Lower Diastolic Pressure Research Articles

Hydrochlorothiazide--Teaching an Old Drug New Tricks.

Hydrochlorothiazide--Teaching an Old Drug New Tricks.

Stroke Volume Adjusted to Afterload for Assessment of Cardiac Performance in Patients with Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Objectives: The aim of this study was to evaluate the relationship between valvular resistance and stroke volume (SV) and to assess SV adequacy to afterload in patients with severe aortic stenosis (AS) and normal left ventricular ejection fraction (LVEF). Methods: We assessed clinical characteristics and echocardiographic parameters in 44 patients with isolated severe AS and preserved LVEF. LV end-diastolic pressure (LVEDP) and LV mean diastolic pressure (LVMDP) were measured by cardiac catheterization. SV values were plotted in relation to valvular resistance. Patients were divided into 2 groups, with an SV that was higher (group 1) or lower (group 2) than the SV calculated by a regression equation using valvular resistance as the dependent variable. Results: At the same degree of valvular stenosis, the patients in group 1 exhibited better contractility as assessed by global longitudinal strain (p < 0.05), higher peak (p < 0.01) and mean gradient (p < 0.05), indexed SV (p < 0.001) and transvalvular flow (p = 0.01) than the patients in group 2, who had a higher heart rate (HR, p < 0.05), shorter ejection time (ET, p < 0.05) and more elevated LVEDP (p < 0.05) and LVMDP (p < 0.05). Conclusion: The presence of inappropriately decreased SV relative to afterload in patients with severe AS and normal LVEF was associated with lower contractility, higher HR, shorter ET and elevated LV diastolic pressure, which suggest failed hemodynamic adaptation to afterload.

Distortions in Sensitivity of Carotid Baroreceptor Reflexes in Rabbits Following Consumption of Two Forms of Palm Oil Diets

Aim: Long term consumption of dietary oils has been implicated in the etiology of hypertension. This study seeks to compare the effects of long term consumption of fresh palm oil (FPO) and thermoxidized palm oil (TPO) on baroreceptor reflex sensitivity (BRS), which is responsible for short term regulation of blood pressure. Methodology: The design of this study involved the use of eighteen, male, five month old New Zealand rabbits weighing 750 – 1000 g. They were divided into three groups (n = 6) as follows; control group (received normal animal feed only), FPO diet – fed group (received animal feed mixed with fresh palm oil in the ratio 85:15, respectively) and TPO diet – fed group (received animal feed mixed with thermoxidised palm oil in the ratio 85:15, respectively). The animals were fed for 6 months, after which they were used for the various experiments. Results: Mean daily food and water intake in FPO and TPO fed groups was significantly (p<0.001) lower compared with control. Heart rate for FPO group was significantly higher than the control Original Research Article Ani et al.; BJMMR, 8(3): 245-255, 2015; Article no.BJMMR.2015.445 246 (p<0.001) and TPO (p<0.01) group. Basal systolic and diastolic blood pressures were significantly higher in TPO group than in the FPO and control (p<0.05) group. The FPO group also had a significantly lower basal systolic (p<0.01) and diastolic pressure (p<0.001) than the control group. The basal pulse pressure was significantly lower in the FPO group than the control (p<0.001) and the TPO group (p<0.01). The mean arterial pressure (MAP) for TPO group was significantly higher (p<0.001) than that of control and FPO groups. The baroreflex sensitivity for FPO group was significantly reduced compared with control (p<0.01) and TPO group (p<0.05). The TPO group showed a significantly lower (p<0.01) baroreflex sensitivity, compared with control. Conclusion: This study observed that chronic consumption of both fresh and thermoxidised palm oil diets caused a significant reduction in carotid baroreceptor reflex sensitivity. However, reduction in BRS was more in fresh palm oil – diet fed group, than the thermally oxidized palm oil diet – fed.

Blood Pressure and Heart Rate Alterations through Music in Patients Undergoing Cataract Surgery in Greece.

