Drop In Systolic Blood Pressure Research Articles

A Case Report of Dizziness with Postural Hypotension Improved by Korean Medicine Treatment

Background: Postural hypotension refers to a drop in systolic blood pressure of 20 mmHg or diastolic blood pressure of 10 mmHg or more within three minutes after standing up from lying down. Symptoms of postural hypotension not only include dizziness and blurred vision but also fatigue, cognitive decline, leg weakness, headache, and, in severe cases, fainting. Postural hypotension is a phenomenon that occurs in about 6% of the total population, and in Korea, the number of patients with postural hypotension is continuously increasing. Both pharmacological and non-drug therapies, which are treatment methods for this disease, do not show a satisfactory symptom improvement effect.Case summary: A 65-year-old male patient who visited the hospital complaining of dizziness and paresthesia due to postural hypotension was treated with acupuncture, moxibustion, and herbal medicine. For symptom evaluation, the numeric rating scale (NRS) of each symptom was used, and blood pressure change according to posture was measured. After treatment, the NRSs of dizziness and dysesthesia were decreased, and blood pressure changes according to posture was improved.Conclusion: This case report suggests that Korean medicine treatment, including acupuncture, electro-acupuncture, moxibustion, and herbal medicine, can be an effective treatment for dizziness with postural hypotension.

#6050 TEMPORAL CHANGES IN PLASMA ENDOTHELIN-1 AND BLOOD PRESSURE DURING MAINTENANCE HAEMODIALYSIS

Abstract Background and Aims Endothelin-1 (ET-1) is a potent endothelium-derived vasoconstrictor that plays an important role in the regulation of arterial blood pressure (BP). Elevated levels of plasma ET-1 have been reported in patients with end-stage renal disease (compared with controls), patients on dialysis (compared with non-dialyzed uremic patients), and patients on haemodialysis (compared with peritoneal dialysis). It has been suggested that ET-1 plays a role in BP response to HD; however, the temporal association of changes in ET-1 with changes in BP during the course of an HD session has not been well defined. Moreover, conflicting results have been reported as to the patterns of intradialytic ET-1 changes, with different studies reporting either a decrease, an increase, or no change in ET-1 during HD. The aim of this study was to investigate temporal changes in ET-1 in patients with different intradialytic BP profiles. Methods Data was obtained from a prospective cohort study of 50 maintenance, thrice-weekly HD patients admitted to Brigham and Women's Hospital in Boston, MA, USA. BP was measured before, after, and every 15 min during dialysis using a calibrated ambulatory BP cuff. Blood samples were drawn before dialysis, at 30, 60, and 120 min into HD, and at the end of treatment. Following the exclusion of cases with missing data, shorter dialysis sessions, or very low pre-dialysis BP (below 85/55 mmHg), 42 patients were included in the analysis (17 females, median age 62 years, over 90% diagnosed with hypertension). One HD session was studied in each patient (median ultrafiltration 2.05 L, median duration 232 min). The patients were divided into three subgroups with different patterns of intradialytic systolic blood pressure (SBP): 1) patients with intradialytic hypotension (IDH) defined as: a) drop of SBP to or below 90 mmHg; or b) drop in SBP by at least 30 mmHg associated with at least two hypotension-related symptoms; or c) drop in SBP associated with multiple symptoms requiring intervention; 2) normotensive patients (NT) defined as patients in whom SBP remained between 90 and 130 mmHg for most of the HD session; 3) hypertensive patients (HT) defined as patients in whom the median intradialytic SBP was above 140 mmHg. Results 9 hypertensive patients (HT), 24 IDH patients, and 9 normotensive patients (NT) were identified. In the IDH group, at the end of HD, the median drop in SBP from the pre-HD level was 28 mmHg [25th–75th percentile 10–45 mmHg]. In HT and NT patients, SBP did not change significantly during HD. IDH patients had lower baseline ET-1 (2.2 pg/mL) compared with HT patients (3.4 pg/mL, P = 0.006) but similar compared with NT patients (2.3 pg/mL). ET-1 decreased over the course of dialysis in HT patients (P = 0.02) and NT patients (P = 0.008), whereas no change was observed in IDH patients (P = 0.30). At the end of HD, IDH patients had a similar ET-1 level (2.4 pg/mL) compared with HT patients (2.6 pg/mL) but higher compared with NT patients (1.4 pg/mL, P = 0.004). A moderate negative correlation was found between the dialysis-associated changes in ET-1 and SBP (r = –0.43, P = 0.005) as well as between the baseline ET-1 and baseline SBP in IDH patients (r = –0.42, P = 0.04). Conclusions HD patients may present various patterns of ET-1 changes during HD, which seem to be associated with BP response to HD. In particular, the patterns of ET-1 response to HD may vary among patients categorized as ‘hypertensive’ (the vast majority of patients in our study), who previously were observed to have an intradialytic increase in ET-1. Our results provide a possible explanation as to why previous studies that did not consider intradialytic BP patterns have yielded conflicting results regarding the direction of ET-1 changes during HD.

Classification of blood pressure during sleep impacts designation of nocturnal nondipping.

