic blood pressure, total cholesterol and BMI, but in the intervention group physical inactivity was reduced more than in the control group (MD 6·7%, 95%CI 2·1 to 11·2) and more participants quit smoking (MD -3·1%, 95%CI -4·8 to -1·5). Interpretation A coach-supported mHealth intervention to improve lifestyle is modestly effective in reducing dementia risk factors in those with low SES in the UK and any SES in China. Implementation is challenging in these populations, but those reached actively participated. Whether this will result in less cognitive decline and dementia requires a larger RCT with long follow-up.

Unsupervised machine learning identifies distinct phenotypes in cardiac complications of pediatric patients treated with anthracyclines

BackgroundAnthracyclines are essential in pediatric cancer treatment, but patients are at risk cancer therapy-related cardiac dysfunction (CTRCD). Standardized definitions by the International Cardio-Oncology Society (IC-OS) aim to enhance precision in risk assessment.ObjectivesCategorize distinct phenotypes among pediatric patients undergoing anthracycline chemotherapy using unsupervised machine learning.MethodsPediatric cancer patients undergoing anthracycline chemotherapy at our institution were retrospectively included. Clinical and echocardiographic data at baseline, along with follow-up data, were collected from patient records. Unsupervised machine learning was performed, involving dimensionality reduction using principal component analysis and K-means clustering to identify different phenotypic clusters. Identified phenogroups were analyzed for associations with CTRCD, defined following contemporary IC-OS definitions, and hypertensive response.ResultsA total of 187 patients (63.1% male, median age 15.5 years [10.4–18.7]) were included and received anthracycline chemotherapy with a median treatment duration of 0.66 years [0.35–1.92]. Median follow-up duration was 2.78 years [1.31–4.21]. Four phenogroups were identified with following distribution: Cluster 0 (32.6%, n = 61), Cluster 1 (13.9%, n = 26), Cluster 2 (24.6%, n = 46), and Cluster 3 (28.9%, n = 54). Cluster 0 showed the highest risk of moderate CTRCD (HR: 3.10 [95% CI: 1.18–8.16], P = 0.022) compared to other clusters. Cluster 3 demonstrated a protective effect against hypertensive response (HR: 0.30 [95% CI: 0.13– 0.67], P = 0.003) after excluding baseline hypertensive patients. Longitudinal assessments revealed differences in global longitudinal strain and systolic blood pressure among phenogroups.ConclusionsUnsupervised machine learning identified distinct phenogroups among pediatric cancer patients undergoing anthracycline chemotherapy, offering potential for personalized risk assessment.

A Comparison of Different Doses Efficacy of Isobaric Ropivacaine 0.5% in Spinal Anesthesia in Cesarean Section

Background: Cesarean delivery is a standard surgical procedure in women. Thus, a practical, affordable, and low-risk anesthetic technique is essential for mother and infant safety. Spinal anesthesia is a popular and efficient technique for anesthesia during cesarean delivery. However, other local anesthesia drugs with negligible side effects should be considered. The most selective medication for this purpose is bupivacaine (marcaine), which creates optimal anesthesia at doses of 10 to 12 mg. Objectives: The most available medicine for spinal anesthesia during cesarean delivery is a 0.5% marine solution. However, ropivacaine for spinal anesthesia can occasionally be accessed as a long-acting amide local anesthetic agent used as an alternative to marcaine during the cesarean delivery. The ropivacaine's advantage over marcaine is its less neurotoxicity and cardiotoxicity, as well as the more stable hemodynamical condition of the patients. So far, no proper therapeutic dose of 0.5% isobaric ropivacaine has been proposed to be used during the cesarean delivery. Any increase in the dose may ensure the block performance, but, by contrast, some side effects may arise, including hypotension, bradycardia, vomiting, and nausea. Herewith, the likelihood of maximum block and most minor side effects was attempted to be assessed at the tiniest doses of this anesthetic agent. Methods: This randomized clinical trial was conducted on C-section candidates. Patients were categorized into three groups receiving 22.5, 25, and 20 mg of the 0.5% isobaric ropivacaine solution. Systolic and diastolic blood pressure, heartbeats, the level of sensational and sympathetic nerve block, duration to reach the maximum motor block, the rate of vasopressors and atropine consumption, rate of vomiting and nausea, the rate of using supplementary drugs, block breakdown, and the patient's satisfaction with the anesthesia were measured and recorded. The collected data were analyzed using IBM SPSS Statistics. Results: No significant difference was found between demographic characteristics. Likewise, there was no significant difference in systolic and diastolic blood pressure, heartbeats, the level of sensational and sympathetic nerve block, duration to reach the maximum motor block, the rate of vasopressors and atropine consumption, rate of vomiting and nausea, and the rate of using supplementary drugs between the three groups. The most significant block breakdown and use of supplementary drugs were found in the first group (20 mg), with a significant difference between the three groups. Conclusions: The three doses used did not result in meaningful differences between the three groups. However, the differences were significant for the block breakdown, with the higher block breakdown and supplementary drug use observed when using 20 mg of the 0.5 ropivacaine solution.