INTRODUCTIONMusic has been proposed as a safe, inexpensive, nonpharmacological antistress intervention. The purpose of this study was to determine whether patients undergoing cataract surgery while listening to meditation music experience lower levels of blood pressure and heart rate.METHODSTwo hundred individuals undergoing cataract surgery participated in the study. Hundred individuals listened to meditation music, through headphones, before and during the operation (intervention group) and 100 individuals received standard care (control group). Patients stress coping skills were measured by the Sense of Coherence Scale (SOC Scale). Systolic and diastolic blood pressure and heart rate were defined as outcome measures.RESULTSAccording to the SOC Scale, both groups had similar stress coping skills (mean score: 127.6 for the intervention group and 127.3 for the control group). Before entering the operating room (OR) as well as during surgery the rise in systolic and diastolic pressures was significantly lower in the intervention group (P < 0.001). Among patients receiving antihypertensive therapy, those in the intervention group presented a lower increase only in systolic pressure (P < 0.001) at both time recordings. For those patients in the intervention group who did not receive antihypertensive treatment, lower systolic blood pressure at both time recordings was recorded (P < 0.001) while lower diastolic pressure was observed only during entry to the OR (P = 0.021). Heart rate was not altered between the two groups in any of the recordings.CONCLUSIONSMeditation music influenced patients’ preoperative stress with regard to systolic blood pressure. This kind of music can be used as an alternative or complementary method for blood pressure stabilizing in patients undergoing cataract surgery.

Serum bicarbonate may independently predict acute kidney injury in critically ill patients: An observational study.

To explore whether serum bicarbonate at admission to intensive care unit (ICU) predicted development of acute kidney injury (AKI). We studied all patients admitted to our ICU over a 2 year period (February 2010 to 2012). The ICU has a case mix of medical and surgical patients excluding cardiac surgical, trauma and neurosurgical patients. We analysed 2035 consecutive patients admitted to ICU during the study period. Data were collected by two investigators independently and in duplicate using a standardised spread sheet to ensure accuracy. Ambiguous data were checked for accuracy where indicated. AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Patients were divided into two groups; patients who developed AKI or those who did not, in order to compare the baseline characteristics, and laboratory and physiologic data of the two cohorts. Regression analysis was used to identify if serum bicarbonate on admission predicted the development of AKI. Of 2036 patients 152 (7.5%) were excluded due to missing data. AKI developed in 43.1% of the patients. The AKI group, compared to the non-AKI group, was sicker based on their lower systolic, diastolic and mean arterial pressures and a higher acute physiology and chronic health evaluation (APACHE) III and SAPS II scores. Moreover, patients who developed AKI had more co-morbidities and a higher proportion of patients who developed AKI required mechanical ventilation. The multi-regression analysis of independent variables showed that serum bicarbonate on admission (OR = 0.821; 95%CI: 0.796-0.846; P < 0.0001), APACHE III (OR = 1.011; 95%CI: 1.007-1.015; P < 0.0001), age (OR = 1.016; 95%CI: 1.008-1.024; P < 0.0001) and presence of sepsis at ICU admission (OR = 2.819; 95%CI: 2.122-23.744; P = 0.004) were each significant independent predictors of AKI. The area under the ROC curve was 0.8 (95%CI: 0.78-0.83), thereby demonstrating that the predictive model has relatively good discriminating power for predicting AKI. Serum bicarbonate on admission may independently be used to make a diagnosis of AKI.

Epidural fentanyl for the prevention of autonomic dysreflexia in chronic spinal cord injury patients undergoing urological procedures

Background Spinal cord injury (SCI) patients with lesions above T6 are susceptible to develop autonomic dysreflexia (AD) during surgery. The aim of this study was to investigate the efficacy of epidural fentanyl for the prevention of AD in chronic SCI patients undergoing urological procedures. Patients and methods Thirty chronic SCI patients scheduled for cystoscopy were randomized to receive epidural anesthesia using 5 ml bupivacaine 0.25% with fentanyl 50 µg in 10 ml saline (group F) or 5 ml bupivacaine 0.25% in 10 ml saline (group C). Results There was a significant decrease in the blood pressure and the heart rate 20 min after epidural anesthesia in both groups, with significantly lower systolic and diastolic blood pressures in group F compared with group C; however, the systolic and diastolic blood pressure showed a significant increase, with a decrease in the heart rate, in group C compared with group F during bladder manipulation (25 min). Six patients in group C showed manifestations of autonomic dysreflexia, with an increase in the systolic blood pressure more than 160 mmHg and diastolic blood pressure more than 100 mmHg in three of them. Conclusion The addition of fentanyl to epidural bupivacaine succeeded in preventing AD manifestations in chronic SCI patients undergoing cystoscopy.

