Decline In Systolic Blood Pressure Research Articles

Blood Pressure Trajectories From Midlife to Late Life in Relation to Dementia in Women Followed for 37 Years

Higher midlife blood pressure increases risk for dementia. To further understand the relation between blood pressure and dementia, it is necessary to examine evolution of blood pressure from midlife to late life. We examined blood pressure trajectories using linear mixed models in a representative sample of middle-aged women (N=1462) who were followed from 1968-1969 until 2005-2006 with comprehensive medical and neuropsychiatric examinations. Dementia was diagnosed according to established criteria. Among those not treated with antihypertensives, higher systolic blood pressure at baseline but not blood pressure trajectories from 1968 to 1992 was associated with dementia and Alzheimer disease. Those with history of antihypertensive treatment had higher baseline systolic blood pressure than those who were never treated. In this group, those who developed dementia and Alzheimer disease had lower baseline systolic blood pressure and steeper increase in systolic blood pressure from 1968 to 1992 than those who did not. A steeper decline in systolic blood pressure during the later part of the study was observed in those who developed dementia regardless of antihypertensive treatment. The latter association was attenuated or disappeared when adjusting for body mass index. The association between blood pressure and dementia is complex and influenced by antihypertensive treatment. The findings emphasize the importance of detecting increased blood pressure in midlife and controlling blood pressure in those treated. Whether the trajectory of blood pressure is a risk factor or part of the clinical course of dementia needs to be elucidated.

Disrupted Regulation of Ghrelin Production Under Antihypertensive Treatment in Spontaneously Hypertensive Rats

Ghrelin is an acylated peptide hormone mainly secreted from the stomach. When administrated externally it modulates vascular tone mainly through the regulation of autonomic nerve activity. However, the effects of blood pressure (BP) on the production and secretion of ghrelin remain to be clarified. We examined the stomach and plasma levels of ghrelin in spontaneously hypertensive (SHR) and Wistar-Kyoto (WKY) rats after a 4-week-intervention with antihypertensive agents (candesartan-cilexetil [ARB], doxazosin [DZN], metoprolol [MP], reserpine [RES]) to clarify the influence of BP on the secretion of ghrelin. The effect of these agents on ghrelin production and secretion were examined by comparing vehicle-treated controls (WKY-Intact, SHR-Intact). Treatment with the 4 antihypertensive drugs all yielded a significant decline in systolic BP in both SHR and WKY. Under these conditions, significantly lower levels of stomach and plasma ghrelin were detected in WKY treated with ARB (P<0.05), DZN (P<0.05), MP (P<0.05) and RES (P<0.05) compared with WKY-Intact, whereas no significant change in the ghrelin levels in the stomach and plasma were detected in SHR under the same treatments. The findings imply that the production and secretion of ghrelin are controlled by the ambient vascular tone and vice versa in normotensive WKY. This inter-relationship between ghrelin and BP seems to be disrupted in SHR.

Effect of intranasal DDAVP in prevention of hypotension during hemodialysis.

The development of intradialytic hypotension during hemodialysis (HD) in which fluid removal is the primary goal, contributes to the excessive morbidity that is associated with the dialysis procedure. In a double blinded clinical trial, we compared the possible effect of intranasal DDAVP with intranasal distilled water as a placebo in prevention of intradialytic hypotension (IDH) in patients with known symptomatic IDH. In the first month of the study, nasal spray of distill water were administrated 30 minutes before all HD session (Placebo Group, Group 1) and then after a 30-day washout period we were used intranasal DDAVP 30 minutes before HD session (Vasopressin Group, Group 2). Blood pressure was measured just before HD, two hours later and after termination of HD. A hypotensive episode was defined as a decline of systolic blood pressure of more than 10mm Hg. In overall Seventeen patients (nine men, eight women; mean age, 47.5 years) with known symptomatic IDH were enrolled in the study. The kind of dialysis membranes, mean of blood flow rate, dialyzate flow rate and ultrafiltration rate were the same in both groups. Each group has 204 HD session (17 * 12). Hypotensive episode occurred 18 times (8.82%) in vasopressin group compared with 125 times (61.27%) in placebo group and there was a significant association between them (p=0.0001). In addition mean arterial blood pressure in vasopressin group was 80.77 and in placebo group was 73.92 and also there was a significant association (p=0.0001). The mean Kt/v in group 1 and 2 were 1.29 and 1.28 without any differences between them (p=0.896). These results indicate that Compared with placebo, Vasopressin is significantly associated with a decreased incidence of intradialytic hypotension episodes during hemodialysis.