The identification of nocturnal nondipping blood pressure (< 10% drop in mean systolic blood pressure from awake to sleep periods), as captured by ambulatory blood pressure monitoring, is a valuable element of risk prediction for cardiovascular disease, independent of daytime or clinic blood pressure measurements. However, capturing measurements, including determination of wake/sleep periods, is challenging. Accordingly, we sought to evaluate the impact of different definitions and algorithms for defining sleep onset on the classification of nocturnal nondipping. Using approaches based upon participant self-reports, applied definition of a common sleep period (12 am -6 am), manual actigraphy, and automated actigraphy we identified changes to the classification of nocturnal nondipping, and conducted a secondary analysis on the potential impact of an ambulatory blood pressure monitor on sleep. Among 61 participants in the Eastern Caribbean Health Outcomes Research Network hypertension study with complete ambulatory blood pressure monitor and sleep data, the concordance for nocturnal nondipping across methods was 0.54 by Fleiss' Kappa (depending on the method, 36 to 51 participants classified as having nocturnal nondipping). Sleep quality for participants with dipping versus nondipping was significantly different for total sleep length when wearing the ambulatory blood pressure monitor (shorter sleep duration) versus not (longer sleep duration), although there were no differences in sleep efficiency or disturbances. These findings indicate that consideration of sleep time measurements is critical for interpreting ambulatory blood pressure. As technology advances to detect blood pressure and sleep patterns, further investigation is needed to determine which method should be used for diagnosis, treatment, and future cardiovascular risk.

Effects of Listening to Music During Blood Pressure Check in Primary Care Clinic Settings

Background: Nearly half of adults in the United States (47% or 116 million) have hypertension and only 1 in 4 adults (24%) have their blood pressure under control. In 2020, more than 670, 000 death had hypertension as contributing cause. Listening to sounds of music can lead to reduction in blood pressure which was demonstrated in previous studies. To our knowledge it is the first study done in busy clinical practice with control group evaluating effects of 30 to 50 seconds of listening to music while blood pressure measurement was repeated. Methods:102 consecutive patients seen in primary care clinic from October 4, 2022, through December 14, 2022, were verbally consented to listening to the solo saxophone music while blood pressure measurement was repeated after initial blood pressure measurement revealed systolic blood above 139 millimeters of mercury (mmHg) and diastolic blood pressure above 89 mmHg. They were compared to 100 consecutive control patients, who were presented to clinic at the same time with the same blood pressure elevation parameters for medical assistant blood pressure check and no music intervention was done when blood pressure was repeated. Results:Systolic blood pressure drop in the study group with music intervention was 29.26 mmHg compared to 11.17 mmHg in control subjects ( P value .006) and diastolic blood pressure drop was from 5.99 mmHg to 3.98 mmHg ( P value .03). When separated by gender large systolic blood pressure drop was seen in control group in female patients 30.52 mmHg compared to controls 11.4 ( P value .002) but diastolic blood pressure did not drop significantly 5.43 mmHg to 4.41 mmHg decrease ( P value .184). Male subjects had significant drop in systolic and diastolic blood pressure in study group compared to control: 24.68 mmHg to 10.71 mmHg ( P value .001) and 8 mmHg to 3.71 mmHg ( P value .02), respectively. Conclusion: No significant extra time was required to implement recorded on smart phone music during repeat blood pressure check, which lead to significant improvement in blood pressure levels which could be lifesaving, taking into consideration harmful effects of the elevated blood pressure. This practice could be implemented in many busy primary care clinics and could lead to more relaxing patients’ experience and better blood pressure control. Patients may be advised to consider listening to music as a stress reduction in post pandemic time.

THE CLINICAL RELEVANCE OF ADOPTING DIFFERENT DEFINITIONS OF NIGHT-TIME WHEN ASSESSING NOCTURNAL BLOOD PRESSURE

Objective: For hypertension diagnosis, the current European guidelines recommend to combine repeated office readings with use of out-of-office blood pressure (BP) measurements, like ambulatory blood pressure monitoring (ABPM). The drop of systolic BP during night (dipping behaviour) is one of the most important information offered by 24h ABPM. Night-time is most defined as the time period between 22 and 6 h. However, ambulatory sleep studies have shown that individual sleep behaviour is heterogenous. Shifted, shortened, or prolonged time-in-bed (TIB) may lead to changes in classification of dipping behaviour. Additionally, 20% of the population suffers from insomnia, meaning that during TIB patients are partially awake. We investigated nocturnal BP and dipping classification based on actual sleep time vs. individual TIB vs. 22 - 6 h. Design and method: Thirty adults (9 women, mean age 65.1 ± 9.5 years) underwent ABPM via a validated Boso TM- 2430 device. Simultaneously, motor activity and body position were recorded (SOMNOtouch™ NIBP, SOMNOmedics) allowing determination of individual TIB and actual sleep time. Results: In nine patients (30%), individual TIB was shifted by more than two hours, usually being shifted towards later hours. Mean duration of TIB was 7:18h (2:13h to 10:08h). Mean sleep efficiency in individual TIB was 85.6% compared to 72.4% in standard 22 - 6 h. When defining TIB as 22 - 6 h, prevalence of non-dippers was 63% (n = 19). After analysing the corrected TIB, only 37% (n = 11) remained non-dippers. Individual adoption of TIB led to a change in dipping classification in 27% (n = 8) of patients (in all cases from non-dipper to dipper). Considering only BP values during actual sleep, dipping classification changed in another four patients, two patients changing from non-dipper to dipper while two patients changed from dipper to extreme dipper. Conclusions: In 12 out of 30 patients (40%), BP dipping classification changed when adjusting TIB individually and considering BP values during actual sleep. This study highlights that individually determined TIB and exclusion of wake phases during night is of critical importance for a correct assessment of dipping behaviour and may play an important role in optimizing the clinical management of arterial hypertension.

