Luis Camera

Diastolic Pressure Underestimates Age-Related Hemodynamic Impairment

It has been hypothesized that as large arteries become more rigid with age, the pattern of hypertension changes from diastolic to systolic. Thus, diastolic blood pressure (DBP) may lose its ability to reflect the increase in vascular resistance with age. To assess this, we studied the age-related changes in blood pressure pattern and its steady-state and pulsatile determinants. We performed an epidemiological analysis based on a national survey of 10,462 subjects from Argentina. A hemodynamic analysis (impedance cardiography) was then carried out in 636 consecutive hypertensive patients (age, 25 to 74 years). Whereas the rate of increment in the prevalence of mild to moderate hypertension (MMH) reached a plateau after the sixth decade, isolated and borderline systolic forms of hypertension began a steep and sustained rise. Among patients with MMH, DBP remained stable from the third to the seventh decade, whereas SBP maintained a sustained increase. Despite similar DBP, the systemic vascular resistance index increased 47% (P<.01) and the cardiac index decreased 27% (P<.01), whereas the ratio of stroke volume to pulse pressure, an index of arterial compliance, decreased 45% (P<.01). However, there were no significant differences between older patients with MMH and those with isolated systolic hypertension in the level of SBP, vascular resistance, stroke volume, and cardiac index. Compared with age-matched normotensive control subjects, the ratio of stroke volume to pulse pressure was much more reduced in isolated systolic hypertension (48%) than in MMH (30%). In summary, the present study, carried out in a large sample of hypertensive subjects with a wide age range, showed a simultaneous impairment in vascular resistance and arterial compliance associated with aging in different patterns of hypertension. The magnitude of these changes, with opposite effects on DBP but additive effects on SBP, suggests that a hemodynamic mechanism could determine the transition in the prevalence of diastolic hypertension toward a systolic pattern of hypertension with aging. Also, the results suggest that SBP, but not DBP, is a reliable indicator of the underlying hemodynamic abnormalities (high resistance and low arterial compliance) in the elderly.

Gait disorders are associated with non-cardiovascular falls in elderly people: a preliminary study

BackgroundThe association between unexplained falls and cardiovascular causes is increasingly recognized. Neurally mediated cardiovascular disorders and hypotensive syndromes are found in almost 20 percent of the patients with unexplained falls. However, the approach to these patients remains unclear. Gait assessment might be an interesting approach to these patients as clinical observations suggests that those with cardiovascular or hypotensive causes may not manifest obvious gait alterations. Our primary objective is to analyze the association between gait disorders and a non-cardiovascular cause of falls in patients with unexplained falls. A second objective is to test the sensitivity and specificity of a gait assessment approach for detecting non-cardiovascular causes when compared with intrinsic-extrinsic classification.MethodsCross-sectional study performed in a falls clinic at a university hospital in 41 ambulatory elderly participants with unexplained falls. Neurally mediated cardiovascular conditions, neurological diseases, gait and balance problems were assessed. Gait disorder was defined as a gait velocity < 0.8 m/s or Tinetti Gait Score <9. An attributable etiology of the fall was determined in each participant. Comparisons between the gait assessment approach and the attributable etiology regarding a neurally mediated cardiovascular cause were performed. Fisher exact test was used to test the association hypothesis. Sensitivity and specificity of gait assessment approach and intrinsic-extrinsic classification to detect a non-cardiovascular mediated fall was calculated with 95% confidence intervals (CI95%).ResultsA cardiovascular etiology (orthostatic and postprandial hypotension, vasovagal syndrome and carotid sinus hypersensitivity) was identified in 14% of participants (6/41). Of 35 patients with a gait disorder, 34 had a non-cardiovascular etiology of fall; whereas in 5 out of 6 patients without a gait disorder, a cardiovascular diagnosis was identified (p < 0.001). Sensitivity and specificity of the presence of gait disorder for identifying a non-cardiovascular mediated cause was 97.1% (CI95% = 85–99) and 83% (CI95% = 36–99), respectively.ConclusionIn community dwelling older persons with unexplained falls, gait disorders were associated with non-cardiovascular diagnosis of falls. Gait assessment was a useful approach for the detection of a non-cardiovascular mediated cause of falls, providing additional value to this assessment.