Differences of age and gender in children with orthostatic hypertension

Objective To explore the differences of age and gender in children with orthostatic hypotension(OH).Methods A total of 1 158 cases of pediatric patients with unexplained syncope,headache,dizziness in syncope specialist children′s clinic of the Second Xiangya Hospital,Central South University,were chosen from Jan.2000 to May 2010.Forty-five patients with OH were diagnosed among 1 158(597 cases were male and 561 cases were female) ones with syncope and dizziness by head-up tilt table test(HUTT),who were 3.1-17.0 years old,mean(10.72±2.80) years old.The patients were divided into ≥12 years old group and 12 years old group according to the age.The course of disease,diagnostic rate,changes of blood pressure in OH children and their relationship with age and gender were analyzed.Results 1.The diagnostic rate:the diagnostic rate of OH was not different in age and gender(χ2=0.631,0.584;Pa0.05).2.The course and onset age of OH:the course was 0.03-60.00(8.13±14.06) months in 12 years old group,which was not different in gender [(4.77±7.86) months vs(10.59±17.10) months;t=0.634,P0.05)].In ≥12 years old group,the course was 0.30-72.00(20.10±22.20) months,there was no difference in gender [(16.55±1.80) months vs(26.03±2.87) months;t=0.273,P0.05].There was no diffe-rence of course between the different age groups[(8.73±16.07) month vs(20.11±22.20) month;t=1.932,P0.05].3.Changes in blood pressure of OH children:there was no difference in systolic and diastolic blood pressure decline within 3 minutes during HUTT between ≥12 years old group and 12 years old group(t=1.495,0.079;Pa0.05).In 12 years old group,there was no difference in systolic and diastolic blood pressure decrease within 3 minutes during HUTT in gender(t=0.019,1.730;Pa0.05).In ≥12 years old group,there was no difference in systolic and diastolic blood pressure decrease within 3 minutes during HUTT in gender(t=0.364,0.843;Pa0.05).Conclusions There is no difference in the course of disease and systolic and diastolic blood pressure decrease within 3 minutes during HUTT of OH in age and gender.There is also no difference of age and gender either in the diagnostic rate.

Safety and Efficacy of Lacosamide in the Intensive Care Unit

Seizures are common in critically ill patients and can impact morbidity and mortality. Traditional anti-epileptic drugs (AEDs) in this setting are not always effective and are associated with adverse events and drug interactions. Lacosamide (LCM) is a new AED which is available in parental form although few studies have evaluated the safety and efficacy of LCM in critically ill patients. Critically ill patients at Emory University Hospital who received LCM from April 1, 2009 to February 1, 2010 were retrospectively reviewed. Primary outcome measure was incidence and time to seizure cessation. Adverse effects were also recorded. LCM was administered in 24 patients including 13 episodes of refractory status epilepticus (RSE) occurring in 10 patients and for treatment of isolated seizures or following resolution of RSE in an additional 14 patients. Seizure cessation was achieved in 5/13 (38%) episodes of RSE (mean 11.2 h) while there was at least a 50% decrease in seizure frequency in 7/13 (54%). 11/14 patients (76%) who received LCM for treatment of isolated seizures or prevention of seizure recurrence remained seizure free. Three patients experienced a decline in systolic blood pressure (> 20 mmHg) while one patient experienced unexplained fever and one patient had elevation of liver function tests. This preliminary data suggests that LCM may be a safe and effective alternative for treatment of seizures in critically ill patients. Further prospective, randomized controlled trials are needed to confirm these findings and further explore the incidence of adverse effects.