Vulnerable carotid plaque characteristics on magnetic resonance vessel wall imaging: potential predictors for hemodynamic instability during carotid artery stenting.

This cross-sectional study sought to explore the possible risk factors assessed with magnetic resonance (MR) vessel wall imaging for hemodynamic instability (HI) during carotid artery stenting (CAS). Patients with carotid stenosis who were referred for CAS from January 2017 to December 2019 were recruited and underwent carotid MR vessel wall imaging. The vulnerable plaque features, including lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), fibrous cap rupture, and plaque morphology, were evaluated. The HI was defined as a drop of systolic blood pressure (SBP) of ≥30 mmHg or the lowest SBP measurement of <90 mmHg after stent implantation. The carotid plaque characteristics were compared between the HI and non-HI groups. The association between carotid plaque characteristics and HI was analyzed. A total of 56 participants (mean age 68.7±8.3 years; 44 males) were recruited. Patients in the HI group (n=26, 46%) had a significantly greater wall area [median 43.2 (IQR, 34.9-50.5) vs. 35.9 (IQR, 32.3-39.4) mm2; P=0.008], total vessel area (79.7±17.2 vs. 69.9±17.3 mm2; P=0.03), prevalence of IPH (62% vs. 30%; P=0.02), prevalence of vulnerable plaque (77% vs. 43%; P=0.01), and volume of LRNC [median 344.7 (IQR, 155.1-665.7) vs. 103.1 (IQR, 53.9-162.9) mm3; P=0.001] in carotid plaque compared to those in non-HI group (n=30, 54%). Carotid LRNC volume (OR =1.005, 95% CI: 1.001-1.009; P=0.01) and presence of vulnerable plaque (OR =4.038, 95% CI: 0.955-17.070; P=0.06) were significantly and marginally associated with HI, respectively. Carotid plaque burden and vulnerable plaque features, particularly a larger LRNC, might be effective predictors for HI during the CAS procedure.

HIGH SALT INTAKE DID NOT DIMINISH BENEFICIAL EFFECT OF RENAL DENERVATION ON BLOOD PRESSURE, KIDNEY FUNCTION AND METABOLIC PROFILE - CROATIAN REAL-LIFE STUDY

Objective: Last trials clearly documented and confirmed the efficacy of renal denervation (RDN) on decrease of blood pressure (BP). Our aim was to analyze the effects of RDN beyond BP lowering in truly resistant hypertensive patients in real-life conditions. Design and method: Out of 31 truly resistant patients whose secondary forms of hypertension were ruled out and were enrolled into the Croatian Spyral RDN registry, 18(10 m, 8 w, average age 49.3) were eligible for analysis. Office BP, ABPM, central BP and PWV were measured with Omron M6, Mobilograph and Sphygmocor devices, respectively. Albuminuria and salt intake were determined from 24-h urine samples, eGFR using the CKD Epi equation. Sympathetic/parasympathetic activity was measured with an ANX-3.0 ANSAR device. All RDN procedures(Spyral Medtronic) were done by one physician (average number of ablation spots was 41/procedure). Patients were examined day before and that day, 1,3,6, and 12 months after the RDN. Reponse was drop of office systolic BP by 10 mmHg or more 6 months after RDN. There were no differences in the RDN procedure between responders and non-responders. Results: Office and ABPM values dropped the day after RDN and remained significantly lower at the end of the follow-up (6.5/-5.5 and -16.2/9 mmHg, respectively). The effect of RDN on BP was not abolished with high salt intake(15.5 g/day at the end of follow up). eGFR remained stable, and even slight improvement was observed at the end of follow-up(+8.4 ml/min/1.72m2); albuminuria significantly decreased (-115 mg/day). All metabolic parameters (lipids, uric acid) improved at the end of follow-up. LFa/RFa decreased the day after RDN and remained lower during the follow-up period. After RND central systolic BP and Aix decreased more in responders than in non-responders (-12.8 vs. -7.3; -7 vs. -2.6) while PP amplification was improved in responders (1.22 to 1.33) but decreased in non-responders (1.33 to 1.25). Conclusions: In real-life circumstances, BP significantly decreased after RDN despite large salt ingestion. eGFR and albuminuria improved as well as metabolic parameters at the end of follow-up and all of the beneficial changes run in parallel with observed decrease in sympathetic activity.

