Hélène Pierre

Night-time and diastolic hypertension are common and underestimated conditions in newly diagnosed apnoeic patients

Background In newly diagnosed apnoeic patients without a history of hypertension, clinical hypertension is underdiagnosed in at least 40% of the cases. An increase in diastolic blood pressure is the most frequent pattern encountered. Objective To assess clinic and 24-h blood pressure, baroreflex sensitivity and left ventricular mass for identifying the prevalence, the type and the consequences of hypertension in newly diagnosed apnoeic patients. Patients and methods Fifty-nine unselected patients (age = 48 ± 12 years, body mass index = 28.1 ± 4.5 kg/m2) referred to a university hospital sleep laboratory for symptoms suggesting obstructive sleep apnoea were included. Diagnosis of apnoea was accepted when respiratory disturbance index was ≥15/h of sleep. Blood pressure was considered as normal by their general practitioner and all of them were free of any medication for hypertension. Echocardiography, 24-hour ambulatory blood pressure monitoring and assessment of the baroreflex sensitivity were performed. Results Forty-two percent of the apnoeic patients demonstrated a clinical hypertension, 34 subjects (58%) had a daytime hypertension, and 45 patients (76%) had a night-time hypertension, using 24-h monitoring. All the daytime hypertensives also had night-time hypertension. Forty-seven of the 59 patients (80%) were hypertensive either in the clinic or using 24-h recording. Diastolic and systolo-diastolic hypertension were the prominent types of hypertension observed both by clinic or ambulatory measurements. Respiratory disturbance index was significantly higher in apnoeic patients suffering isolated diastolic hypertension than in the normotensives (50.9 ± 26.5/h versus 36.0 ± 12.3/h, respectively; P = 0.02). The prevalence rate of left ventricular hypertrophy was high (between 15 and 20%) and occurred independently of associated hypertension. Baroreflex sensitivity was altered whatever the type of hypertension and decreased with the severity of obstructive sleep apnoea. Conclusion Hypertension is hugely underdiagnosed in apnoeic patients unknown to be hypertensive. Use of 24-h blood pressure monitoring allowed the diagnosis of twice as much hypertension than did clinical measurement. Even at the beginning of their history of hypertension, apnoeic patients exhibited chronic adaptations of their cardiovascular system, as shown by early changes in baroreflex sensitivity and an increased prevalence of left ventricular hypertrophy.

Masked hypertension in obstructive sleep apnea syndrome.

Background Ambulatory blood pressure (BP) monitoring (ABPM) detects subjects with normal clinic but high ambulatory 24-h BP, that is, masked hypertension. Methods One hundred and thirty newly diagnosed obstructive sleep apnea syndrome (OSAS) patients, free of recognized cardiovascular disease were included (111 men, age = 48 ± 1 years, BMI = 27.6 ± 0.4 kg/m2, respiratory disturbance index (RDI = 42 ± 2/h). Clinic BP, 24-h ABPM, baroreflex sensitivity (BRS), echocardiography and carotid intima–media thickness (IMT) were assessed. Results Forty-one patients (31.5%) were normotensive, 39 (30.0%) exhibited masked hypertension, four (3.1%) white-coat hypertension and 46 (35.4%) hypertension. Significant differences were found between normotensive, masked hypertensive and hypertensive patients in terms of BRS (10.5 ± 0.8, 8.0 ± 0.6 and 7.4 ± 0.4 ms/mmHg, respectively, P < 0.001), carotid IMT (624 ± 17, 650 ± 20 and 705 ± 23 μm, respectively, P = 0.04) and left ventricular mass index (37 ± 1, 40 ± 2 and 43 ± 1 g/height2.7, respectively, P = 0.003). A clinic systolic BP more than 125 and a diastolic BP more than 83 mmHg led to a relative risk (RR) of 2.7 and a 90% positive predictive value for having masked hypertension. Conclusion Masked hypertension is frequently underestimated in OSAS and is nearly always present when clinic BP is above 125/83 mmHg.

EVAluation of the prognostic value of BARoreflex sensitivity in hypertensive patients: the EVABAR study.