The application of supine bicycle exercise stress echocardiograph for identification of susceptibility to acute mountain sickness

Abstract Background Exposure to high altitude is likely to lead to acute mountain sickness (AMS). At present, there are no definite parameters that can accurately predict the occurrence of AMS. Objectives The purposes of this study are (1) to assess the relationship between stress echocardiographic parameters and AMS, (2) to identify the predictors of AMS at sea level by exercise stress echocardiography. Methods A total of 36 healthy adults were enrolled and underwent resting and exercise stress echocardiography on a supine bicycle at sea level. Heart rate (HR) and blood pressure (BP) were monitored during stress echocardiography. Left ventricular (LV) ejection fraction and E/e’ were calculated at rest and peak stage. Other right ventricular systolic function parameters and pulmonary artery pressure (PAP) were calculated at the same time, which included tricuspid regurgitation velocity (TRV), tricuspid annular peak systolic excursion (TAPSE), systolic PAP (sPAP), right ventricular (RV) dimension by 2D, right ventricular area at the end of diastole (RVAD), right ventricular area at the end of systolic (RVAS),RV fraction of area change (FAC), right ventricular outflow tract velocity time integral (RVOT VTI).Pulmonary vascular resistance (PVR) was calculated. All subjects ascended to 3600m within 24 hours by bus. AMS was identified by 2018 Lake Louise Questionnaire Score. Univariable and multivariable logistic regression analysis assessed independent factors associated with AMS. Results At the altitude of 3600m, 13 of 36 subjects had AMS, which defined as AMS (+) group. And the rest was AMS (-) group. There were no significant differences in HR, BP, and LV systolic and diastolic function between the two groups (P &amp;gt; 0.05). TRV, sPAP, and PVR were much higher at peak stage in AMS (+) group (P &amp;lt; 0.05). No significant differences were found in RV systolic function at rest and peak stage between the two groups. By multivariable logistic regression model, PVR and RVAD at peak stage were significantly associated with AMS occurrence (PVR-OR =1.962,95% CI: 0.689-0.973,p =0.002; RVAD-OR =1.962,95% CI: 0.638-0.967,p =0.005;). The cutoff value to predict AMS were 1.55 for PVR (AUC: 0.831) and 11.45 cm2 for RVAD (AUC: 0.802). Conclusions Supine bicycle exercise stress echocardiography is a useful and noninvasive technique to identify subjects susceptible to AMS. Subjects with higher PVR and RVAD at peak stage were associated with susceptibility to AMS.