BLOOD PRESSURE VARIABILITY AND CIRCADIAN PATTERN AFTER RENAL DENERVATION - CROATIAN REAL-LIFE STUDY

Objective: Recent trials confirmed the lowering effect of renal denervation (RDN) on blood pressure (BP). We aimed to analyze the impact of RDN on BP variability and circadian rhythm. Design and method: Out of 31 truly resistant patients whose secondary forms of hypertension were ruled out and were enrolled into the Croatian Spyral RDN registry, 18 (10 m, 8 w, average age 49.3) were eligible for analyses. Office BP, ABPM, central BP, and PWV were measured with Omron M6, Mobilograph, and Sphygmocor devices. Sympathetic/parasympathetic activity was measured with ANX-3.0 ANSAR device. All RDN procedures (Spyral Medtronic) were done by one physician (average number of ablation spots was 41/procedure). Patients were examined the day before and that day, 1,3,6, and 12 months after the RDN. The response was a drop of office systolic BP by 10 mmHg or more 6 months after RDN. There were no differences in the RDN procedure between responders and non-responders. Results: Office and ABPM values dropped the day after RDN and remained significantly lower at the end of the follow-up (6.5/-5.5 and -16.2/9 mmHg, respectively). We failed to find changes in BP variability (SD) after RDN. However, a significant decrease in morning BP surge was observed immediately the day after RDN (-12.4) and was even lower at the end of the follow-up (-18.8 mmHg). Substantial number of patients who had an abnormal nocturnal BP pattern became dippers. Central systolic BP and PWV decreased (-6.3 mmHg and -0.72 m/s, respectively). LFa/RFa decreased the day after RDN and reminded lower during the follow-up period. After RDN morning BP surge remained stable and normal in responders; however, in non-responders, it decreased immediately after RDN (-21.2) and remained lower during the follow-up till the last visit (-33.3). Conclusions: Significant improvements in circadian rhythm and several parameters of central hemodynamics were observed after RDN indicating that RDN might be considered as a pathway to the complete, so-called perfect 24-hour BP control. Observed beneficial effects run in parallel with the observed decrease in sympathetic activity. Importantly, even in non-responders, RDN had a beneficial effect on morning BP surge.

EXERCISE RELATED HYPOTENSIVE EFFECT IN A CARDIAC REHABILITATION PROGRAM AS A POSSIBLE PROGNOSTIC MARKER OF CARDIOVASCULAR RISK

Objective: There are some studies that analyze the correlation between the magnitude of the hypotensive effect after exercise and the long-term cardiovascular benefit. However, this same effect in a cardiac rehabilitation program (CRP) is unknown. The aim was meausuring the benefit of this effect in patients undergoing a cardiac rehabilitation program. Design and method: We analyzed 19 patients who completed a CRP for 3 months (2 weekly sessions of cardiovascular and resistance exercise), in the period between September 2021 and September 2022, after an Acute Coronary Syndrome or hospitalization for Decompensated Heart Failure. In each rehabilitation session, the blood pressure values were evaluated before the beginning of the exercise and after (1st minute and 5th minute of recovery). The effect was compared in two different moments of the program - 1st and 12th session - having defined as main “outcome” a magnitude of higher systolic blood pressure drop in the 12th compared to the 1st session. After completion of the CRP, all patients included in the study were given two validated questionnaires to assess insomnia (“Insomnia Severity Index – ISI”) and the impact of the current illness on quality of life (EQ-5D). Results: Regarding the patients included, the clinical and sociodemographic characteristics are described in table 1. Comparing males and females, using a T-student analysis, there was a statistically significant difference in relation to a greater systolic hypotensive effect in the male group compared to the female group (91.7% vs 40.0%, p &lt; 0.05) – table 2. Regarding the analysis of the impact on quality of life, the total number of patients with improvement in the hypotensive effect of systolic blood pressure showed statistically significant lower values in the questionnaire (EQ5D) – 6.8±1.3 vs 9.0±1.0 (p&lt;0.05) and higher in the score of insomnia 10.7 ± 9.0 vs. 3.9 ± 4.1 - table 2. Conclusions: The systolic hypotensive effect of exercise, observed in the rehabilitation program of the current study, is associated with better rates of insomnia and impact on quality of life. The authors intend to confirm this hypothesis in the longitudinal evaluation of future events.

Exercise systolic blood pressure indexed to work rate predicts future risk of incident stroke

