Luigina Guasti

Twenty-Four–Hour Noninvasive Blood Pressure Monitoring and Pain Perception

Although a hypertension-related hypalgesia has been described, the relation between pain perception and the 24-hour blood pressure trend is still unknown. The ambulatory blood pressure monitoring parameters and dental pain sensitivity were correlated in 67 male subjects. The pulpar test (graded increase of test current of 0 to 0.03 mA) was performed on three healthy teeth, and mean dental pain threshold (occurrence of pulp sensation) and pain tolerance (time when the subjects asked for the test to be stopped) were evaluated. Three groups of subjects with normal (n = 34), intermediate (n = 13), and high (n = 20) blood pressure values were identified according to ambulatory monitoring results. Pain threshold differed among the three groups (P < .02), being higher in the group with highest blood pressure. The groups of hypertensive subjects showed higher pain tolerance than the normotensive group (P < .02). Pain threshold was correlated with 24-hour, diurnal, and nocturnal blood pressure values. Pain tolerance was also related to 24-hour blood pressure and to diurnal and nocturnal diastolic and mean arterial pressure values. Systolic and diastolic blood pressure loads were significantly associated with pain threshold, and diastolic load was also associated with tolerance. The blood pressure variability (SD) did not relate to pain perception. The 24-hour arterial pressure was more closely associated with pain perception than the blood pressure values obtained before the pulpar test. A close correlation between pain perception and 24-hour ambulatory blood pressure was demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment with enalapril modifies the pain perception pattern in hypertensive patients.

The cardiovascular system shares numerous anatomic and functional pathways with the antinociceptive network. The aim of this study was to investigate whether angiotensin-converting enzyme (ACE) inhibitor treatment could affect hypertension-related hypalgesia. Twenty-five untreated hypertensive patients, together with a control group of 14 normotensive subjects, underwent dental pain perception evaluation by means of a pulpar test (graded increase of test current applied to healthy teeth). After the evaluation of the dental pain threshold (occurrence of pulp sensation) and tolerance (time when the subjects asked for the test to be stopped), all the subjects underwent a 24-hour ambulatory blood pressure monitoring. The hypertensive group then was treated with 20 mg/d enalapril, whereas the normotensive subjects remained without any treatment. After a time interval of 6+/-2 months, the dental pain sensitivity was retested in all the subjects, and ambulatory blood pressure was recorded during treatment in the hypertensive patients. At the first assessment, hypertensive patients showed a higher pain threshold than normotensive subjects (P<.001). On retesting of pain sensitivity in hypertensive patients, a significant decrease of both pain threshold and tolerance, leading to their normalization, was observed during treatment (P<.001 and P<.005, respectively), in the presence of reduced 24-hour and office blood pressure values. A slight, though significant, correlation was observed between variations in pain tolerance and baseline blood pressure changes occurring during treatment. During follow-up, the normotensive subjects did not show any significant pain perception or office blood pressure changes. Hypertension-related hypalgesia was confirmed. Mechanisms acting both through lowering of blood pressure and specific pharmacodynamic properties may account for the normalization of pain sensitivity observed in hypertensive patients during treatment with ACE inhibitors.

Endogenous beta-endorphins in hypertension: Correlation with 24-hour ambulatory blood pressure

OBJECTIVESnThe aims of this study were to determine whether hypertensive patients showed increased endogenous opioid tone and to find a possible correlation between beta-endorphin levels and 24-h ambulatory blood pressure. We also investigated whether circulating beta-endorphin levels were associated with pain perception at rest.nnnBACKGROUNDnExperimental studies suggest an involvement of the endogenous opioid system in cardiovascular control mechanisms.nnnMETHODSnWe determined baseline beta-endorphin plasma levels by radioimmunoassay in 81 consecutive subjects (48 hypertensive, 33 normotensive) after a 30-min rest and before 24-h ambulatory blood pressure monitoring. In 72 of 81 subjects with a dental formula suitable for the pulpar test (graded increase of test current -0 to 0.03 mA applied to three healthy teeth), pain perception was also investigated.nnnRESULTSnHypertensive patients showed higher beta-endorphin plasma levels than normotensive subjects (p < 0.002). Circulating endogenous opioid levels correlated with 24-h diastolic blood pressure (p < 0.01), whereas the relation with systolic pressure did not reach statistical significance. When 24-h blood pressure recordings were divided into daytime and nighttime values, and blood pressure loads (percent of measurements > or = 140 mm Hg for systolic blood pressure and > or = 90 mm Hg for diastolic pressure) were calculated, a significant correlation was found between beta-endorphin levels and diastolic pressures and load. Similarly, presampling diastolic blood pressure was significantly correlated with beta-endorphin levels. Of the 72 subjects tested, hypertensive patients showed a lower pain sensitivity than normotensive subjects. A positive correlation was found between pain threshold and circulating beta-endorphin levels (p < 0.05).nnnCONCLUSIONSnSustained arterial pressure is probably involved in the tonic activation of cardiovascular mechanisms linked to endogenous opioid tone. Circulating plasma endorphins may account, at least in part, for the pain perception pattern relating to blood pressure levels at rest.