Abstract 12440: Does Low Diastolic Blood Pressure Contribute to the Risk of Recurrent Cardiovascular Disease Events? The Framingham Heart Study

Background: The clinical significance of low diastolic blood pressure (DBP) as a risk for recurrent cardiovascular disease (CVD) events in persons with isolated systolic hypertension (ISH) is controversial. Methods: We examined risk for recurrent CVD events in 791 individuals (age 75 years, 47% female, mean follow-up time: 8±6 years) with DBP&lt;70 (N=225) versus 70-89 mmHg (N=566) following initial CVD events in the original and offspring cohorts of the Framingham Heart Study. Results: Recurrent CVD events occurred in 153 (68%) participants with lower DBP and 271 (48%) with higher DBP (p&lt;0.0001). Risk of recurrent CVD events in risk factor-adjusted Cox regression was higher in those with DBP&lt;70 mmHg versus DBP 70-89 mmHg in both treated [HR, 5.1 (95% CI: 3.8-6.9) p&lt;0.0001] and untreated individuals [HR, 11.7 (6.5-21.1) p&lt;0.0001] (treatment interaction: p=0.10). Individually, coronary heart disease, heart failure, and stroke recurrent events were more likely with DBP&lt;70 mmHg versus 70-89 mmHg (p&lt;0.0001). To judge the potential modifying effect of wide pulse pressure (PP) on excess risk associated with low DBP, we defined 4 binary groupings of median PP (≥ 68 verses &lt;68 mmHg) and categorical DBP (&lt;70 versus 70-89 mmHg), and found that CVD event rates were higher only in the group with wide PP and DBP&lt;70 mmHg (Chi Square = 32.6, p&lt;0.001, see Figure). Conclusions: Persons with ISH and initial CVD events have increased risk for recurrent CVD events in the presence of DBP&lt;70 mmHg versus DBP 70-89 mmHg, supporting wide PP as an important risk modifier of the adverse effect of low DBP; we postulate increased CVD risk is related to the pernicious effects of faulty microvascular function resulting from increased elastic artery stiffness in combination with low diastolic perfusion pressure.

Resistance training improves hemodynamic function, collagen deposition and inflammatory profiles: experimental model of heart failure.

The role of resistance training on collagen deposition, the inflammatory profile and muscle weakness in heart failure remains unclear. Therefore, this study evaluated the influence of a resistance training program on hemodynamic function, maximum strength gain, collagen deposition and inflammatory profile in chronic heart failure rats. Thirty-two male Wistar rats submitted to myocardial infarction by coronary artery ligation or sham surgery were assigned into four groups: sedentary sham (S-Sham, n = 8); trained sham (T-Sham, n = 8); sedentary chronic heart failure (S-CHF, n = 8) and trained chronic heart failure (T-CHF, n = 8). The maximum strength capacity was evaluated by the one maximum repetition test. Trained groups were submitted to an 8-week resistance training program (4 days/week, 4 sets of 10–12 repetitions/session, at 65% to 75% of one maximum repetition). After 8 weeks of the resistance training program, the T-CHF group showed lower left ventricular end diastolic pressure (P<0.001), higher left ventricular systolic pressure (P<0.05), higher systolic blood pressure (P<0.05), an improvement in the maximal positive derivative of ventricular pressure (P<0.05) and maximal negative derivative of ventricular pressure (P<0.05) when compared to the S-CHF group; no differences were observed when compared to Sham groups. In addition, resistance training was able to reduce myocardial hypertrophy (P<0.05), left ventricular total collagen volume fraction (P<0.01), IL-6 (P<0.05), and TNF-α/IL-10 ratio (P<0.05), as well as increasing IL-10 (P<0.05) in chronic heart failure rats when compared to the S-CHF group. Eight weeks of resistance training promotes an improvement of cardiac function, strength gain, collagen deposition and inflammatory profile in chronic heart failure rats.