High altitude exercise stress echocardiograph for identification of susceptibility to acute mountain sickness

Abstract Background Acute high-altitude exposure increases the risk of acute mountain disease (AMS) and high-altitude pulmonary edema. After the initial exposure to high altitude, mountain climbers are worried about whether they will develop AMS. At high altitudes, there are no accurate indicators to predict the near future occurrence of AMS. Objectives To investigate whether treadmill exercise stress echocardiography at high altitude can predict the occurrence of AMS, and to find out some powerful factors associated with the susceptibility to AMS. Methods 36 healthy lowlanders were taken by bus from sea level to an altitude of 3600 m the next morning, during which they rested overnight at an altitude of 2150 m. Treadmill exercise stress echocardiography was performed immediately upon arrival at 2150 m, and the 2018 Lake Louise Questionnaire Score was performed the next day when arrived at the altitude of 3600 m. Heart rate (HR) and blood pressure (BP) were monitored during stress echocardiography. Left ventricular (LV) ejection fraction and E/e’ were calculated at rest and immediately after exercise. Other right ventricular systolic function parameters and pulmonary artery pressure (PAP) were calculated at the same time, which included tricuspid regurgitation velocity (TRV), tricuspid annular peak systolic excursion (TAPSE), systolic PAP (SPAP), right ventricular (RV) dimension by 2D, RV fraction of area change (FAC), right ventricular outflow tract velocity time integral (RVOT VTI). Pulmonary vascular resistance (PVR) was calculated according to the formula: TRV/RVOT VTI*10+0.16. Mean PAP (mPAP) was calculated as the formula: sPAP*0.61+2. All subjects ascended to 3600m within 24 hours by bus. AMS was identified by 2018 Lake Louise Questionnaire Score. Univariable and multivariable logistic regression analysis assessed independent factors associated with AMS. Results At the altitude of 3600m, 13 of 36 subjects had AMS, which defined as AMS (+) group. And the rest was AMS (-) group. There were no significant differences in HR, BP, SO2 and LV systolic and diastolic function between the two groups (P &amp;gt; 0.05). No significant differences were noted at rest except for TV s' (P &amp;lt; 0.05). Immediately after exercise, TRV, TAPSE, SPAP, mPAP, PVR, and RV area at the end of systole were much higher in AMS (+) group (all P &amp;lt; 0.05). While FAC and TVs’/SPAP were much lower in AMS (+) group (P &amp;lt; 0.05). By multivariable logistic regression model, mPAP immediately after exercise was significantly correlated with AMS occurrence (OR =1.332, 95% CI: 0.669-0.993, P= 003). The cutoff value of mPAP to predict AMS was 32 mmHg (AUC: 0.831, specificity: 86.7%, sensitivity: 76.9%). Conclusions The mPAP immediately after exercise upon arrival at an altitude of 2150 m is a strong predictor of near future AMS, and treadmill exercise stress echocardiography is a simple and non-invasive tool to help mountain climbers avoid more severe mountain sickness.

Blood pressure response to exercise in endurance athletes with and without paroxysmal atrial fibrillation.