Recent Respiratory Infection Predicts Atherothrombotic Stroke: Case―Control Study in a Buenos Aires Healthcare System

Background and Purpose— Increasing evidence links infections to atherosclerosis. Case–control and cohort studies have found that infections, especially respiratory and dental, are associated with coronary heart disease. However, data on the association of infections with cerebrovascular disease are limited, especially beyond Europe and the United States. We assessed the relationship between recent infections and atherothrombotic disease in a South American cohort. Methods— We conducted a case–control study of 105 cases and 354 control subjects in a Buenos Aires healthcare system matched by age (mean age, 73.2±12.3 and 72.9±12.8 years), sex, and major cardiovascular risk factors. Cases were patients hospitalized with atherothrombotic ischemic stroke from December 2006 to October 2007. Control subjects were randomly assigned from an electronic outpatient database. Data from the preceding year on inpatient and ambulatory respiratory, urinary and abdominal infections as well as peripheral white blood cell count were collected. Results— Infections were more frequent in cases than control subjects (29% versus 13%; OR, 2.6; 95% CI, 1.4 to 4.5; P=0.0004); however, this was driven by community-acquired respiratory tract infections (19% versus 6%; OR, 3.9; 95% CI, 1.9 to 8; P<0.001) because there were no differences between cases and control subjects for other types of infection. Respiratory tract infections were the most prevalent type of infection during the 3 months before an atherothrombotic ischemic event, occurring more in cases compared with control subjects (17% versus 4%; OR, 5; 95% CI, 2.2 to 11.3; P<0.001). In multivariable analysis adjusting for major vascular risk factors, history of respiratory infection in the prior year was associated more with cases than control subjects (OR, 4.9; 95% CI, 2.3 to 10.2;P<0.001). White blood cell count was slightly higher in cases versus control subjects (7602±2058 versus 7121.6±1947, P=0.01). Conclusion— In this South American cohort, recent respiratory tract infections were significantly associated with atherothrombotic stroke, suggesting that prompt identification and treatment of individuals with or at risk for these infections may mitigate the burden from this type of stroke.

Lack of effective blood pressure control among an elder hypertensive population in Buenos Aires.

Our purpose was to determine the level of awareness, treatment, and control of hypertension in a population of subjects aged 65 or more. We studied a random sample from the national health care program in Buenos Aires. Letters were mailed to 1000 selected individuals. Among those eligible, 41.4% (n = 414) were enrolled. The mean age was 73.8 years and 68% were women. Prevalence of hypertension in our sample was 77.5% (n = 321). Awareness of hypertension was 60.7% (n = 195). Fifty-four percent (n = 173) of the hypertensive subjects were receiving pharmacologic treatment and only 18.5% (n = 32) of them were controlled. These results show that there is a low level of awareness, pharmacologic treatment, and control of hypertension in the studied elderly subjects.

Prevalence of hyperhomocysteinemia in an elderly population

BACKGROUND Currently, total hyperhomocysteinemia (tHHcy) is a well-known condition linked to a higher risk of vascular disease. Prevalence of HHcy increases in elderly persons as the risk associated with it persists. Because factors can be potentially reduced in the elderly, it is important to carry out epidemiologic studies of HHcy. PROCEDURE Previously we described the prevalence of hypertension control in an elder population; now, in an observational cross-sectional simple blind study, total homocysteine (tHcy) concentration was determined in 196 of 400 patients from the original cohort. RESULTS Mean Hcy concentration was 13.2 ,amol/L (95% confidence interval 12.4-14.0; range, 5.0 to 48.9); 15.0 ,imol/L for men and 12.3 pAmol/L for women. Mean serum folic acid levels were 4.9 + 3.1 ng/mL (range, 2.0 to 20.0 ng/mL), and vitamin B12 levels were 384.8 314.1 pg/mL (range, 48.0 to 1500.0 pg/mL). Taking into account the reference values established by the Third National Health and Nutrition Examination Survey III study, HHcy was detected in 69.8% of all the subjects evaluated. The study showed that 76.2% of the men and 66.4% of the women had high Hcy levels. CONCLUSIONS The very high prevalence of tHHcy in the elderly population, and the consequent risks associated with it suggest that although there are no trials that effectively prove the benefit of tHcy decrease, nutritional intervention is still justified.

Prevención de eventos cardiovasculares en hipertensos mayores de 65 años bajo el cuidado de un programa de control: Estudio de cohorte