Hypertension in Primary Open Angle Glaucoma

The impact of vascular factors in POAG is well known and controversial. Some reports have shown high blood pressure in POAG, some low systolic blood pressure and some described no difference in blood pressure between POAG and controls. However decreased ocular perfusion pressure was found in most of the studies. Our study aims to assess the role of hypertension in POAG . It was cross-sectional case-control hospital based study carried out from 1st June 2012 to 1st June 2013. There were 40 cases and 100 controls included in the study. The role of hypertension were compared with those hypertensive patients with glaucoma (cases) and hypertensive patients without glaucoma (controls). Age above 50 years (odds ratio: 4.827 with 95% CI 1.862-12.517), male genders (odds ratio: 3.10 with 95% CI 1.356-7.146) and low diastolic perfusion pressure (odds ratio: 3.857 with 95% CI 1.362-11.224) showed strongly positive association with POAG. High systolic blood pressure (odds ratio: 1.476 95% CI 0.627-3.476), high diastolic blood pressure (odds ratio: 1.348 95% CI 0.587-3.096) and low systolic perfusion pressure (odds ratio: 1.8661 with 95% CI 0.649- 5.335) were weakly associated with glaucoma in our study. Age above 50 years, male gender and low diastolic perfusion pressure were strong risk factor for the development of POAG.

Pro brain natriuretic peptide (BNP) hormone and tissue Doppler abnormalities in patients with homozygous sickle cell disease in Bahrain: echocardiographic study

Background: Pulse Doppler echocardiography has a diagnostic value in right and left ventricular function in patients with homozygous sickle cell disease (SCD), however the role of the tissue Doppler is unclear. Aim: To evaluate the diagnostic role of tissue Doppler in the assessment of right ventricle (RV) and left ventricular function in adult patients with SCD. And to study the prevalence of pulmonary hypertension (PAH) in patients with SCD using the tricuspid valve velocity on echocardiogram. Method: Seventy patients with homozygous SSD were compared with healthy control. Every patient had clinical assessment, had pulsed and tissue Doppler evaluation, in addition to assessing serum level of hemoglobin, ferritin and pro Brain Natriuretic Peptide (BNP). The mean difference between the two groups for tissue Doppler and biometric variables was assessed. Results: Seventy patients had SCD (mean age 28 years, 14-40) and 54 (77%) were males. The age and gender proportions were similar in both groups. Patients with SCD compared with the control had significantly low diastolic pressure, lower hemoglobin level, but high serum ferritin and pro BNP hormone. Furthermore, there was a significant increase in the diameter of left atrium, higher left ventricle mass index, and higher right ventricle diameter and wall thickness. The left ventricle ejection fraction percentage was similar between both groups, but SCD had significantly higher right ventricle tricuspid annular plane systolic excursion (TAPSE) of 1.420.21 vs. 1.110.23 cm (P= 0.02). The RV pulsed Doppler data showed restrictive filling pattern with significantly higher E wave, high E/A ratio and short Deceleration time ; likewise, the upper pulmonary vein systolic/diastolic velocity was significantly lower 1.5 0.12 vs. 2.40.11cm (p=0.002). The tissue Doppler of lateral annulus of tricuspid valve and the septum mitral annulus in SCD patients showed a significant lower S wave, higher E/E- ratio and lower A wave. The incidence of pulmonary hypertension in SCD patients via tricuspid valve regurgitation (TVR) velocity of &gt;2.6 m/s was 22 %. There was a positive correlation between serum level of ferritin, pro BNP and tricuspid valve regurgitation velocity (r=0.35) and (r=0.43) respectively. Conclusion: Adult patients with SCD have included right ventricular diameter and increased RV wall thickness. The LV systolic function is normal but with RV systolic and diastolic dysfunction that was suggestive of restrictive pattern. The incidence of pulmonary hypertension in SCD was 22% with positive correlation between serum level of ferritin, pro BNP and the development of pulmonary hypertension. Keywords: Sickle Cell Anemia, Tissue Doppler, Bahrain.

When does low normal blood pressure become too low? The J-curve phenomenon

The J-shaped relationship between blood pressure lowering and cardiovascular morbidity and mortality has been the topic of debates in the last three decades, especially because it has been shown that this relationship is not the same in different populations of hypertensive patients. This phenomenon is very important from a clinical point of view because it determines blood pressure cut-off values in patients with different comorbidities (diabetes, coronary artery disease, kidney disease, previous stroke). There is still no consensus about the J-shaped relationship. However, the number of studies supporting the existence of the inverse relationship between blood pressure reduction, especially diastolic pressure lowering, and cardiovascular morbidity and mortality, is increasing each year. The aim of this review is to summarize current knowledge about the J curve in a different population of hypertensive patients.