Living Donor Kidney Donation: Another Form of White Coat Effect

Background/Aims: Living donor nephrectomy can be associated with increases in blood pressure several years following the procedure, but the best method to assess blood pressure during the living donor evaluation process is unclear. Methods: Living kidney donors underwent casual clinic and ambulatory blood pressure monitoring (ABPM) and measurement of central aortic pressures at baseline and 6 months following donor nephrectomy. Results: There was a significant decline in clinic systolic blood pressure (SBP; p = 0.001) and central aortic systolic pressure (p = 0.011) during the study period. However, average ABPM was unchanged and other measures of central arterial pressures and Augmentation Index were unchanged at 6 months compared to baseline. Conclusions: The remarkable differences between clinic SBP and ambulatory SBP prior to donation, and the disappearance of these differences 6 months later, suggest a substantial white coat effect on SBP associated with living kidney donor evaluation. Also, ABPM represents a better way to assess blood pressure prior to kidney donation.

Elevation of serum high molecular weight adiponectin in patients with Type 2 diabetes and orthostatic hypotension: association with arterial stiffness and hypercoagulability

Orthostatic hypotension is a hallmark of diabetic autonomic neuropathy and is associated with increased mortality. The serum level of adiponectin is elevated in patients with heart failure or renal failure. In the present study, we measured serum levels of total and high molecular weight adiponectin in patients with Type 2 diabetes and orthostatic hypotension. We also investigated the relationship between the presence of orthostatic hypotension and various clinical variables in patients with Type 2 diabetes. We studied 105 patients with Type 2 diabetes. Orthostatic hypotension was defined as a decrease of 20 mmHg or more in systolic blood pressure and/or 10 mmHg in diastolic blood pressure when blood pressure was measured for 3 min while standing. The brachial-ankle pulse-wave velocity was also measured as an index of arterial stiffness. Orthostatic hypotension was found in 30 patients with diabetes (28.6%). The haematocrit and estimated glomerular filtration rate were significantly lower in patients with orthostatic hypotension than in those without it. Brachial-ankle pulse-wave velocity and serum total and high molecular weight adiponectin were significantly higher in patients with orthostatic hypotension than in those without. Furthermore, the high molecular weight/total adiponectin ratio was higher in patients with orthostatic hypotension than in those without and hypertension was more common in patients with orthostatic hypotension. Plasma prothrombin F1 + 2, a coagulation maker, was higher in patients with orthostatic hypotension than in those without, while there were no differences of fibrinolytic markers between the two groups. Multivariate analysis showed that HDL cholesterol, haematocrit, F1 + 2, brachial-ankle pulse-wave velocity and a decline of systolic blood pressure on standing were independent determinants of high molecular weight adiponectin. Patients with Type 2 diabetes and orthostatic hypotension had an elevated serum level of high molecular weight adiponectin, which was associated with the simultaneous presence of renal dysfunction, anaemia, arterial stiffness and hypercoagulability.

Phenomenon of declining blood pressure in elderly - high systolic levels are undervalued with Korotkoff method

BackgroundSystolic blood pressure (SBP) decline has been reported in octogenarians. The aim was to study if it could be observed while measuring SBP with two methods: Korotkoff (K-BP) and Strain-Gauge-Finger-Pletysmography (SG-BP), and which of them were more reliable in expressing vascular burden.MethodsA cohort of 703 men from a population of Malmö, Sweden, were included in "Men born in 1914-study" and followed-up at ages: 68 and 81 years. 176 survivors were examined with K-BP and SG-BP at both ages, and 104 of them with Ambulatory Blood Pressure at age 81/82. Ankle Brachial Index (ABI) was measured on both occasions, and Carotid Ultrasound at age 81.ResultsFrom age 68 to 81, mean K-BP decreased in the cohort with mean 8.3 mmHg, while SG-BP increased with 13.4 mmHg. K-BP decreased in 55% and SG-BP in 31% of the subjects. At age 81, K-BP was lower than SG-BP in 72% of subjects, and correlated to high K-BP at age 68 (r = --.22; p < .05). SG-BP at age 81 was correlated with mean ambulatory 24-h SBP (r = .480; p < .0001), daytime SBP (r = .416; p < .0001), nighttime SBP (r = .395; p < .0001), and daytime and nighttime Pulse Pressure (r = .452; p < .0001 and r = .386; p < .0001). KB-BP correlated moderately only with nighttime SBP (r = .198; p = .044), and daytime and nightime pulse pressure (r = .225; p = .021 and r = .264; p = .007). Increasing SG-BP from age 68 to 81, but not K-BP, correlated with: 24-h, daytime and nighttime SBP, and mean daytime and nighttime Pulse Pressure. Increasing SG-BP was also predicted by high B-glucose and low ABI at age 68, and correlated with carotid stenosis and low ABI age 81, and the grade of ABI decrease over 13 years.ConclusionIn contrast to K-BP, values of SG-BP in octogenarians strongly correlated with Ambulatory Blood Pressure. The SG-BP decline in the last decade was rare, and increasing SG-BP better than K-BP reflected advanced atherosclerosis. It should be aware, that K-BP underdetected 46% of subjects with SG-BP equal/higher than 140 mmHg at age 81, which may lead to biased associations with risk factors due to differential misclassification by age.