Introduction: We started on year 2000 a Complex Intervention Program addressed at hypertension control among our patients. Aim: To compare the risk of cardiovascular events and of dying in hypertensive patients under Program care. Method: We started follow-up of a cohort of 1922 patients over 65 years in August 2000. Hipertension diagnosis was ascertained if patient reported to be hypertensive, or was under anti hypertensive treatment or if he/she had two blood pressure measurements ≥ 140/90 mm Hg. Cardiovascular events were considered to be admissions due to coronary disease, cardiac insufficiency or stroke. Incidence is reported by 100 person years follow-up. Relative risks between hypertensive and normotensive patients were calculated and Cox regresidn was used to adjust for potential confounders. We compared time to first cardiovascular event and to death with Log Rank Test. Results: Fourty eight point three percent of patients were hypertensive and differed from normotensive patients as to age (79 (5) years vs. 77 (5) p < 0.001), proportion of diabetic patients (16.1% vs. 7.6% p < 0.001). Mean follow-up time was 28 months. Mortality RR was 1.04 (95% CI 0.69-1.58). As to incidence of cardiovascular events it was 1.86 in normotensive vs. 3.02 (RR 1.62 95% CI 1.09-2.42). When adjusted by age, sex, smoking, dislipemia and diabetes, OR was 1.3 (95% CI 0.86-1.98) Conclusions: Hypertension did not increase the risk in cardiovascular events among our hypertensive patients at 2.3 years follow-up.

Abstract WMP63: Neuroimaging Findings and Incidence of Atrial Fibrillation on Follow-up in Patients With Embolic Stroke of Undetermined Source

Background and purpose: paroxysmal AF is detected during follow-up in approximately 30% of ESUS. We aim to identify patterns of brain lesions suggestive of embolic events and to evaluate the incide...

DIAGNOSTIC PERFORMANCE OF THE EXTENDED FUNCTIONAL STUDY (EFE) FOR COMPLEX ACTIVITIES OF DAILY LIVING IN PATIENTS WITH MILD COGNITIVE IMPAIRMENT (MCI) AND CONTROLS

memory complaints (MAC-Q 25). 17 were excluded from the study. Thus, the final sample consisted of 91 patients (14,28% with spontaneous complaints and 85,72% with inquired complaints). 26,37% were men and 73,63% were women (mean age 67,6 years; mean educational level of 4 for 8 years); 56% are married. 13,18% were alcoholics, 10,99% were smokers and 24,17% reported regular practice of physical activity. Themost common comorbidities were hypertension (69.23%), diabetes mellitus (36.26%), dyslipidemia (24.17%) hypothyroidism (21.97%), anxiety (17.58%) and depression (12,08%). After the neuropsychological tests, 24.2% of the patients were classified as subjective cognitive impairment, 38.5% as non-amnestic MCI, 7.7% as amnestic MCI and 29.7% as dementia. Patients with mild cognitive impairment or suspected dementia were referred to cranial tomography and evaluated individually. Conclusions:Subjective cognitive impairment is a frequent condition in primary care. Mild cognitive impairment and dementia are underdiagnosed. These data may be considered for the establishment of public health policies in underdeveloped countries.

FREQUENCY OF ANOSOGNOSIA AT DIAGNOSIS OF COGNITIVE IMPAIRMENT IS INFLUENCED BY COGNITIVE RESERVE

into 65-79 years and >80. The 65-79 years old age group were defined as Middle LOAD (MOAD) and the >80 years old group were defined as Late LOAD (LLOAD). Furthermore we aimed to investigate additional factors that may affect the rate of decline. Methods:The study used longitudinal data from the Essex Memory Clinic which included a total of 306 participants, 56 had YOAD and 249 LOAD (165 MOAD and 84 LLOAD). The rate of cognitive decline was measured using scores from theMini Mental State Examination (MMSE), and covariates included gender, years in education and vascular risk factors. The data were examined using multilevel modelling analysis. Results: At baseline, when comparing individuals with YOAD to LOAD, those with YOAD had lower MMSE scores at baseline (18.3) compared to those with LOAD (23.0; p<.001). The MOAD group had a baseline MMSE of 23.2 and the LLOADgroup 22.8 (ns). Beingmale, having better education and being diabetic were associated with higher baseline MMSE scores. The YOAD group deteriorated faster than the LOAD group (p<.001). The MOAD group declined faster than the LLOAD group despite having similar baseline MMSE scores. Conclusions: Patients with YOAD at the time of diagnosis deteriorated faster than those with LOAD. When age was split into three categories there was a gradual slowing of decline with increasing age. Of significance was that there was also a difference in the rate of decline between the MOAD and the LLOAD groups with the LLOAD group having a more benign disease course.

COGNITIVE RESERVE INDEX QUESTIONNAIRE (CRIQ) VERSUS YEARS OF FORMAL EDUCATION AS RISK FACTORS FOR COGNITIVE IMPAIRMENT

tients can be captured with a limited set of questions and categories. In addition, the data of a depressive group suggest a partially different complaint profile as compared to the MC-group. We work toward further refinement of the interview and coding glossary in order to derive a feasible clinical rating scale to elicit and quantify those SMC features (e.g. context information about memory problems, sense of progression over time) which are most closely associated with prodromal and preclinical Alzheimer’s disease.