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): 1) The CircM network, Linköping University 2) The Swedish Stroke Association. Background Hypertension is a major risk factor for stroke. Exaggerated peak systolic blood pressure (SBP) during exercise is associated with increased risk of hypertension in normotensive subjects, whereas low, rather than high, peak exercise SBP predicts cardiovascular and all-cause mortality. Purpose We aimed to study the risk of incident fatal and non-fatal stroke in relation to absolute and work rate indexed exercise SBP, in patients referred for exercise testing. Methods We cross-linked clinical data from 14,428 bicycle ergometer exercise tests with data from the National Patient Registry and the Registry of Prescribed Medications up until December 2019. Subjects with a history of cerebrovascular disease were excluded, as well as subjects with submaximal tests, a drop in SBP during exercise, or with missing SBP data at the end of exercise. Baseline comorbidity was defined as diagnosis of, or treatment for, hypertension, diabetes, hyperlipidemia, and coronary artery disease (CAD). Work rate indexed SBP response (SBP/Watt-slope) was calculated as the increase in SBP during exercise divided by the increase in work rate. We applied Cox regression to calculate hazard ratios (HR) with 95% confidence intervals (95% CI) for the risk of incident stroke in association to peak SBP and the SBP/Watt-slope. We used absolute values as well the upper limit of normal (≥2 Z scores) of a recently published reference population, with reference equation including age, sex, SBP at rest, Wmax (for SBP peak only) and height (for SBP/W-slope only). Analyses were adjusted for age, sex, and baseline comorbidity. Results In total, 7,946 subjects (54% male, age 55±13 years) were included, with baseline comorbidity of hypertension (28%), diabetes (7%), hyperlipidemia (16%), and CAD (13%). During a median follow-up of 8.4 years (inter quartile range 5.8-11.5), 3.1% developed ischemic (2.2%) or hemorrhagic (1.0%) stroke. There were positive associations to future stroke with absolute peak exercise SBP (HR: 1.08 [1.03 – 1.13] per 10 mmHg increase) and with SBP/Watt-slope (HR: 1.09 [1.05 – 1.14] per 1 mmHg/10 Watt increase), but not after adjustment for sex, age and baseline comorbidity. However, having a SBP/Watt-slope ≥2 Z scores was associated with an increased risk for stroke (HR: 1.56 [1.08 – 2.25)] after adjustment for baseline comorbidity, whereas an adjusted SBP peak ≥2 Z scores was not (HR: 0.62 [0.32 – 1.21]). Conclusion A workload-indexed SBP response (SBP/Watt-slope) above the upper limit of normal may help to identify subjects with no history of cerebrovascular disease at risk of future stroke. In contrast, the absolute exercise SBP response to exercise does not add substantial information to the risk estimation above age, sex, and baseline comorbidity.

Influence of cardiac rehabilitation on blood pressure in patients with coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction One of the main goals of cardiac rehabilitation is the optimalisation of the cardiovascular risk to prevent the progression of heart disease. Arterial hypertension is one of the most important risk factors that however remains often undertreated. Purpose We analysed the patient data from our cardiac rehabilitation center over the last 3 years to assess the evolution in exercise capacity and blood pressure before and after the rehabilitation program. Methods Patients diagnosed with coronary artery disease (acute coronary syndrome, elective percutaneous coronary intervention or coronary artery bypass graft) between October 2019 and September 2022 were retrospectively included if they followed at least 50% of the total training sessions. Mean blood pressure at the beginning and end of the cardiac revalidation was derived from the mean values of the first 5 sessions and of the last 5 sessions. A change in 5 mmHg was investigated. Results The study enrolled 378 patients, of which 17 % female, with a mean age of 65.3 ± 9.68 years. Every patient followed an average of 42 training sessions (over &amp;lt; 6 months) and 149 patients (41%) had a systolic blood pressure drop of at least 5 mmHg. This decrease was more prevalent in men (133 of 149 (89%) in this group vs. 171 of 218 (78%) in the group with no difference in blood pressure (p &amp;lt;0,05)). These 149 patients had higher systolic blood pressure at the beginning of the sessions (mean systolic blood pressure of 132 ± 9,64 mmHg, p &amp;lt;0,05) and a significant difference in the number of patients who stopped smoking (86 of 129 (58%) vs. 98 of 218 (45%) (p&amp;lt; 0.05)) and were more likely to have no acute coronary syndrome (i.e. more elective procedures) (107 of 149 (72%) vs. 133 of 218 (61%) (p &amp;lt;0,05)). There was no difference in the antihypertensive treatment between the 2 groups at the beginning of the cardiac rehabilitation. The evolution in exercise capacity between the beginning and the end of the rehabilitation sessions showed in both groups together an increase in exercise capacity of 3ml/min/kg in peak VO2 (=18% improvement in peak VO2). In the group with a decrease of 5 mmHg in blood pressure, the exercise capacity improved on average with 1,6 METS (32%) vs. 1,1 METS (19%) in the group with no change in blood pressure. In other words, a positive trend could be observed for a drop in the systolic blood pressure with at least 5 mmHg in relation with an improvement in exercise capacity (p=0,06). The mean systolic blood pressure for all patients at the end of the cardiac rehabilitation was 124 ± 8.36 mmHg. Conclusion Following cardiac rehabilitation in patients with coronary artery disease, a decrease in blood pressure was seen in 41% of the participants. This decrease was mainly seen in males that stopped smoking and had no acute coronary disease. A trend towards a significant relation between improved exercise capacity (in METS) and improved blood pressure was observed.