Early postural blood pressure response and cause-specific mortality among middle-aged adults: what is the role of diastolic blood pressure?

Dear Editor, With interest we have read the article by Fedorowski et al. [1], which provides valuable information about cause-specific mortality in middle-aged subjects with orthostatic hypotension. In their study orthostatic hypotension (defined as a decrease in systolic blood pressure ≥20 mmHg and/or decrease in diastolic blood pressure ≥10 mmHg within 3 min of standing) was associated with mortality through injuries and neurologic diseases. Our major comment is that the article lacks data on the postural diastolic pressure response, both in describing the whole group with orthostatic hypotension, and the analyses of all cause and cause-specific mortality. Surprisingly, orthostatic hypotension and postural systolic blood pressure decline was not associated with cardiovascular mortality, although there was such an association in a smaller rescreened subsample. In other studies orthostatic hypotension was associated with myocardial infarction in middle-aged adults [2] and home dwelling elderly [3]. Unfortunately Fedorowski et al. [1] did not study the influence of postural diastolic blood pressure decline on cause-specific mortality. There might be a crucial role of diastolic blood flow on myocardial perfusion and subsequently myocardial infarction and cardiovascular mortality [3]. Postural diastolic, but not systolic blood pressure decline, seems to be associated with an increased risk of myocardial infarction [3]. Moreover in the same study population of the Malmo Preventive Project already the association was found that postural diastolic, but not systolic blood pressure decline predicts coronary events [4]. In conclusion, Fedorowski et al. [1] added very valuable information to the current knowledge of orthostatic hypotension through information on cause-specific mortality. However we miss in their study specific data on cause-specific mortality in relation to postural diastolic blood pressure decline and especially regarding cardiovascular mortality. References Fedorowski A, Hedblad B, Melander O. Early postural blood pressure response and cause-specific mortality among middle-aged adults. Eur J Epidemiol 2011. Rose KM, Tyroler HA, Nardo CJ, Arnett DK, Light KC, Rosamond W et al. Orthostatic hypotension and the incidence of coronary heart disease: the Atherosclerosis Risk in Communities study. Am J Hypertens 2000; 13(6 Pt 1): 571–8. Luukinen H, Koski K, Laippala P, Airaksinen KE. Orthostatic hypotension and the risk of myocardial infarction in the home-dwelling elderly. J Intern Med 2004; 255(4): 486–93. Fedorowski A, Stavenow L, Hedblad B, Berglund G, Nilsson PM, Melander O. Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project). Eur Heart J 2010; 31(1): 85–91.

Feasibility and safety of propofol sedation in flexible bronchoscopy

Propofol is a sedative-hypnotic with a rapid onset of action. There are only limited data evaluating propofol for flexible bronchoscopy. We analysed the feasibility and safety of propofol for bronchoscopy in a high output tertiary care centre. Prospective data on patients undergoing flexible bronchoscopy at the University Hospital Basel, Switzerland, were analysed. Patient demographics, ASA class, Mallampati class, indication for bronchoscopy, bronchoscopic procedures, duration of examination, medication requirements, minor and major adverse events, haemodynamic parameters, as well as cough scores during the procedure were documented. Patients were followed up to discharge from the bronchoscopy suite. Data from 440 patients with a mean age 60 years (±15.5, 260 male) were analysed. The main indication for bronchoscopy was a suspicion of malignancy. The most common diagnostic procedures were bronchoalveolar lavage in 253 cases (31.5%) and bronchial washing in 174 cases (21.7%). The mean duration of the procedure was 19.6 min (±12.08). The mean propofol dose was 200 mg (±107.5) corresponding to 2.89 mg/kg (±1.70). Minor adverse events included oxygen desaturation in 72 (16.4%), hypotension in 68 (15.4%) and minor bleeding in 11 (2.5%) patients. No major adverse events were recorded. The median decline in systolic blood pressure after initiation of sedation was 14 mm Hg (3-28). A drop in systolic blood pressure greater than 20 mm Hg was observed in 166 of the 440 patients (37%). Propofol sedation for flexible bronchoscopy is feasible and safe.