Abstract Background Atrial fibrillation (AF) is more prevalent among endurance-trained athletes when compared to non-athletes. The underlying pathophysiology and mechanisms for this phenomenon remain unknown but repeated exposure to an exaggerated blood pressure (BP) response during exercise may contribute to the development of AF in this population. Purpose We aimed to assess whether endurance athletes with AF have a higher maximal systolic BP (SBP) or a higher BP relative to exercise intensity compared to endurance athletes without AF. Methods Endurance athletes with paroxysmal AF (n=66, 96% male) from the ProAFHeart, NEXAF Detraining and Master@Heart studies were matched for age and sex to endurance athletes without AF (n=66, 96% male). Participants with a history of hypertension were excluded. All athletes underwent a maximal graded cardiopulmonary exercise test on a cycle ergometer to assess exercise BP using an automated auscultatory BP machine, maximal oxygen uptake (VO2peak) and peak workload. All athletes were in sinus rhythm at the time of testing and BP was measured pre-exercise seated on the bike and every 2 min throughout the test. Exercise BP measurements included the maximum exercise SBP (SBPmax) and the slopes of the relationships between SBP, diastolic BP (DBP) and workload (W) as determined from linear regression analysis (SBP/W-slope and DBP/W-slope, respectively). The resting SBP and DBP were measured in the supine position after 10min of rest. Independent T-test (parametric data) or the Mann-Whitney U-test (non-parametric data) assessed for the differences between the two groups. Results The 66 athletes with AF were of similar age and sex as the 66 athletes without AF, median age (55 [IQR 45, 61] vs 54 [IQR 44, 62] years, p=0.839), 4% female. There was no difference in (mean±SD) VO2peak (46 ±9 vs 49±10 mL/kg/min, p=0.114) and peak workload (365±67 vs 385±83 W, p=0.136), nor resting SBP (131±13 vs 128±13 mmHg, p=0.169) and resting DBP (76±9 vs 75±11 mmHg, p=0.465) between athletes with and without AF respectively (Table 1). Athletes with AF showed no significant difference to athletes without AF for exercise BP responses (Figure 1) including SBPmax (222±22 vs 219±28 mmHg, p=0.479), SBP/W-slope (0.22±0.07 vs 0.24±0.08 mmHg/W, p=0.310) and median DBP/W-slope (-0.01 [IQR -0.02, 0.01] vs -0.01 [IQR -0.03, 0.02] mmHg/W, p=0.703). Conclusion When comparing endurance athletes with and without paroxysmal AF, there were no differences in the maximal BP attained during exercise or in their BP response indexed to external workload (SBP/W-slope) suggesting that exercise-induced hypertension does not explain the athletic predisposition to AF.

Higher systolic blood pressure in left not right upper limb is associated with all-cause mortality risk in a community-based population

Abstract Background and Purpose Previous studies have shown that elevated inter-arm systolic blood pressure difference (SBPD) is a valuable indicator for assessing the risk of all-cause mortality. However, no research currently reports that the different impact of higher SBP in which upper limb on all-cause mortality risk. This study investigates which side of the upper limbs has a higher SBP that is more associated with all-cause mortality risk in a community population. Methods The subjects were from the a Atherosclerosis Cohort of the Department of Cardiology of our University First Hospital from 2012 to 2021, and those with missing data of brachial-ankle pulse wave velocity and a history of myocardial infarction or stroke in the baseline survey were excluded. The endpoint was defined as all-cause mortality. SBPD was defined as the difference between the systolic blood pressure of the right arm minus the systolic blood pressure of the left arm by the noninvasive arteriosclerosis detection device BP-203RPEIII (Omron, Japan). SBPD was categorized into four groups: 0-10 mmHg (right arm higher &amp;lt;10mmHg), ≥ 10 mmHg (right arm higher ≥ 10 mmHg ), -10 to &amp;lt; 0 mmHg (left arm higher ≤10 mmHg), and &amp;lt; -10 mmHg (left higher &amp;gt; 10mmHg). The relationship between SBPD and all-cause mortality risk was determined by multivariable Cox proportional hazards regression after adjusting for covariates (age, body mass index, gender, current smoking, current drinking, estimated glomerular filtration rate, diabetes, hypoglycemic treatment, total cholesterol, triglycerides, lipid-lowering treatment, and antihypertensive treatment). Results Totally, 8628 participants were included, with a mean age of 56.58 ± 8.97 years old, and 64.51% (5566) were female. Among them, 380 (4.40%) had an SBPD ≥ 10 mmHg, and 409 (4.74%) had an SBPD &amp;lt; -10 mmHg. During a median follow-up of 9.87 years, 442 cases of all-cause mortality (5.19%) occurred. The Kaplan-Meier curve suggested that the greater the difference in SBPD, the higher the cumulative risk of all-cause mortality. The Log-rank test showed a significant statistical difference (P= 0.0115). Compared to right arm higher &amp;lt;10mmHg group, the risk of all-cause mortality was not significantly elevated in right arm higher ≥ 10 mmHg (adjusted HR=1.17, 95% CI: 0.74-1.84, P=0.507) or left arm higher ≤10 mmHg group (adjusted HR=0.90, 95%CI: 0.74-1.11, P=0.329). However, the risk of all-cause mortality significantly increased by 59% in left higher &amp;gt; 10mmHg Group (adjusted HR=1.59, 95% CI: 1.10-2.30, P=0.013). The results remained significant after adjusting for peripheral right arm SBP (adjusted HR=1.56, 95% CI: 1.08-2.24, P=0.018). Conclusion This study found that a higher SBP in the left arm is associated with a higher risk of all-cause mortality in a Beijing community-based population, and they should be monitored and intervened more intensively.Hazard Ratios for all-cause mortalitySurvival curves for SBPD groups