How to initiate aspirational embolectomy program for pulmonary embolism: single centre initial experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Recent advances in percutaneous mechanical thrombectomy provide lytic-free methods for treatment of pulmonary embolism (PE). Although guidelines recommend aspirational embolectomy only for high-risk PE patients with contraindication to or failed fibrinolysis, the method is currently being used in treatment of intermediate-high risk PE patients. We present our initial experiences with large bore percutaneous aspirational embolectomy catheter. Methods Patients with intermediate-high risk PE and at least one clinical feature (persistent hypoxemia, tachycardia, hypotension without shock, or dyspnoea on minimal exertion) were considered eligible for the method. Positive high-sensitive troponin was obligatory. PE was diagnosed by computed tomography. Echocardiography and doppler ultrasound of lower limbs venous system were performed upon admission. All procedures were performed by interventional cardiologist in cardiology suite. Light sedation with dexmedetomidine and/or midazolam was used. Ultrasound guided right or left femoral approach was used in all patients. A 7F balloon tipped catheter was used to cross the tricuspid and pulmonary valves and engage pulmonary artery (PA). After exchanging for 6F pigtail catheter an angiography was performed. Then, via multipurpose 6F catheter an extra-stiff wire was introduced distal to the thrombus. Over the wire a 20F or 24F aspirational embolectomy catheter was placed in front of the thrombus followed by the aspiration with 60 ml syringe. Up to 10 aspirations were allowed. Unfractionated heparin was used for periprocedural anticoagulation followed by apixaban or rivaroxaban as soon as hemostasis was achieved. Patients outcomes were recorded prospectively. Results From March to October 2022 a total of 10 patients were treated with aspirational embolectomy (6 females, median age 68.5 years (interquartile range 53.25-74)). Only the first case was performed with 20F catheter. In 9 patients sheathless approach was used due to material unavailability. In one case switching to left-side access was required due to inability to introduce the catheter in common femoral vein. In two cases a "lollipop" phenomenon occurred, one of which was a thrombus-in-transit (TIT) case. This case was complicated with TIT fragmentation on exit and re-embolism with circulatory arrest requiring veno-arterial extracorporeal circulatory support. Procedural success was achieved in all cases (in TIT patient two procedures were needed). All patients reported improvements in dyspnea levels. One patient required oxygen supplementation beyond 24h (TIT patient). Average PA systolic and diastolic blood pressure drop was 24.3±11.0 and 12.3±4.9 mmHg. Nine patients were alive at discharge, while TIT patient was still requiring hospitalisation. Conclusion Aspirational embolectomy can provide sufficient drop in PA pressures and symptom relief. Randomised trials are needed to determine the long term outcomes of the procedure.

Relationship Among Surgical Fibroid Removal, Blood Pressure, and Biomarkers of Renin-Angiotensin-Aldosterone System Activation.

Fibroids are common benign neoplasms in women and have recently been associated with cardiometabolic risk factors including hypertension. The objective of this study is to determine whether fibroid removal is associated with lower blood pressure (BP). We performed a single-center IRB-approved retrospective chart review of patients undergoing hysterectomy/myomectomy for fibroids and other benign gynecological surgical procedures from January 2016 to December 2019, and a prospective cohort study of patients undergoing hysterectomy/myomectomy for fibroids from August 2021 to April 2022. We measured demographic factors, preoperative/postoperative BP on day of surgery and at postoperative visit. In our prospective cohort, to evaluate for alterations in the renin-angiotensin-aldosterone system (RAAS) induced by fibroid removal, we measured serum angiotensin-II (Ang-II) and angiotensin converting enzyme (ACE) levels pre- and post-operatively. In our retrospective study (n = 294; mean age 41.9 ± 10.6, 43.5% Black, 50% with fibroids), we found that compared to patients without fibroids, patients with fibroids had significantly elevated systolic BP (SBP) (pre-op: p = 0.0005; post-op: p = 0.02), although this did not hold after adjusting for covariates. Fibroid removal was associated with a marginally albeit not statistically significant decrease in SBP (p = 0.062). In our prospective study (n = 11), there was a significant decrease in SBP following fibroid removal, but no change in diastolic BP (p = 0.019, p = 0.18, respectively). Serum levels of Ang-II and ACE were not significantly altered following surgical fibroid removal (p = 0.72, p = 0.81, respectively). Altogether, these findings suggest that fibroids are not independently associated with BP or RAAS activation, but do suggest that fibroid removal may be associated with a small drop in SBP.

Orthostatic hypotension in school children and youth

&lt;b&gt;Introduction.&lt;/b&gt; Haemodynamic disturbances occurring solely in a standing position, consisting of a simultaneous drop in systolic and diastolic blood pressure and an increased pulse rate are defined as orthostatic hypotension (OH). &lt;b&gt;Aim.&lt;/b&gt; To determine the incidence of OH in school population and to provide its clinical characteristics. To determine the influence of the applied treatment on the arterial blood pressure, well-being, learning results and sickness absence. &lt;b&gt;Materials and methods.&lt;/b&gt; The study involved 1208 students, aged 7–18, and 400 students referred by the Psycho-Educational Counselling Centre who reported a variety of health and school problems. Medical histories guided to detect faintness and syncope were collected from all the studied patients. Crampton test (a screening test) was performed, and when the results were incorrect – Schellong’s orthostatic test (a diagnostic test). &lt;b&gt;Results and discussion.&lt;/b&gt; A significant decrease in the arterial pressure amplitude with a simultaneously increased pulse rate revealed in Schellong’s test were assumed to be diagnostic and differential criteria with common hypotension. Based on these criteria, medical histories and examinations, OH was diagnosed: in 71 cases (5.8%) in the randomly chosen group and in 39 (9.8%) students referred by the PsychoEducational Counselling Centre. Girls aged 13–15 (8.7%), of an asthenic body structure type, formed the most numerous group. Long-term treatment was devised for the students diagnosed with OH, mainly focusing on changing their lifestyles and intensifying their physical activities. The observation period lasted 3–4 years, the longest – 10 years. Among the adults, 9 people manifested OH, which may testify to constitutional aetiology (family) of the disease. &lt;b&gt;Conclusions.&lt;/b&gt; OH is a significant problem, especially in the case of girls at puberty. The obtained results point to a need for co-operation between a physician, teacher and parents.