Ethnic differences in the effects of the DASH diet on nocturnal blood pressure dipping in individuals with high blood pressure.

Ethnic differences in nocturnal blood pressure (BP) dipping may contribute to the increased risk for adverse cardiovascular events noted in African Americans (AAs). The DASH (Dietary Approaches to Stop Hypertension) diet has been shown to be efficacious in lowering clinic and ambulatory BP; however, the effect of the DASH diet on BP dipping is unclear. One hundred and eighteen men and women with high clinic BP (systolic BP (SBP) 130-159; diastolic BP 85-99) and above ideal body weight were randomized to a DASH diet intervention or to a usual diet control (UC) condition. Measures of 24-h ambulatory BP were obtained at baseline and at the end of the 4-month intervention period. At baseline, AAs (n = 43) displayed blunted nocturnal SBP dipping compared to Caucasians (CAs; n = 75) and were more likely to be categorized as nondippers (<10% nocturnal decline in SBP, AAs: 51% vs. CAs: 27%). AAs randomized to the DASH diet intervention showed a significant improvement in SBP dipping postintervention compared to AAs in the UC condition (P = 0.04), whereas there was no appreciable change in SBP dipping in CAs (P = 0.72). Following the intervention, ethnic differences in SBP dipping were no longer statistically significant (nondipper status: AAs: 44% vs. CAs: 32%; P = 0.19). Our study provides preliminary evidence suggesting that in overweight men and women with high BP, AAs may be especially likely to benefit from augmented SBP dipping associated with consumption of the DASH diet.

Sufentanil preserves hemodynamics and left ventricular function in patients with ischemic heart disease

Sufentanil has been reported to provide stable hemodynamics similar to other opioids. However, it has not been reliably established whether this stability can be attributed only to Sufentanil and translates into fully preserved left ventricular (LV) function. The purpose of this study was to evaluate the effect of Sufentanil on hemodynamics and LV systolic and diastolic function using invasive monitoring and echocardiography in patients with ischemic heart disease. Prospective observational study of thirty patients acting as their own control undergoing echocardiographic imaging before and after bolus Sufentanil 1.5-2.0 μg/kg. Full invasive hemodynamic monitoring was established before Sufentanil administration. Global LV systolic function was evaluated with a global longitudinal peak systolic strain (GLPSS) by speckle tracking ultrasound; systolic displacement by tissue tracking (TT) and diastolic function was evaluated using Doppler tissue imaging and pulse wave Doppler. Hemodynamic monitoring showed a minor decline in systolic blood pressure from 159 to 154 mmHg (P=0.046). No changes were observed in the cardiac index, stroke volume index and heart rate. An unchanged TT score index (9.9 vs. 10.2 mm, P=0.428) and GLPSS (14.3 vs. 14.5%, P=0.658) indicated preserved LV global systolic function and unchanged E'/A' (0.95 vs. 0.89, P=0.110) and E/E' ratio (15.4 vs. 14.9, P=0.612) indicated unchanged diastolic function. Sufentanil preserves hemodynamic parameters as well as echocardiographic indices of LV systolic and diastolic function in patients with ischemic heart disease (IHD).