Noninvasive evaluation of cardiotoxicity of 5-fluorouracil and low doses of folinic acid: A one-year follow-up study

PURPOSEnTo conduct a serial evaluation of the cardiac effects of antineoplastic therapy with 5-fluorouracil (5-FU) and low-dose folinic acid.nnnPATIENTS AND METHODSnSixteen patients with colon-rectal carcinoma, without cardiac disease, treated with 400 mg/ m2/die of 5-FU and 20 mg/m2/die of folinic acid for five days, once a month, for six months. Parameters evaluated: blood pressure, ECG, two-dimensional and digitized M-mode echocardiograms before and after the first and fifth drug administrations of the first cycle, after the fifth drug administration of the sixth cycle and six months after the treatment.nnnRESULTSnBlood pressure, heart rate, left ventricular (LV) diameter and LV mass index did not change; all of the patients showed a decrease in the peak shortening rate of the LV diameter index of systolic function, and of the peak lengthening rate of the LV diameter and peak thinning rate of LV posterior wall, indexes of diastolic function, with abnormal values in 11 patients at the end of treatment LV wall motion remained normal in all; two patients developed transient T wave inversion without chest pain and with normal cardiac enzymes and myocardial scintigraphy during dypiridamole stress test. Six months after the treatment all indexes of LV systolic and diastolic function had returned within the normal limits and were similar to pre-treatment values.nnnCONCLUSIONSn5-FU and low-dose folinic acid treatment induced a decrease of LV systolic function and an impairment of diastolic function, that developed without symptoms and were transient and reversible.

Hyperinsulinemia, family history of hypertension, and essential hypertension

The aim of this study was the evaluation of the relationships among hyperinsulinemia, a family history of hypertension, and essential hypertension. Insulin and C-peptide responses to an oral glucose load were studied in 175 lean normotensives (N) and untreated hypertensives (H) with (F+) and without (F-) a family history of hypertension: 30 NF-, 30 NF+, 45 HF-, and 70 HF+. The groups were comparable for age, sex, body mass index, and blood pressure. The following parameters were evaluated: plasma glucose (G), serum insulin (I), and C-peptide (Cp) before and 30, 60, 90, and 120 min after the glucose load, fasting glucose/insulin ratio (ISI), fasting insulin/C-peptide ratio (I/Cp), and 24-h ambulatory blood pressure monitoring. Plasma glucose was measured, fasting and during the test, and it and I/Cp were similar in the four groups. Serum insulin and Cp, both fasting and stimulated, were significantly higher and ISI lower in normotensives and hypertensives with hypertensive parents. Grouping the subjects first on the basis of blood pressure and then on the basis of family history, no differences were found between normotensives and hypertensives, whereas I and Cp, fasting and stimulated, were significantly higher and ISI lower in subjects with positive as compared to negative family history. The closest correlations between insulin and ambulatory blood pressure were found in normotensive with hypertensive parents; in hypertensives with hypertensive parents we only found a direct correlation between fasting Cp and nocturnal blood pressure fall; in hypertensives with normotensive parents insulin inversely correlated with nocturnal blood pressure fall. Insulin resistance seems to have a familial basis, independently of the presence of hypertension. Instead of showing a causal relationship between insulin resistance and hypertension, our results indicate that the two are partly independent components of a common familial pattern.

Influence of family history of hypertension on insulin sensitivity in lean and obese hypertensive subjects

We evaluated the influence of family history of hypertension on insulin sensitivity in lean and obese hypertensive subjects (H): 40 lean [body mass index (BMI) u200325u2003kgu2003m−2] H with normotensive parents (F−), 50 lean H with one or two parents hypertensive (F+), 30 obese HF− (BMI u200330u2003kgu2003m−2) and 35 obese HF+. The four groups were comparable in terms of age, sex and ambulatory blood pressure values. We evaluated glucose, insulin and C‐peptide before and 30, 60, 90 and 120u2003min after an oral glucose load, insulin sensitivity index (ISI, fasting glucose/insulin ratio), fasting insulin/C‐peptide ratio (I/Cp). Glucose, fasting and during test, and I/Cp were similar among the four groups; insulin and C‐peptide, fasting and stimulated, were significantly higher and ISI lower in obese H than in lean H; at similar BMI, insulin and C‐peptide were significantly higher in F+ than in F−. Insulin directly correlated with night‐time blood pressure only in lean HF−. The correlation between insulin and BMI was significantly closer in F− than in F+. In conclusion, family history of hypertension appears to play a relevant role in insulin sensitivity in hypertensive subjects also in the presence of obesity.