Abstract P436: Objective Physical Activity and Orthostatic Hypotension in Older Adults: The STURDY Trial

Introduction: Orthostatic hypotension (OH) is prevalent in older adults and associated with poor health outcomes. Physical activity (PA) may attenuate the risk of OH, but evidence of the association between daily volume and patterns of objectively measured PA and OH is lacking. Hypothesis: Lower daily volume and higher fragmentation of PA are associated with greater risk of OH. Methods: We included 196 participants (age ≥70) of the Study To Understand Fall Reduction and Vitamin D in You (STURDY) trial who wore an accelerometer for 7 days at their baseline visit and completed a supine-to-standing OH assessment at 2-year follow-up. We defined OH as a 20 mm Hg drop in systolic blood pressure or 10 mm Hg drop in diastolic blood pressure 3 minutes after changing from supine to standing position. Using accelerometry, daily total activity counts (TAC; counts/day) and time spent active (mins/day) were used to measure volume of daily PA. Active-to-sedentary transition probability (ASTP) was calculated as the reciprocal of the average PA bout duration to measure PA fragmentation. Multivariable robust Poisson regression estimated the risk ratio between baseline PA and OH after 2-years of follow up. Results: Among 196 participants, 12.2% of participants had OH after 2-years of follow up; 62.2% were male, and mean baseline age was 76.4 (SD=5.2). In this prospective analyses, lower daily activity (lowest vs highest tertile of TAC: RR = 6.49, 95% CI: 2.15-19.58; lowest vs highest tertile of time spent active: RR= 4.30, 95% CI:1.55-11.92) and higher fragmentation (highest vs lowest tertile of ASTP: RR = 5.36, 95% CI: 1.57-18.34) of PA were associated with higher risk of OH after 2 years (Figure) . Conclusions: Both lower daily activity volume and higher fragmentation of PA were associated with increased risk of OH in older adults over follow-up. Longitudinal studies to assess whether changes in PA volume or fragmentation alter the risk of OH should be explored.

Case Studies in Physiology: Is blackout in breath-hold diving related to cardiac arrhythmias?

Syncope or "blackout" (BO) in breath-hold diving (freediving) is generally considered to be caused by hypoxia. However, it has been suggested that cardiac arrhythmias affecting the pumping effectivity could contribute to BO. BO is fairly common in competitive freediving, where athletes aim for maximal performance. We recorded heart rate (HR) during a static apnea (STA) competition, to reveal if arrhythmias occur. Four male freedivers with STA personal best (PB) of 349 ± 43 s, volunteered during national championships, where they performed STA floating face down in a shallow indoor pool. A non-coded Polar T31 chest strap recorded R-R intervals and a water- and pressure-proof pulse oximeter arterial oxygen saturation. Three divers produced STA near their PB without problems, whereas one diver ended with BO at 5 min 17s, which was 12 s beyond his PB. He was immediately brought up by safety divers and resumed breathing within 10 s. All divers attained similar lowest diving HR (47 ± 4 beats/min), but HR recordings displayed a different pattern for the diver ending with BO. After a short tachycardia, the three successful divers developed bradycardia, which became more pronounced during the second half of the apnea. The fourth diver developed pronounced bradycardia earlier, and at 2.5 min into the apnea, HR started alternating between approximately 50 and 140 beats/min, until the diver lost consciousness. At resumed breathing, HR returned to baseline. Nadir oxygen saturation was similar for all divers. We speculate that arrhythmia could have contributed to BO, by lowering stroke volume leading to a systolic blood pressure drop, affecting brain perfusion.NEW & NOTEWORTHY Heart rate during prolonged breath-holding until the point of loss of consciousness has not previously been published. The recordings show that blackout was preceded by a period of persistent alterations in R-R intervals, whereby an ectopic beat followed every normal heartbeat. Explanations for this deviating heart rate pattern could be either premature atrial contractions or premature ventricular contractions following every atrial beat, i.e., bigeminy, which could have compromised cardiac pumping function and caused/contributed to blackout.

COVID-19 Monoclonal Antibody Administration Linked to Drop in Blood Pressure: A Retrospective Cohort Study.

This study reports on hemodynamic changes observed during monoclonal antibody (mAb) administration for patients with severe acute respiratory distress syndrome-coronavirus-2. Findings from this study may have implications for patient safety. Hemodynamic data from 705 patients who received subcutaneous or intravenous mAb therapy during February 1, 2021-September 30, 2021 in clinics in Arkansas, USA were reviewed. Descriptive statistics and paired t-tests were used to assess blood pressure before and after treatment. Results showed 386 (54.7%) patients experienced a drop in systolic blood pressure (SBP) or diastolic blood pressure (DBP) >5 mmHg. The average drop in SBP was 9.2 mmHg for those patients. Two hundred and eighty-one (39.9%) patients experienced a drop in SBP of >10 mmHg with an average drop in SBP of 12.0 mmHg. The Emergency Use Authorization for mAb does not list hypotension as a contraindication for treatment. Our findings suggest mAb therapy should be administered in an environment where vitals are monitored.

