Felipe Costa Fuchs

Efficacy of isolated home blood pressure monitoring for blood pressure control: randomized controlled trial with ambulatory blood pressure monitoring - MONITOR study.

Background Rates of control of hypertension remain unsatisfactory worldwide and simple methods to encourage patients to adhere to treatments are still necessary. In this randomized controlled trial, we evaluated the efficacy of a protocol of home blood pressure monitoring (HBPM), without medication titration, to improve BP assessed by ambulatory BPM (ABPM). Methods Patients with hypertension under drug treatment and with uncontrolled BP at office and by 24-h ABPM were randomly assigned to HBPM or usual care. The treatment was not modified during the trial. Follow-up visits were conducted at 7 and 30 days after randomization, and at 60 days to assess the outcome. Deltas between baseline and final ABPM measurements were calculated for 24-h, nightly and daily ambulatory SBP and DBP. Results Of 558 patients screened, 136 fulfilled the eligibility criteria and were randomized, and 121 (89%) completed the trial. The between groups deltas (95% confidence interval) of variation of 24 h, nightly and daily SBP were 5.4 (0.9–9.8) (P = 0.018), 10.9 (2.9–18.9) (P = 0.012) and 4.4 mmHg (−0.1 to 8.8) (P = 0.055), respectively; the corresponding deltas for DBP were 4.5 (1.6–7.4) (P = 0.003), 3.4 (0.4–6.3) (P = 0.025) and 5.8 mmHg (2.5–9.0) (P = 0.001), respectively. At the end of the trial, 32.4% of patients of the HBPM groups and 16.2% of the control group had 24-h SBP less than 130/80 mmHg (P = 0.03). Conclusion A protocol of HBPM without medication titration enhances the control of BP assessed by ABPM.

Home Blood Pressure Monitoring Is Better Predictor of Cardiovascular Disease and Target Organ Damage than Office Blood Pressure: A Systematic Review and Meta-Analysis

The available, albeit rare, evidence indicates the superiority of home- over office blood pressure monitoring (HBPM vs OBP) to predict cardiovascular (CV) outcomes. We performed a systematic review to update the efficacy of HBPM vs OBP as predictors of all-cause mortality, CV death, and target organ damage. Two reviewers independently performed the literature search in various databases. A meta-analysis with a fixed-effect model was conducted, and the heterogeneity and inconsistency indices were assessed. The search identified 291 articles, of which 10 were eligible for inclusion in the study, and five articles published in 2012 were included in the meta-analysis. A previous meta-analysis showed the superiority of HBPM over OBP to predict all-cause mortality, CV mortality, and CV events. The meta-analysis of articles published in 2012 identified that HBPM was also a better predictor of proteinuria than OBP. In conclusion, the results of our systematic review and meta-analysis confirm that HBPM is a better predictor of CV outcomes and target organ damage than OBP.

Myocardial blush and microvascular reperfusion following manual thrombectomy during percutaneous coronary intervention for ST elevation myocardial infarction: insights from the TOTAL trial

AIMS Thrombectomy during primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) has been thought to be an effective therapy to prevent distal embolization and improve microvascular perfusion. The TOTAL trial (N = 10 732), a randomized trial of routine manual thrombectomy vs. PCI alone in STEMI, showed no difference in the primary efficacy outcome. This angiographic sub-study was performed to determine if thrombectomy improved microvascular perfusion as measured by myocardial blush grade (MBG). METHODS AND RESULTS Of the 10 732 patients randomized, 1610 randomly selected angiograms were analysable by the angiographic core laboratory. Primary outcomes included MBG and post-PCI thrombolysis in myocardial infarction (TIMI) flow grade. Secondary outcomes included distal embolization, PPCI complications, and each component of the complications. The primary end point of final myocardial blush (221 [28%] 0/1 for thrombectomy vs. 246 {30%} 0/1 for PCI alone group, P = 0.38) and TIMI flow (712 [90%] TIMI 3 for thrombectomy vs. 733 [89.5%] TIMI 3 for PCI alone arm, P = 0.73) was similar in the two groups. Thrombectomy was associated with a significantly reduced incidence of distal embolization compared with PCI alone (56 [7.1%] vs. 87 [10.7%], P = 0.01). In multivariable analysis, distal embolization was an independent predictor of mortality (HR 3.00, 95% CI 1.19-7.58) while MBG was not (HR 2.73, 95% CI 0.94-5.3). CONCLUSIONS Routine thrombectomy during PPCI did not result in improved MBG or post-PCI TIMI flow grade but did reduce distal embolization compared with PCI alone. Distal embolization and not blush grade is independently associated with mortality.