Changes in haemostatic and platelet activation markers in non-dipper hypertensive patients

Non-dipper hypertensive patients are at increased risk for cardiovascular disease. Coagulation and fibrinolysis activation factors are considered as risk factors for cardiovascular disease. The aim of this study was to examine the relationship between the haemostatic and platelet activation markers and the non-dipping pattern in treated hypertensive patients. Seventy-one treated hypertensive patients (53 with essential and 18 with secondary hypertension, due to chronic kidney disease-stage 4), aged 33 to 81 years (30 men), were classified as dippers and non-dippers, according to the presence or absence, respectively, of a decline of nocturnal average systolic blood pressure (BP) by more than 10% of the diurnal BP (non-dipping pattern) on 24-hour ambulatory BP monitoring. Plasma levels of factors VIII and IX, fibrinogen, prothrombin fragment 1 + 2, thrombin-antithrombin complex, protein C, plasmin-alpha-2 antiplasmin complex, D-dimer and platelet factor 4 were measured in all patients. Thirty-seven patients were classified as dippers and 34 as non-dippers. The percentages of patients with essential and with secondary hypertension were similar in the dippers and in the non-dippers groups (both P = 0.754). Multivariate analysis of variance showed statistically significant differences in all measured variables between dippers and non-dippers (P = 0.043). Plasma levels of factors VIII and IX, fibrinogen, prothrombin fragment 1 + 2, protein C, plasmin-alpha-2-antiplasmin complex, and D-dimers were significantly higher in non-dippers when compared to dippers (P < 0.05 for all). In contrast, there were no significant differences in plasma levels of thrombin-antithrombin complex (P = 0.955) and platelet factor 4 (P = 0.431) between the two groups. This study provides evidence that non-dipper treated hypertensive patients exhibit alterations in haemostasis, which may affect their cardiovascular risk.

The Effect of Transdermal Glyceryl Trinitrate on 24 h Ambulatory Blood Pressure in Acute/Subacute Stroke

High blood pressure is a common complication in acute stroke and is associated with a poor outcome. Aims This study assesses the effects of transdermal glyceryl trinitrate on 24 h ambulatory blood pressure in patients with recent stroke. One hundred and seven patients with acute ischaemic or haemorrhagic stroke were included. The patients had been enrolled in one of two trials of transdermal glyceryl trinitrate (5 mg daily) or placebo/control, and underwent 24 h ambulatory blood pressure monitoring (56 glyceryl trinitrate, 51 control). Ambulatory blood pressure data were analysed using area under the curve for the entire 24 h, and day and night periods. Nocturnal dipping was defined as a decline in systolic blood pressure >10%. Comparisons of blood pressure between groups were performed by analysis of covariance (ANCOVA) with adjustments for trial and baseline measure. In comparison with control, glyceryl trinitrate significantly lowered 24 h blood pressure (systolic blood pressure/diastolic blood pressure 9.4/4.8 mmHg, P < 0.001/0.001, n=104), daytime blood pressure (8.7/4.2, P < 0.001/ <0.001, n=103) and night-time blood pressure (6.9/1.7, P=0.008/0.458, n=86). Only 86 patients (glyceryl trinitrate 45, placebo/control 41) had sufficient night blood pressure measurements to assign dipping status; 28 were dippers (12 glyceryl trinitrate, 16 control) and 58 were nondippers (33 glyceryl trinitrate, 25 control); glyceryl trinitrate significantly lowered systolic but not diastolic blood pressure in both dippers and nondippers. Treatment with glyceryl trinitrate increased the daytime heart rate (4·8 beats/min) but not the night-time heart rate. Patients whose blood pressure did not dip at night had a worse functional outcome at three-months. Transdermal glyceryl trinitrate (5 mg) significantly lowered 24 h blood pressure by 9/5 mmHg (equivalent to a 6% reduction) in both dipping and nondipping patients with acute/subacute stroke. This reduction in blood pressure is clinically relevant and is unlikely to be excessive.

Propofol Versus Propofol/Ketamine for Brief Painful Procedures in the Emergency Department: Clinical and Bispectral Index Scale Comparison

