János Nemcsik

Ambulatory arterial stiffness in chronic kidney disease: a methodological review.

Cardiovascular mortality is the leading cause of death in chronic kidney disease (CKD) and end-stage renal disease (ESRD). This can be explained in part by an increased and progressive calcification of the medial layer of the large arteries leading to arterial stiffening. The prognostic value of measurements of arterial stiffness, especially pulse wave velocity (PWV), in the general population and in CKD and ESRD patients is high, and is above that of traditional risk factors with respect to cardiovascular outcome. In recent years, as an alternative to office measurements, methods for monitoring ambulatory arterial stiffness have been developed. The ambulatory arterial stiffness index (AASI) allows derivation of a parameter from ambulatory blood pressure measurements; however, doubts have emerged about the usefulness of this parameter. Recently, new oscillometric methodologies using simple brachial cuffs, such as Mobil-O-Graph, Vasotens or Arteriograph 24, have been introduced. They measure parameters of 24-h arterial stiffness including PWV, augmentation index and central blood pressure. This enables study of the 24-h variability of these parameters, which will hopefully lead to better cardiovascular risk stratification and improved cardiovascular outcomes of patients. Our review summarizes the present data and future directions of AASI and the methods for monitoring oscillometric 24-h stiffness in different patient populations and especially in CKD.

Case report of exercise and statin-fibrate combination therapy-caused myopathy in a patient with metabolic syndrome: contradictions between the two main therapeutic pathways

BackgroundLifestyle modifications including exercise are beneficial and fundamentally part of the therapy of metabolic syndrome, although in most of the cases medical interventions are also required to reach the target values in the laboratory parameters. Statin and fibrate combination therapy is considered to be safe and effective in dyslipidaemia and metabolic syndrome. However, increased physical activity can enhance the statin and fibrate-associated myopathy. Myositis and the rare but life-threatening rhabdomyolysis are causing a conflict between exercise and statin-fibrate therapy, which is yet to be resolved.Case presentationWe present a case of a 43-year-old Caucasian man with metabolic syndrome who had the side-effect of exercise and drug-associated myositis. The patient had only transient moderate complaints and rhabdomyolysis could be avoided with the one-month creatine kinase control, a test which is not recommended routinely by the new guidelines.ConclusionsWe would like to turn the spotlight on the possible complications of statin-fibrate therapy and exercise, when strict follow-up is recommended. In this condition high number of patients can be affected and the responsibility of general practitioners is accentuated.

Association of affective temperaments with blood pressure and arterial stiffness in hypertensive patients: a cross-sectional study

BackgroundAffective temperaments (anxious, depressive, cyclothymic, irritable and hyperthymic) measure subclinical manifestations of major mood disorders. Furthermore, cumulating evidence suggests their involvement in somatic disorders as well. We aimed to assess associations between affective temperament scores and blood pressure and arterial stiffness parameters in hypertensive patients.MethodsIn this cross-sectional study, 173 patients with well-controlled or grade 1 chronic hypertension, with no history of depression, completed the TEMPS-A, Beck Depression Inventory (BDI) and Hamilton Anxiety Scale (HAM-A) questionnaires in three GP practices. Arterial stiffness was measured with tonometry (PulsePen).ResultsAccording to multiple linear regression analysis, cyclothymic temperament score was positively associated with brachial systolic blood pressure independently of age, sex, total cholesterol, brachial diastolic blood pressure, BDI, HAM-A and the use of alprazolam (βu2009=u20090.529, pu2009=u20090.042), while hyperthymic temperament score was negatively related to augmentation index independent of age, sex, smoking, heart rate, BDI, HAM-A and the use of alprazolam (βu2009=u2009-0.612, pu2009=u20090.013). A significant interaction was found between cyclothymic temperament score and sex in predicting brachial systolic blood pressure (pu2009=u20090.025), between irritable and anxious temperament scores and sex in predicting pulse wave velocity (pu2009=u20090.021, pu2009=u20090.023, respectively) and an interaction with borderline significance between hyperthymic temperament score and sex in predicting augmentation index (pu2009=u20090.052).ConclusionsThe present findings highlight elevated blood pressure among subjects with high cyclothymic temperament as well as an increased level of arterial stiffening in subjects with low hyperthymic scores suggesting that affective temperaments may play a role in the development of hypertension and arterial stiffening and may thus represent markers of cardiovascular risk. Sex differences were also present in these associations.