Blood pressure lowering effects of the CFTR‐F508del mutation are associated with reduced arterial reactivity rather than circulating blood volume (700.1)

CFTR‐F508del mutation is the most common cause of cystic fibrosis. F508del homozygous patients and female F508del carriers have decreased blood pressure (BP). We tested the hypothesis that heterozygote F508del mice have lower BP and reduced aortic contractility. By radiotelemetry, female F508del carriers had significantly lower systolic BP than wild‐type C57 controls (112±1 versus 119±2 mmHg). Although male carriers did not have lower baseline BP, they had significantly lower diastolic pressures after intraperitoneal co‐injection of isoproterenol + epinephrine (60±3 versus 78±8 mmHg). Aortas isolated from male and female F508del carriers had reduced constriction to noradrenaline (0.9±0.2 versus 2.9±0.7 mN). Inhibition of wild‐type CFTR or the inositol triphosphate receptor replicated the phenotype of F508del aortas. CFTR carrier status did not alter circulating blood volume. We conclude the CFTR‐F508del mutation decreases aortic contractility and arterial pressures. As a cAMP‐activated chloride channel that facilitates calcium mobilization, we speculate wild‐type CFTR co‐activation during beta‐adrenergic receptor stimulation buffers the vasodilatory response to catecholamines, and loss of this compensatory vasoconstrictor tone may contribute to the lower BP seen in heterozygote carriers of a CFTR‐F508del mutation.Grant Funding Source: Supported by NIH R01 HL102659

The effect of lower body weight support on arterial wave reflection in healthy adults

Body weight support (WS) during treadmill exercise is used to rehabilitate orthopedic/neurological patients. WS lowers musculoskeletal strain and load. It compresses the lower body and increases intrathoracic volume. We studied short-term effects of WS on wave reflection indices using applanation tonometry during progressive WS of 25%, 50%, and 75% of body weight in 25 healthy men. WS decreased mean heart rate from 79 to 69 beats/min (P < .001). Peripheral and central mean arterial, systolic, and pulse pressures (PP) remained unchanged. There was a trend toward lower peripheral and central diastolic pressure. PP amplification ratio decreased significantly (P = .005). Reflected wave characteristics: Augmented pressure and index increased in a stepwise manner with WS (both P < .001). Both ejection duration and systolic duration of the reflected pressure wave (Ätr) increased progressively (both P < .001). The round-trip travel time (Δtp) was unchanged. Left ventricular workload and oxygen demand: Left ventricular wasted pressure energy increased (P < .001), and the subendocardial viability ratio decreased (P = .005), whereas the tension time index remained unchanged. In normal men, WS acutely decreases the PP amplification ratio, increases the amplitude and duration of the reflected aortic pressure wave, and increases measures of wasted left ventricular pressure energy and oxygen demand.

Cold pressor response in high landers versus low landers.

Native high landers face two main environmental challenges i.e. hypobaric hypoxia and low ambient temperatures. Both factors contribute to increased sympathetic stimulation and increased blood pressure. Despite these challenges, subjects living at high altitude have lower systolic and diastolic pressures as compared to subjects living in plains. Present study investigated cold pressor test (CPT) which is a potential predictor of future hypertension in high landers and low landers Materials and Methods: Vascular reactivity in terms of changes in systolic and diastolic blood pressure and heart rate in response to cold pressor test has been compared in high lander (n=45) and low lander (n=46) population. Systolic and diastolic blood pressure changes and heart rate changes with cold pressor test are lower in high landers as compared to low landers. Females in both the groups in general exhibited greater cold pressor response than males. Hypo-reactive cold pressor test is due to higher parasympathetic tone and lower sympathetic tone. Decreased cold pressor response in high landers reflects another adaptive modulation of sympatho-vagal activity that enables them to stay in hypobaric atmosphere and lower temperatures without undue autonomic stress.