ABSTRACTThe ideal procedural sedation drug for emergency department (ED) use would be easily titrated, rapid in onset, brief in duration, and provide sedation and analgesia without respiratory or hemodynamic compromise. Although many agents have been tried, no single drug fits this profile. The authors evaluated the comparative effectiveness and safety of propofol versus propofol/ketamine combination for procedural sedation using bispectral index monitoring for measuring depth of sedation. A prospective, randomized case series of patients undergoing procedural sedation for fracture manipulation was studied in a Level 1 trauma center emergency department. Patients were randomized to a propofol (P) group with a target dose of 0.5 to 1.5 mg/kg or a propofol/ketamine (P/K) group with a target dose of both ketamine and propofol of 0.75 mg/kg. Procedural success, bispectral index (BIS) score, adverse effects, recovery time, and vital signs were measured. Twenty-eight patients were enrolled. The P/K group experienced a smaller decline in systolic blood pressure (1.6% versus 12.5%) and BIS score at goal sedation (77 versus 61), a smaller difference between baseline and goal sedation BIS score (18.78 ± 10 versus 34.64 ± 11) and a lower mean propofol dose (92.5 ± 58 versus 177.27 ± 11 mg). No patient in either group experienced respiratory depression or required any intervention. The combination of propofol and ketamine provides an attractive combination for procedural sedation in the emergency department. Compared to propofol alone, “ketofol” results in less hypotension, better sedation, and enhanced patient comfort and safety.

Translesional Pressure Gradients to Predict Blood Pressure Response After Renal Artery Stenting in Patients With Renovascular Hypertension

In previous studies on the effect of renal stenting on arterial hypertension, patients were selected mainly on the basis of angiographic parameters of the renal artery stenosis. The aim of the present study was to evaluate whether translesional pressure gradients could identify the patients with renal artery stenosis who might benefit from stenting. A total of 53 consecutive hypertensive patients with unilateral RAS scheduled for renal artery intervention were recruited. Transstenotic pressure gradients were measured at baseline and during maximal hyperemia, before renal artery stenting. Twenty-four-hour ambulatory blood pressure measurements were performed in all patients before and 3 months after the intervention. Average reductions in systolic blood pressure and diastolic blood pressure at follow-up were -20±30 mm Hg and -2±12 mm Hg, respectively. At multivariate analysis, dopamine-induced mean gradient was the only independent predictor of the variations of both systolic blood pressure (regression coefficient=-4.03, standard error=1.11; P<0.001) and diastolic blood pressure (regression coefficient=-3.11, standard error=1.20; P=0.009). Patients who showed a decline in systolic blood pressure from the baseline value >20 mm Hg were considered as "responders." The optimal cutoff for identification of "responders" was a dopamine-induced mean gradient ≥20 mm Hg (area under the curve, 0.77; 95% confidence interval, 0.64 to 0.90; P=0.001). A dopamine-induced mean pressure gradient of ≥20 mm Hg is highly predictive of arterial hypertension improvement after renal stenting, and therefore this measurement is useful for appropriate selection of patients with arterial hypertension.

Secular Trends in Treatment and Control of Type 2 Diabetes in an American Indian Population: A 30-Year Longitudinal Study

OBJECTIVETreatment guidelines for diabetes have become increasingly stringent as most research shows that more aggressive intervention reduces the risks for complications. Community data on the effect of these interventions are lacking.RESEARCH DESIGN AND METHODSChanges in the pharmacologic treatment of diabetes, blood pressure, and cholesterol in adults with diabetes were analyzed in a longitudinal population-based study of American Indians from 10 independent 3-year time intervals between 1975 and 2004. Trends in drug use were assessed by logistic regression models and trends in glycemia, blood pressure, and cholesterol were assessed by linear models.RESULTSAmong the study participants, the use of any medicine for the treatment of diabetes increased from 53% in 1975–1978 to 67% in 2002–2004, Ptrend < 0.0001. The use of insulin as a single agent declined, and the use of combinations of insulin and oral agents increased. In 1990–1992, 23% of subjects had an A1C <7% and by 2002–2004, the proportion had increased to 33%, Ptrend < 0.0001. The use of anti-hypertensive medicine increased from 21% in 1975–1977 to 58% in 2002–2004, Ptrend < 0.0001, coincident with a decline in mean systolic blood pressure from 137 mmHg in 1975–1977 to 123 mmHg in 2002–2004, Ptrend < 0.0001. The use of lipid-lowering medicine also increased with an accompanying increase in HDL and a decrease in non-HDL cholesterol concentration.CONCLUSIONSMajor changes in community treatment patterns for diabetes and related conditions coincided with improvements in glycemia, blood pressure, and cholesterol.