Validation and development of a scoring system for comprehensively evaluating arterial damage in the elderly chinese

Abstract Background and aims Existing assessments on arterial damage focus on specific segments of arterial system (e.g., carotid artery), lacking a comprehensive index to evaluate overall arterial health. We aimed to integrate existing assessments for arterial damage and develop a new score, named Arterial Damage Index (ADI), to comprehensively evaluate arterial health status of the whole-body arterial system. Methods A total of 3075 community-dwelling elderly Chinese (age ≥65 years) from the North Shanghai Study (2014–2022) were included. Assessments on arteries including ankle-brachial index (ABI), pulse wave velocity (PWV), carotid intima-media thickness (CIMT) and plaques, pulse pressure (PP), and inter-arm (IASBPD) and -leg (ILSBPD) systolic blood pressure difference were included for screening. Cox proportional hazards regressions of MACEs (non-fatal myocardial infarction, non-fatal stroke, and all-cause mortality) were conducted to acquire the ADI algorithm. Internal and external validation on ADI were also performed. Results Over a median follow-up period of 6.4 years, 316 individuals (10.3%) experienced an incident of MACE. After screening, PWV, ABI, PP, CIMT, and carotid plaque were included for ADI scoring system. Survival analysis revealed a significant difference in the rates of composite events across different ADI stratifications (p for trend &amp;lt; .05). ADI showed superior discriminative performance (C-index 0.65±0.02) compared to any individual arterial-related indicator. Calibration curve shows the predictive model showed that the predicted and actual probabilities were broadly consistent. Additionally, ADI provided better incremental value when added to the base model (net reclassification improvement, 36.2% [95% CI, 15.3%-52.1%]; p &amp;lt; .05, integrated discrimination improvement, 7.9% [95% CI, 4.9%-11.0%]; p &amp;lt; .05) compared to any individual arterial-related indicator. These findings were confirmed in internal validation sets (p for DeLong tests &amp;gt;0.05), and was externally validated in 2155 participants from a community-based cardiovascular disease cohort among residents in Beijing, China. Conclusion ADI can comprehensively assess arterial damage and provide a valuable tool for further assessment of future cardiovascular risk.central illustration

A Decade-Long Retrospective Study of Factors Influencing Survival in Ruptured Abdominal Aortic Aneurysm

Background: Ruptured abdominal aortic aneurysm (rAAA) carries a high mortality risk, requiring rapid diagnosis and intervention. This study assesses various clinical factors influencing rAAA management outcomes in alignment with evolving guidelines from 2011 to 2024. Methods: A retrospective analysis of 62 rAAA patients treated at Vivantes Clinic, Berlin, from July 2014 to May 2024 was conducted. Data were obtained from medical records, focusing on vital parameters at admission and during treatment. Both numerical and categorical variables were analyzed to identify survival determinants. Results: The overall survival rate was 55%. Significant differences in systolic and diastolic blood pressures during surgery were noted between survivors and non-survivors, with lower pressures observed in non-survivors at critical surgical stages. Other vital signs showed no significant variations. Survival was significantly associated with gender, fluid therapy, and aneurysm location. Conclusions: Effective blood pressure management during surgery is crucial for improving survival in rAAA cases. This study emphasizes adherence to current clinical guidelines and highlights the need for ongoing research to fill existing knowledge gaps. Further investigations are essential to enhance patient care and outcomes in rAAA.