Hyperthymic affective temperament and hypertension are independent determinants of serum brain-derived neurotrophic factor level

BackgroundBrain-derived neurotrophic factor (BDNF) has neuroprotective, proangiogenic and myogenic effects and, therefore, possibly acts as a psychosomatic mediator. Here, we measured serum BDNF (seBDNF) level in hypertensive patients (HT) and healthy controls (CONT) and its relation to affective temperaments, depression and anxiety scales, and arterial stiffness parameters.MethodsIn this cross-sectional study, affective temperaments, anxiety, and depression were studied with questionnaires (TEMPS-A, HAM-A, and BDI, respectively). SeBDNF level and routine laboratory parameters were measured as well. Arterial stiffness was evaluated with a tonometric method.ResultsAllover, 151 HT, and 32 CONT subjects were involved in the study. SeBDNF level was significantly higher in HT compared to CONT (24880xa0±xa08279 vs 21202.6xa0±xa06045.5xa0pg/mL, pxa0<xa00.05). In the final model of regression analysis, hyperthymic temperament score (Betaxa0=xa0405.8, pxa0=xa00.004) and the presence of hypertension (Betaxa0=xa06121.2, pxa0=xa00.001) were independent determinants of seBDNF. In interaction analysis, it was found that in HT, a unit increase in hyperthymic score was associated with a 533.3 (95xa0%CI 241.3–825.3) pg/mL higher seBDNF. This interaction was missing in CONT.ConclusionsOur results suggest a complex psychosomatic involvement of BDNF in the pathophysiology of hypertension, where hyperthymic affective temperament may have a protective role. BDNF is not likely to have an effect on large arteries.

Identification of hypertensive patients with dominant affective temperaments might improve the psychopathological and cardiovascular risk stratification: a pilot, case–control study

BackgroundAlthough mood disorders and cardiovascular diseases have widely studied psychosomatic connections, data concerning the influence of the psychopathologically important affective temperaments in hypertension are scarce. To define a possibly higher cardiovascular risk subpopulation we investigated in well-treated hypertensive patients with dominant affective temperaments (DOM) and in well-treated hypertensive patients without dominant temperaments the level of depression and anxiety, arterial stiffness and serum Brain-derived Neurotrophic Factor (seBDNF).Methods175 hypertensive patients, free of the history of psychiatric diseases, completed the TEMPS-A, Beck Depression Inventory and Hamilton Anxiety Scale questionnaires in two primary care practices. Of those 175 patients, 24 DOM patients and 24 hypertensive controls (matched in age, sex and the presence of diabetes) were selected for measurements of arterial stiffness and seBDNF level.ResultsBeck and Hamilton scores in DOM patients were higher compared with controls. Pulse wave velocity and augmentation index did not differ between the groups while in the DOM patients decreased brachial systolic and diastolic and central diastolic blood pressures were found compared with controls. SeBDNF was lower in the DOM group than in the controls (22.4xa0±xa07.2 vs. 27.3xa0±xa07.8xa0ng/mL, pxa0<xa00.05).ConclusionsAlthough similar arterial stiffness parameters were found in DOM patients, their increased depression and anxiety scores, the decreased brachial and central diastolic blood pressures as well as the decreased seBDNF might refer to their higher vulnerability regarding the development not only of major mood disorders, but also of cardiovascular complications. These data suggest that the evaluation of affective temperaments should get more attention both with regard to psychopathology and cardiovascular health management.

Measurement of Arterial Stiffness: A Novel Tool of Risk Stratification in Hypertension

Cardiovascular diseases are the leading causes of morbidity and mortality in industrialized countries worldwide, despite highly effective preventive treatments available. As a difference continues to exist between the estimated and true number of events, further improvement of risk stratification is an essential part of cardiovascular research.Among hypertensive patients measurement of arterial stiffness parameters, like carotid-femoral pulse wave velocity (cfPWV) or brachial-ankle pulse wave velocity (baPWV) can contribute to the identification of high-risk subpopulation of patients. This is a hot topic of vascular research including the possibility of the non-invasive measurement of central hemodynamics, wave reflections and recently, 24-h arterial stiffness monitoring as well. This chapter discusses the past and the present of this area including the scientific achievements with cfPWV, baPWV and other measures, provides a short overview of methodologies and the representation of arterial stiffness parameters in guidelines.

INTEGRATED CENTRAL PRESSURE-STIFFNESS SCORE, A POTENTIAL NEW TOOL FOR CARDIOVASCULAR RISK STRATIFICATION: FIRST RESULTS IN CHRONIC KIDNEY DISEASE