Individually adjusted absolute blood volume feedback control: A promising solution for intradialytic hypotension.

Intradialytic hypotension (IDH) remains one of the most frequent complications associated to hemodialysis (HD), frequently triggered by a reduction in absolute blood volume (ABV) not compensated by vascular refilling. A recently developed dilutional method allows routinary measurement of ABV and, by a simple algorithm, may turn blood volume monitor (BVM) guided UF (ultrafiltration) biofeedback into an ABV control, automatically adjusting UF rate to maintain ABV above a preset threshold. The aim of this study is to identify an individual critical ABV threshold and test the ability of an ABV feedback control to avoid IDH. We studied 24 patients throughout three consecutive midweek HD treatments. ABV and blood pressure (BP) were measured every 30 min and anytime the patient referred any symptoms to identify each patient's critical ABV (ABV at the time of hypotension). A fixed bolus dilution approach at the start of HD was used to calculate ABV. Then, patients were followed through three additional HD treatments and IDH development was analyzed. Seventy-one treatments performed in 24 patients. ABV monitoring showed a constant decrease as HD treatment progressed. Thirteen IDH events were observed in eight different patients, with a mean systolic BP drop in IDH treatments of 37.38 ± 4.31 mmHg and a mean adjusted ABV at hypotension of 71.07 ± 14.88mL/kg. Critical ABV was individually set in patients prone to IDH. As expected, ABV feedback control successfully maintained ABV over preset critical ABV. IDH events were avoided in 21 out of 22 treatments performed. ABV drop was successfully reduced, as well as SBP drop (despite similar UF than prior to ABV feedback control implementation). ABV feedback control avoided IDH in 21 out of 22 treatments performed by maintaining blood volume above critical ABV, significantly reducing ABV variations without compromising prescribed UF.

Blood pressure changes during routine transthoracic echocardiography

BackgroundIncreased afterload affects many of the flow dependent metrics assessed during transthoracic echocardiography (TTE) especially in the evaluation valvular disease. A single timepoint blood pressure (BP) may not accurately reflect the afterload present at the time of flow-dependent imaging and quantification. We assessed the magnitude of change in BP at discrete timepoints during routine TTE. MethodWe conducted a prospective study where participants underwent automated BP measurement while undergoing a clinically indicated TTE. The first reading was obtained right after the patient lay supine and subsequent readings were taken at 10-min intervals during image acquisition. ResultWe included 50 participants (66% were male, with a mean age of 64 years). After 10 min, 40 (80%) participants had a drop in systolic BP of >10 mmHg. Compared to the baseline, there was a significant drop in systolic BP (mean decrease 20.0 ± 12.8 mmHg; P < 0.05), and diastolic BP (mean decrease 15.7 ± 13.2 mmHg; P < 0.05) at 10 min. The systolic BP remained different from the baseline value throughout the duration of the study (average decrease from baseline to study end was 12.4 ± 16.0 mmHg, p < 0.05). ConclusionBP recorded just prior to TTE does not accurately reflect the afterload present during most of the study. This finding has important implications for valvular heart disease imaging protocols that incorporate flow dependent metrics, where the presence or absence of hypertension may lead to under- or over-estimation of disease severity.

The role of plasma volume and fluid overload in the tolerance to ultrafiltration and hypotension in hemodialysis patients

Introduction Ultrafiltration (UF) in hemodialysis (HD) patients is accompanied by irregular falls in plasma volume (PV) and blood pressure (BP). Methods We obtained in 321 patients (large cohort), body weight (BW), BP, samples of blood to determine hemoglobin (Hb) and hematocrit (Ht), Pre and Post HD. We estimated the % variation of the PV and its effect on the BP. In a small cohort of 38/321 patients, arterial blood was drawn Pre and Post HD and at 2, 48, and 72 h to determined Hb and Ht and % variation of the PV. Bio-impedance spectroscopy (BIS) was performed, in the same times, to estimate: dry weight (DW), total body water (TBW), extracellular water (ECW), Fluid overload (FO) and phase angle (PhA). Results We divided our large cohort in two groups. The Hypotensive group with a fall equal or more than 20 mmHg (96/321,30%) and Normotensive group with a drop equal or less than 19 mmHg (225/321,70%). The UF was 2.73 ± 0.72 L in the Hypotensive group and 2.53 ± 0.85 L in the Normotensive group (p < 0.0001). The % PV was −11.7 ± 17.8 in the Hypotensive group and −8.53 ± 10.07 in the Normotensive group (p < 0.0001). The systolic blood pressure (SBP) correlated with the % change of the PV (r = -0.232; p < 0.0001). The FO was contrasted with the % of water removed by UF (r = -0.890; p < 0.0001). Conclusion The SBP drop was secondary to the fall in the PV after UF. The FO was irregular and modulates in part the fall in the SBP.