A modified ajmaline test for prediction of the effective refractory period of the accessory pathway in the wolff-parkinson-white syndrome

Patients with the Wolff-Parkinson-White syndrome in whom the atrioventricular accessory pathway has a short anterograde effective refractory period (ERP) are considered at risk of sudden death if atrial fibrillation occurs. 1 Administration of ajmaline during sinus rhythm (50-mg intravenous bolus over 3 minutes) has been suggested as a test for identifying patients with an accessory pathway ERP shorter than 270 ms; in such patients the drug usually does not block anterograde conduction over the accessory pathway. 2 This study evaluates (1) the relation between dose of ajmaline, injected at a constant rate of 10 mg/min, blocking conduction over the accessory pathway, and duration of the accessory pathway ERP; (2) the reproducibility of the test, so modified; and (3) the possibility of predicting accessory pathway ERP on the basis of the dose of ajmaline blocking conduction over the accessory pathway. Thirty-two consecutive patients (21 men, 11 women), mean age 34 4- 15 years, with Wolff-ParkinsonWhite syndrome were studied. During continuous 6lead (I, II, III, V1,V~ and V6) electrocardiographic recording, ajmaline was administered intravenously at a constant rate of 10 mg,/min up to conduction block of the accessory pathway or a maximum total dose of 100 mg. The next day, after the patient gave informed written consent, electrophysiologic study was performed; the anterograde accessory pathway ERP was determined as the longest atrial premature beat interval not followed by anterograde conduction over the accessory pathway, at a driven rate 10 beats/rain faster than sinus rate. In 15 patients the ajmaline test was repeated after 24 to 72 hours. In 6 of the first 22 patients treated, ajmaline did not block conduction aver the accessory pathway: in 2 of them the accessory pathway ERP could not be determined because it was less than atrial refractoriness (250 and 200 ms, respectively) and in 4 the mean acces

Clinical Feasibility of Echocardiographic Automated Border Detection in Monitoring Left Ventricular Response to Acute Changes of Preload in Normal Subjects

Echocardiographic automated border detection (ABD) provides an instantaneous measurement of left ventricular (LV) volume and its rate of change. We tested the clinical feasibility of ABD in monitoring on-line LV response to acute changes in preload. We examined 20 healthy males in the supine position, with legs elevated, back in the supine position, 5 min after the inflation of blood pressure cuffs at the root of the four limbs, 5 min after the deflation of cuffs. End-diastolic and end-systolic LV volumes significantly increased with elevated legs and decreased during cuff inflation; ejection fraction remained unchanged. Peak filling and peak emptying rates did not change with elevated legs and increased significantly during cuff inflation. The values of LV parameters were stable in the three resting conditions, demonstrating a good reproducibility of the ABD technique. Our results demonstrate that ABD may be useful in clinical practice for monitoring on-line small acute changes in LV volume and function.

785-2 Clinical Feasibility of Echocardiographic Automated Boundary Detection in Monitoring Left Ventricular Response to Acute Changes of Preload in Normal Subjects

Automated Boundary Detection (ABD), recently incorporated into standard echocardiographic system, provides an on-line instantaneous measurement of left ventricular (LV) volume and its derivative as a function of time (dV/dt). The aim of our study was to test the clinical feasibility of ABD in monitoring acute LV changes. We evaluated the LV response to acute changes in preload in 15 normal males (mean age 32xa0±xa06 years), examined 5 times: in the supine position (A). with legs elevated 45° to 60° (B), back in the supine position (C), 5’ after the simultaneous inflation of blood pressure cuffs at the root of the 4 limbs (D) (pressure of the cuffs set at 10xa0mmHg below the basal diastolic pressure of each subject) and back in the supine position (E). Real time LV volumes by ABD were obtained in the 4 chamber view, with gains optimized to detect the most continuous ABD. We evaluated: systolic (SBP) and diastolic blood pressure (DB PI, heart rate (HR), LV end-diastolic (EDV) and end-systolic volume (ESV). ejection fraction (EF). normalized peak filling rate (PFR), defined as maximal positive dVldt, and normalized peak ejection rate (PER), defined as maximal negative dVldt, both standardized for EDV. A B C D E SBP (mmHg) 119xa0±xa012 122xa0±xa011 120xa0±xa010 117xa0±xa010 121xa0±xa011 DBPlmmHg) 77xa0±xa06 79xa0±xa06 76xa0±xa08 77xa0±xa05 78xa0±xa05 HR (bimini 66xa0±xa04 68xa0±xa06 65xa0±xa05 66xa0±xa05 67xa0±xa06 EDV(ml) 91xa0±xa022 102xa0±xa030 * 89xa0±xa020 75xa0±xa021 ** 87xa0±xa019 ESV(mll) 33xa0±xa010 43xa0±xa011 * 35xa0±xa013 26xa0±xa011 * 32xa0±xa09 EF % 61xa0±xa010 57xa0±xa09 60xa0±xa0 8 64xa0±xa010 59xa0±xa07 PFR (mllsec) 448xa0±xa00.7 4.49xa0±xa006 4.45xa0±xa00.7 5.03xa0±xa00.7 * 451xa0±xa008 PER (mllsec) 4.20xa0±xa00.5 4.00xa0±xa004 4 0.14xa0±xa00.5 4.77xa0±xa00.5 ** 4.23xa0±xa006 * p l 0.005; ** P l 0.001 Bvs A, D vs C Measurements in A, C and Ewere practically identical, thus demonstrating a good reproducibility of the ABD technique. Our results demonstrate that ABO can be used in clinical practice when acute changes in LV volume and its rate of change are to be monitored.