Paravalvular aortic regurgitation as the reason for second CoreValve bioprosthesis implantation in a patient with native bicuspid valve

We present the case of a 70-year-old male patient who was admitted to our centre with severe symptomatic aortic stenosis. His medical history included: hypertension, stroke (1998 and 2013) with subsequent left-sided paraparesis and status after traumatic upper right limb amputation in his youth. Patient’s logistic EuroSCORE was 18.1%, EuroSCORE II 5.7% and the Society of Thoracic Surgeons Score 2.7%. Transthoracic echocardiography showed impaired left ventricular ejection fraction of 27%, mean aortic pressure gradient of 70.5 mm Hg, aortic valve area of 0.6 cm2, and peak velocity of 6.3 m/s. For precise aortic annulus measurement, transoesophageal echocardiography (TEE) and a computed tomography scan were performed and revealed a heavily calcified bicuspid valve with mean annulus diameter of 24 mm. Angiography demonstrated a significant lesion in the 3rd segment of right coronary artery (RCA). Due to the high operative risk, the patient was referred by the Heart Team for percutaneous coronary intervention of RCA and transcatheter aortic valve implantation (TAVI) via the femoral route (considering the absence of atherosclerotic lesions in ilio-femoral arteries). Native valve was predilated with a 22 mm Numed balloon catheteter (Fig. 1A). On the basis of pre-procedural imaging, a 29 mm Medtronic CoreValveTM bioprosthesis was implanted at the annulus level. However, control angio and TEE showed low implantation accompanied by significant paravalvular aortic regurgitation (Fig. 1B). Haemodynamic measurement also confirmed a suboptimal effect with low diastolic aortic pressure (DAP) and high left-ventricular end-diastolic pressure (LVEDP) (Fig. 2A). Therefore, the decision was made to implant a second bioprosthesis — another 29 mm CoreValve was placed and deployed 8–10 mm higher than the first one (Fig. 1C). Implantation of the second valve significantly decreased the magnitude of regurgitation from severe to no or mild, both in angiography and pressure recordings (Figs. 1D and 2A, respectively). It has been shown in several observational and randomised trials that even mild paravalvular regurgitation after TAVI is an independent predictor of long-term mortality. It is therefore of crucial importance to diagnose early and minimise the grade of regurgitation by post-dilatation or second valve deployment. This case demonstrates that apart from imaging modalities, direct pressure measurement is an easy, reliable and reproducible method of paravalvular leak detection. Recently, it has been shown in a non-selected population of TAVI procedures that pressure gradient DDAP-LVEDP is a powerful predictor of mortality.

Shock State

Some patients with drug reaction with eosinophilia and systemic symptoms (DRESS) are probably admitted in intensive care unit (ICU), but data concerning their clinical features at admission are scarce. Therefore, in the present study, we used a clinical network of French intensivists to study the clinical features and evolution of DRESS patients hospitalized in ICU. A national, retrospective, multicenter study collected DRESS cases hospitalized in ICU for DRESS from 2000 to end of 2011. All files were analyzed through the RegiSCAR scoring system as "no," "possible," "probable," or "definite" DRESS. Patients were included only if they had a probable or definite DRESS. Demographic, hemodynamic, biological, and infectious data were recorded. Twenty-one patients were included. Hospital mortality was 10 (47%) of 21, and 16 of 21 patients had on admission a shock state necessitating vasopressor agents. Echocardiographic ejection fraction in shock patients was depressed (47% ± 13%). Mechanical ventilation was required in 13 of 21 cases. Hepatic failure was observed in 11 of 21 cases, acute renal failure in 18 of 20 cases, and lactic acidosis in 12 of 20 patients. Initial bacteriology was negative in all patients. Human herpesvirus reactivations were found in five of 15 cases. In conclusion, shock without bacteriological documentation associated with multiple organ failure is the most common presentation of DRESS at admission in ICU and is associated with a higher mortality than previously described.

Low Diastolic Blood Pressure and Chronic Kidney Disease Are Associated With Increased Mortality

When treating hypertension, physicians, patients, and clinical guidelines focus on reducing systolic blood pressure. Diastolic blood pressure tends to be a secondary concern, as it usually decreases when systolic pressure is reduced. But when diastolic pressure is too low�in general, less than 70 mm Hg�it is associated with increased cardiovascular events (including mortality), especially in older patients and those with established coronary artery disease and diabetes. Now, a new study adds chronic kidney disease to the list of conditions that appear to be adversely affected by low diastolic pressure (Kovesdy CP et al. Ann Intern Med. 2013;159[4]:233-242).