Aims The prognostic value of baroreflex sensitivity in hypertensive patients has not much been studied. Method A cohort of 451 hypertensive patients without cardiovascular history was studied for an average of 6.2 ± 2.8 years follow-up. Each patient had a baroreflex sensitivity measurement by the sequence method, which is represented by the slope of up-sequences (systolic blood pressure+/pulse interval+) and down-sequences (systolic blood pressure−/pulse interval−) of spontaneous fluctuations in systolic blood pressure and pulse interval. Results During the follow-up, there were 20 deaths from any cause and 30 patients presented a major adverse cardiovascular event. Deaths and major adverse cardiovascular events were associated with a reduction in baroreflex sensitivity (systolic blood pressure+/pulse interval+ and systolic blood pressure−/pulse interval−). In multivariate analysis, the reduction in baroreflex sensitivity systolic blood pressure+/pulse interval+ was associated with an increased risk of deaths from any cause (Odds ratio 1.23; 95% confidence interval 1.02–1.67, P = 0.04). A baroreflex sensitivity systolic blood pressure+/pulse interval+ under 4.5 ms/mmHg was associated with a 2.5-increased relative risk of major adverse cardiovascular event (95% confidence interval 1.11–5.93, P = 0.03). However, multivariate analysis showed that baroreflex sensitivity systolic blood pressure−/pulse interval− was not associated either with death or major adverse cardiovascular events. Conclusions Reduction in baroreflex sensitivity marked by a reduction in vagal reflexes is an independent marker of the risk of mortality and major adverse cardiovascular events in hypertensive patients.

Structural and functional abnormalities of large arteries in the Turner syndrome

Objective: To analyse the structural and functional abnormalities in the large arteries in women with the Turner syndrome. Methods: Aortic stiffness (assessed by means of the carotid femoral pulse wave velocity), level of amplification of the carotid pressure wave (by applanation tonometry), and carotid remodelling (by high resolution ultrasound) were studied in women with the Turner syndrome. Clinical and ambulatory blood pressures were taken into account in the analysis. Thus, 24 patients with the Turner syndrome and 25 healthy female subjects matched for age were studied. Results: Women with the Turner syndrome had a higher augmentation index than the controls (Turner, mean (SD) 0.04 (0.14) v controls, −0.14 (0.13), p < 0.001) but a lower peripheral pulse pressure (39 (8) mm Hg v 47 (11) mm Hg, p  =  0.010 in the clinic; 44 (5) mm Hg v 47 (6) mm Hg, p  =  0.036 during the 24 hour ambulatory recording). The luminal diameter of the common carotid artery and the carotid–femoral pulse wave velocity were similar in the two groups, whereas carotid intima–media thickness tended to be higher in women with the Turner syndrome (0.53 (0.06) mm v 0.50 (0.05) mm, p  =  0.06). After correction for body surface area, carotid intima–media thickness and pulse wave velocity were higher in women with the Turner syndrome. Conclusions: Vascular abnormalities observed in the Turner syndrome are implicated in the origin of the cardiovascular complications that occur in this syndrome. These abnormalities are morphological but also functional. An increase in the augmentation index can be explained in part by the short height of these patients.

Early cardiovascular abnormalities in newly diagnosed obstructive sleep apnea

Obstructive sleep apnea (OSA) is associated with high cardiovascular morbidity and mortality. Recent studies have shown that it is associated with atherosclerosis and left ventricular dysfunction markers. The aim of this study was to assess the cardiovascular effects of OSA depending on its severity, in patients without clinically diagnosed cardiovascular disease. One hundred thirty newly diagnosed, nondiabetic OSA patients (mean age 49 ± 10 years), without vasoactive treatment were included. They underwent clinical and ambulatory blood pressure measurements, echocardiography, carotid ultrasound examination, and a carotid–femoral pulse wave velocity (PWV) measurement. Seventy-five percent of the subjects were hypertensive according to the clinical or ambulatory measurement. More patients with the most severe forms (respiratory disturbance index >37/hour) had a nondipper profile (52% vs 34%; P = 0.025) and their left ventricular mass was higher (40 ± 7 vs 36 ± 8 g/m, p = 0.014). This last parameter was independently and inversely associated with mean nocturnal oxygen saturation (P = 0.004). PWV and carotid intima-media thickness did not differ between one OSA severity group to another, but the prevalence of carotid hypertrophy was higher when mean SaO2 was below 93.5% (29.5 vs 16%; P = 0.05). Our study shows that in OSA patients without clinically diagnosed cardiovascular disease, there is a significant left ventricular and arterial effect, which is even more marked when OSA is severe.