Longitudinal Associations between Blood Pressure and Dementia in the Very Old

Background/Aims: Midlife hypertension is associated with an increased risk for dementia, but the association between blood pressure and dementia in very old age is unclear. Methods: In a population-based cohort study, a total of 102 individuals aged 85, 90 or ≧95 years participated in 2 examinations with a 5-year interval. The investigations consisted of a structured interview, blood pressure measurement, rating scales such as the Mini-Mental State Examination (MMSE) and an investigation of medical charts. Results: The majority of participants exhibited a decline in blood pressure. Baseline systolic blood pressure (SBP), diastolic blood pressure or pulse pressure (PP) were not associated with incident dementia or with decline in MMSE scores in multiple regression analyses adjusted for age and sex. However, incident dementia cases exhibited a greater decline in SBP (p = 0.02) and PP (p = 0.04), and decline in SBP was associated with a decline in MMSE score (p = 0.008). Conclusion: In this small longitudinal study on the very old, no association between baseline blood pressure and incident dementia was found, but individuals who developed dementia exhibited a greater blood pressure decline. Low blood pressure could be an effect of dementia in the very old.

Blood pressure control in patients receiving bevacizumab in an outpatient cancer center

Hypertension is a common adverse effect of vascular endothelial growth factor (VEGF) signaling inhibitors, such as bevacizumab, with an incidence upwards of 35%. The management of bevacizumab-induced hypertension is important in order to avoid dose interruption/discontinuation and/or end organ damage. The efficacy of antihypertensive medications for this cause of hypertension has not been demonstrated. This study seeks to determine if antihypertensives are effective in treating anti-VEGF-induced hypertension from bevacizumab and determine which classes of antihypertensive agents are effective. A retrospective review of all patients who received bevacizumab between January 2007 and September 2009 at two medical centers was conducted. Patients were included if they experienced new onset or exacerbation of preexisting hypertension, during bevacizumab treatment. Efficacy of antihypertensives was determined by recording a 28-day change in systolic blood pressure from the initiation or dose increase of individual antihypertensive medications. Secondary endpoints included an efficacy analysis of antihypertensive classes. Five-hundred thirteen patients were identified as receiving bevacizumab during the indicated time period. Fifty-seven patients met the full inclusion/exclusion criteria for analysis. The average systolic blood pressure declined by 23 mm Hg with 4 weeks of treatment (p < 0.0001). Each class had a statistically significant decline in systolic blood pressure of 15.5-57 mm Hg with the exception of diuretics and a group of miscellaneous antihypertensives. This is the first data that demonstrates individual classes of antihypertensives are effective in bevacizumab-induced hypertension. Most antihypertensives were effective in reducing blood pressure, with the exception of diuretics and miscellaneous antihypertensives, which may be due to a limited sample size.

The midgestational maternal blood pressure decline is absent in mice lacking expression of the angiotensin II AT2 receptor

The midgestational maternal blood pressure (BP) decrease is absent in mice treated with an angiotensin II AT2 receptor blocker. We tested the hypotheses that there would be 1) no midgestational decrease in maternal systolic BP (SBP) in AT2-/- mice, and 2) a pattern of increased AT2 and/or decreased AT1a mRNA expression in tissues from normal (wild-type, WT) mice, corresponding with SBP changes. Heart, aorta, placenta and kidney tissue were obtained from WT and AT2-/- mice before pregnancy and on gestational days (Gd) 5-6, 12-13 and 18-19. AT1a and AT2 mRNA expression was quantified. SBP was measured. SBP was significantly decreased in WT Gd12-13 mice, but did not change during pregnancy in AT2-/- mice. In WT mice, aortic AT1a mRNA expression levels were significantly higher at Gd12-13 and Gd18-19 compared with before pregnancy. AT1a kidney and heart mRNA did not change during pregnancy. There were no changes in AT2 mRNA expression. There was no distinct pattern of change in AT1a expression in AT2-/mice. Placental AT1a and AT2 expression levels increased markedly between Gd12-13 and Gd18-19 in WT mice. We conclude that the AT2 receptor is essential for the midgestational SBP decline in WT mice. There is no consistent relationship between changes in tissue angiotensin II receptor mRNA expression and SBP in WT mice.