Objective: To develop an integrated central pressure-stiffness (ICPS) score to predict cardiovascular events. Design and method: One hundred chronic kidney disease (CKD) patients on conservative therapy were included in our study. Pulse wave velocity (PWV), central systolic blood pressure (cSBP) and central pulse pressure (cPP) were measured. A score was assigned to tertiles of PWV (0 to 2), cSBP (0 to 2) and cPP (0 to the first and second and 1 to the third tertile) based on each parameters ability to individually predict cardiovascular events. The sum of these scores (ICPS) and three ICPS risk categories as predictors were studied. Finally, we compared discrimination of the ICPS risk categories with that of the Framingham CVD score. Results: High (ICPS 3 to 4; nu200a=u200a37) and very high risk ICPS risk categories (ICPS 5; nu200a=u200a12) had an increased cardiovascular risk (HR: 4.95, 95%CI: 1.97–12.42, HR: 9.73, 95%CI: 3.06–20.23, respectively) compared to the average risk group (ICPS 0 to 2; nu200a=u200a51). The very high ICPS risk category remained an independent predictor (HR: 4.87, 95%CI: 1.81–13.08) in a model further adjusted for the Framingham CVD score (HR: 1.66, 95%CI: 1.13–2.43 per 1 SD increase). When comparing discrimination of the Framingham score (Harrellsu200aC: 0.704, 95%CI: 0.625–0.784) and with ICPS added to the Framingham score (C: 0.729, 95%CI: 0.647–0–810), the difference was not significant probably due to the limited power of our study. Conclusions: The ICPS score may clinically importantly improve the identification of CKD patients with elevated cardiovascular risk, but larger studies are required.

Inverse association between hyperthymic affective temperament and coronary atherosclerosis: A coronary computed tomography angiography study

OBJECTIVEnA bidirectional relationship exists between psychiatric disorders and cardiovascular diseases, however less is known with regards to personality traits. Accumulating data suggest that affective temperaments are both associated with psychiatric and somatic diseases. The aim of our study was to evaluate the associations between different affective temperaments and the presence of coronary atherosclerosis.nnnMETHODSn200 consecutive patients referred to coronary computed tomography angiography (CCTA) due to suspected coronary artery disease (CAD) were included in our study. Medical history and demographic parameters were recorded and all patients completed the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) and the Beck Depression Inventory (BDI). The presence of coronary artery disease was evaluated based on the CCTA images.nnnRESULTSn39 patients were free of any coronary atherosclerosis (CCTA-) and 161 had coronary atherosclerosis (CCTA+). Hyperthymic affective temperament score was higher in CCTA- subjects as compared to CCTA+ (13.1±3.0 vs 11.5±4.6, p=0.010, respectively). Hyperthymic affective temperament score showed a significant independent, inverse relationship with coronary atherosclerosis (OR: 0.91 CI: 0.82-0.99, p=0.04).nnnCONCLUSIONnOur results suggest that hyperthymic affective temperament is independently associated with the absence of CAD. It requires further research to delineate the mechanism mediating the effect of hyperthymia on better coronary artery health and establishing potential biochemical or behavioral factors, both of which could be exploited for prevention and treatment purposes. But it is plausible, that the evaluation of affective temperaments have importance both in relation with psychiatric and cardiovascular disorders.

THE METHOD OF DISTANCE MEASUREMENT AND TORSO LENGTH INFLUENCES THE RELATIONSHIP OF PULSE WAVE VELOCITY TO CARDIOVASCULAR MORTALITY: PP.31.235

Objective: The method of estimating the distance traveled by the pulse wave, used in the calculation of pulse wave velocity (PWV), is not standardized. Our objective was to assess whether different methods of distance measurement influenced the association of PWV to cardiovascular mortality in hemodialysis patients. Design and Methods: 98 chronic hemodialysis patients had their PWV measured using three methods for distance estimation; PWV1: sternal notch–femoral site minus sternal notch–carotid site, PWV2: carotid–femoral site, PWV3: carotid–femoral site minus sternal notch–carotid site. Carotid–femoral distance was used to approximate torso length. Patients were followed for a median of 30 (range 1–51) months and the association of PWV and cardiovascular mortality was assessed using survival analysis before and after stratification for torso length. Results: The three methods resulted in significantly different PWV values (11.2 (3.3), 14.8 (4.2), 12.6 (3.7) m/s, respectively). During follow up 50 patients died (mortality rate 20.3/100 patient years), 32 of cardiovascular causes. In log-rank tests only PWV1 tertiles but not those of PWV2 or PWV3 were significantly related to outcome (p-values 0.017, 0.257, 0.138, respectively). In adjusted Cox proportional hazards regression only PWV1 was related to cardiovascular mortality (HR for 1m/s higher PWV 1.18[1.03–1.35], 1.10[0.99–1.21], 1,13[1.00–1.27], for the three PWVs respectively). In stratified analysis, however, among patients with below median torso length all three PWV values were related to outcome, while in patients with above median torso length neither PWV methods resulted in significant relationship to outcome. Conclusion: PWV calculated using the sternal notch–femoral distance minus sternal notch–carotid distance provides the strongest relationship to cardiovascular mortality. Longer torso weakens the predictive value of PWV, possibly due to more tortuosity of the aorta hence more error introduced when using surface tape measurements.