Is there any real target organ damage associated with white-coat normotension?

Abstract.Subjects with white-coat normotension (WCNT) or masked hypertension, i. e. a normal office blood pressure (BP) reading but elevated ambulatory blood pressure monitoring (ABPM) results, have not been extensively studied. The aim of this work was to compare true normotensive subjects (NT), WCNT and nevertreated hypertensive subjects (HT, with elevated BP according to both office and ABPM readings). One hundred and fifty subjects were recruited to analyze cardiovascular characteristics. Office BP readings coupled with ABPM results were used to break this population down into 51 NT, 18 WCNT and 81 HT. Office BP readings were higher in WCNT than in NT. In WCNT, carotid-femoral pulse wave velocity (PWV) was higher than in NT (with a borderline significance p = 0.05) and the standing baroreflex sensitivity (BRS) was lower (p = 0.04). Left ventricular mass index (LVMI) and carotid intima-media thickness (IMT) tended to increase and BRS measurements tended to decrease from NT through WCNT to HT. However, the difference across the board is only significant (p < 0.05) between NT and HT. If only the subset of NT subjects with SBP readings comparable to those of the WCNT subjects (i. e. SBP > 120 mmHg) is considered, no significant difference is detected in PWV and the only difference is detected in BRS (respectively for standing [PS+/RR+]: 5.7 ± 1.4 ms/mmHg vs 4.9 ± 1.2 ms/mmHg, p = 0.04).In conclusion, the principal cardiovascular differences measured between the NT and the WCNT can probably be explained by their difference in clinical level of pressure at rest. Only the BRS remains different between NT and WCNT when the real level of clinical pressure is taken into account.

Hypertension diagnosis in obstructive sleep apnea: Self or 24-hour ambulatory blood pressure monitoring?

blood pressure monitoring? Jean-Philippe Baguet ⁎, Isabelle Boutin , Gilles Barone-Rochette , Patrick Levy , Renaud Tamisier , Hélène Pierre , Laetitia Boggetto-Graham , Jean-Louis Pépin d,e a Department of Cardiology, University Hospital, Grenoble, France b Bioclinic Radiopharmaceutics Laboratory, INSERM U1039, Joseph Fourier University, Grenoble, France c Respiratory and Sleep Medicine, Laval University, Quebec City, Canada d HP2 Laboratory (Hypoxia: Pathophysiology), INSERM U1042, Joseph Fourier University, Grenoble, France e Sleep Laboratory, EFCR, University Hospital, Grenoble, France

237 Assessment of blood pressure control after surgical treatment of acute thoracic aortic disease

Purpose Hypertension is an important predisposing factor for the occurrence of acute type A aortic dissection (AD) or intramural hematoma (AH), both conditions requiring urgent surgical treatment. It is also a recognized pejorative factor for morbidity and mortality after aortic surgery. Despite of this, the assessment of blood pressure (BP) control after surgical treatment of AD or AH is little studied. Method We performed a pilot study among patients treated by surgery for AD or AH between 1990 and 2005 in our institution. Clinical BP measurement and 24 hours ambulatory BP monitoring (ABPM) were performed especially for the study. Results Among the 217 patients of the cohort, 81 were died. We analyzed the results of the first 43 surviving patients (34 men, mean age = 66 + 10 years). Clinical BP parameters were: systolic BP = 148 + 24 mmHg and diastolic BP = 81 + 11mmHg. ABPM results were: 24-hours systolic BP = 127 + 15 mmHg and 24-hour diastolic BP = 70 + 9 mmHg). The mean number of drugs for hypertension was 2.6 + 1.2. Thirty two patients (72%) received a beta-blocker and 20 patients (46%) an angiotensin-converting enzyme inhibition. At mean follow-up of 14 years, Hypertension was diagnosed in 34 (79%), 26 (60%) of the patients using respectively clinic and ABPM. Conclusion In this very high cardiovascular risk population, only 21% and 40% patients were normotensives in clinic and in ABPM respectively. This result must be improved using a more systematic BP follow-up by cardiologists, particularly by using systematically ABPM. Moreover, the number of antihypertensive drugs must be increased to improve the BP control.