Positive effect of mushrooms substituted for meat on body weight, body composition, and health parameters. A 1-year randomized clinical trial

Reducing energy density (ED) of the diet is an important strategy for controlling obesity. This 1-year, randomized clinical trial examined the effect of substituting mushrooms for red meat (‘mushroom diet’), compared to a standard diet (‘meat diet’), on weight loss and maintenance among 73 obese adults (64 women, 9 men). The subjects completed anthropometric measurements and 7-day food records four times during a standardized weight loss and maintenance regimen. At the end of the 1-year trial, compared to participants on the standard diet, participants on the mushroom diet (n=36) reported lower intakes of energy (mean±[SE]=−123±113kcals) and fat (−4.25±6.88g), lost more pounds and percentage body weight (−7.03±3.34lbs, 3.6%), achieved lower body mass index (−1.53±0.36), waist circumference (−2.6±3.5in.) and percent total body fat (−0.85±0.53), and had lower systolic and diastolic pressure (−7.9 and −2.5mmHg); their lipid profile and inflammatory markers also improved. After initial weight loss, subjects following the mushroom diet maintained that loss well. Those who completed the full 12-month trial still weighed a mean of 7lbs less than baseline. Thus, encouraging adults to substitute mushrooms for red meat was a useful strategy for enhancing weight loss, weight maintenance, and health parameters.

Blood Pressure and Progression of Brain Atrophy

Studies have shown that both high and low blood pressure (BP) may play a role in the etiology of brain atrophy. High BP in midlife has been associated with more brain atrophy later in life, whereas studies in older populations have shown a relation between low BP and more brain atrophy. Yet, prospective evidence is limited, and the relation remains unclear in patients with manifest arterial disease. To examine the associations of baseline BP and change in BP over time with progression of brain atrophy. The Secondary Manifestations of ARTerial disease-Magnetic Resonance (SMART-MR) Study is a prospective cohort study with baseline measurements in 2001-2005 and follow-up measurements in 2006-2009. The mean follow-up time was 3.9 years. University Medical Center Utrecht, the Netherlands. A total of 663 patients (mean [SD] age, 57 [9] years; 81% male) with coronary artery disease, cerebrovascular disease, peripheral artery disease, or abdominal aortic aneurysm were included. Using automated segmentation at baseline and follow-up, change in brain parenchymal fraction, cortical gray matter fraction, and ventricular fraction (%ICV) were quantified as indicators of progression of global, cortical, and subcortical brain atrophy. Multivariable adjusted regression analysis showed that patients with lower baseline diastolic BP (DBP) or mean arterial pressure had more progression of subcortical atrophy. The mean differences in the change in ventricular fraction between low and high DBP was 0.07% (95% CI, 0.01-0.14) and between low and high mean arterial pressure was 0.05% (95% CI, 0.00-0.10). Furthermore, in patients with higher baseline BP (DBP, mean arterial pressure, or systolic BP), those with declining BP levels over time had less progression of subcortical atrophy compared with those with rising BP levels. In patients with manifest arterial disease, low baseline DBP was associated with more progression of subcortical atrophy, irrespective of the BP course during follow-up. Furthermore, in patients with higher baseline BP, declining BP levels over time were associated with less progression of subcortical atrophy. This could imply that BP lowering is beneficial in patients with higher BP levels, but caution should be taken with further BP lowering in patients who already have a low DBP.

KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Management of Blood Pressure in CKD

In response to the 2012 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for blood pressure management in patients with chronic kidney disease not on dialysis, the National Kidney Foundation organized a group of US experts in hypertension and transplant nephrology to review the recommendations and comment on their relevancy in the context of current US clinical practice and concerns. The overriding message was the dearth of clinical trial evidence to provide strong evidence-based recommendations. For patients with CKD with normal to mildly increased albuminuria, goal blood pressure has been relaxed to ≤140/90 mm Hg for both diabetic and nondiabetic patients. In contrast, KDIGO continues to recommend goal blood pressure ≤130/80 mm Hg for patients with chronic kidney disease with moderately or severely increased albuminuria and for all renal transplant recipients regardless of the presence of proteinuria, without supporting data. The expert panel thought the KDIGO recommendations were generally reasonable but lacking in sufficient evidence support and that additional studies are greatly needed.