The pulmonary artery wedge pressure response to sustained exercise is time-variant in healthy adults

Objectives The clinical and prognostic significance of ‘exaggerated’ elevations in pulmonary artery wedge pressure (PAWP) during symptom-limited exercise testing is increasingly recognised. However, the paucity of normative data makes the identification of abnormal responses challenging. Our objectives was to describe haemodynamic responses that reflect normal adaptation to submaximal exercise in a group of community-dwelling, older, non-dyspnoeic adults. Methods Twenty-eight healthy volunteers (16 men/12 women; 55±6 years) were studied during rest and two consecutive stages of cycle ergometry, at targeted heart rates of 100 bpm (light exercise) and 120 bpm (moderate exercise). Right-heart catheterisation was performed to measure pulmonary artery pressures, both early (2 min) and after sustained (7 min) exercise at each intensity. Results End-expiratory PAWP at baseline was 11±3 mm Hg and increased to 22±5 mm Hg at early-light exercise (p<0.01). At sustained-light exercise, PAWP declined to 17±5 mm Hg, remaining elevated versus baseline (p<0.01). PAWP increased again at early-moderate exercise to 20±6 mm Hg but did not exceed the values observed at early-light exercise, and declined further to 15±5 mm Hg at sustained-moderate exercise (p<0.01 vs baseline). When analysed at 30 s intervals, mean and diastolic pulmonary artery pressures peaked at 180 (IQR=30) s and 130 (IQR=90) s, respectively, and both declined significantly by 420 (IQR=30) s (both p<0.01) of light exercise. Similar temporal patterns were observed at moderate exercise. Conclusions The range of PAWP responses to submaximal exercise is broad in health, but also time-variant. PAWP may routinely exceed 20 mm Hg early in exercise. Initial increases in PAWP and mean pulmonary artery pressures do not necessarily reflect abnormal cardiopulmonary physiology, as pressures may normalise within a period of minutes.

Heart Rate–Dependent Left Ventricular Diastolic Function in Patients With and Without Heart Failure

BACKGROUND Chronic heart rate (HR) reduction in the treatment of heart failure (HF) with systolic dysfunction is beneficial, but the immediate mechanical advantages or disadvantages of altering HR are incompletely understood. We examined the effects of increasing HR on early and late diastole in humans with and without HF. METHODS AND RESULTS We studied force-interval relationships of the left ventricle (LV) in 11 HF patients and 14 control subjects. HR was controlled by right atrial pacing, and LV pressure was recorded by a micromanometer-tipped catheter. The time constant of isovolumic relaxation (tau) was calculated, and simultaneous sonographic images were analyzed for LV volumes. The end-diastolic pressure-volume relationship (EDPVR) was analyzed with the use of a single-beat method. Tau was shortened in response to increasing HR in both groups; the slope of this relationship was steeper in HF than in control subjects. The predicted volume at a theoretic pressure of 0 mm Hg (V30) increased at higher HRs compared with baseline, shifting the predicted EDPVR compliance curve to the right in HF patients but not in control subjects. CONCLUSIONS In HF, changes in HR affect early relaxation and diastolic compliance to a greater extent than in control subjects. Our study reinforces current recommendations for HR-lowering drug treatment in HF.