Pere Torguet

Doppler ultrasound in the measurement of pulse wave velocity: agreement with the Complior method

Aortic stiffness is an independent predictor factor for cardiovascular risk. Different methods for determining pulse wave velocity (PWV) are used, among which the most common are mechanical methods such as SphygmoCor or Complior, which require specific devices and are limited by technical difficulty in obtaining measurements. Doppler guided by 2D ultrasound is a good alternative to these methods. We studied 40 patients (29 male, aged 21 to 82 years) comparing the Complior method with Doppler. Agreement of both devices was high (R = 0.91, 0.84-0.95, 95% CI). The reproducibility analysis revealed no intra-nor interobserver differences. Based on these results, we conclude that Doppler ultrasound is a reliable and reproducible alternative to other established methods for the measurement of aortic PWV.

The Relationship Between Renal Resistive Index, Arterial Stiffness, and Atherosclerotic Burden: The Link Between Macrocirculation and Microcirculation

The renal resistive index (RRI) measured by Doppler sonography is a marker of microvascular status that can be generalized to the whole of the arterial tree. Its association with large‐vessel dysfunction, such as arterial stiffness or the atherosclerotic burden, can help to establish physiopathological associations between macrocirculation and microcirculation. The authors conducted a cross‐sectional study of hypertensive patients (n=202) and a healthy control group (n=16). Stiffness parameters, atherosclerotic burden, and determination of the RRI in both kidneys were performed. The average RRI was 0.69±0.08 and was significantly greater in patients with diabetes and chronic kidney disease. Renal resistive index positively correlated with age, creatinine, and albuminuria. Positive correlations were found with arterial stiffness parameters (pulse wave velocity, ambulatory arterial stiffness index, and 24‐hour pulse pressure), as well as atherosclerotic burden and endothelial dysfunction measured as asymmetric dimethylarginine in serum. In the multivariate analysis, independent factors for increased RRI were age, renal function, 24‐hour diastolic blood pressure, and arterial stiffness. The authors concluded that there is an independent association between renal hemodynamics and arterial stiffness. This, together with the atherosclerotic burden and endothelial dysfunction, suggests that there is a physiopathologic relationship between macrovascular and microvascular impairment.

Reproducibilidad de la MAPA en pacientes con diabetes mellitus 2

Objetivo Estudiamos la reproducibilidad de las cifras tensionales y de los trastornos del ritmo nictameral en pacientes afectos de diabetes mellitus 2. Asimismo valoramos la concordancia del estudio tensional con las complicaciones micro y macrovasculares presentes. Pacientes y metodo Se estudia a 58 pacientes afectos de diabetes mellitus 2 con dos registros ambulatorios de presion arterial (MAPA) en un periodo inferior a las 8 semanas sin cambios en la medicacion hipotensora. Resultados La concordancia de las cifras de PA sistolica y PA diastolica tanto de las 24 horas como de dia y noche es superior al 73%. La reproducibilidad para la situacion dipper/no dipper es muy baja. Doce de los pacientes se comportan repetidamente como dipper, otros 12 como no dipper y el resto son dipper variables. Sin alcanzar significacion estadistica los diabeticos repetidamente no dipper tienen una excrecion urinaria de albumina mas elevada. Conclusiones En el diabetico tipo 2 las cifras de PA medidas por MAPA tienen una elevada reproducibilidad. Sin embargo, los trastornos del ritmo nictameral la tienen muy baja. La condicion no dipper persistente comporta, probablemente, mayor repercusion visceral.

Nefropatía, ritmo nictemeral y presión de pulso en la diabetes mellitus tipo 2

Fundamento La perdida del ritmo nictemeral de la presion arterial y la presion de pulso elevada se consideran factores de riesgo cardiovascular independientes que pueden relacionarse con la afeccion microvascular de los pacientes con diabetes mellitus tipo 2. Pacientes Y Metodo Estudio observacional, transversal, de una poblacion de pacientes con diabetes mellitus tipo 2. Las variables se estudian mediante registro ambulatorio de la presion arterial. Los resultados se comparan con los diversos grados de nefropatia. Resultados Se estudia a un total de 61 pacientes, 31 de los cuales tienen un comportamiento no dipper. La proporcion de no dipper aumenta con la excrecion urinaria de albumina (p = 0,024). La presion de pulso es superior en los pacientes con macroalbuminuria (p = 0,004). Conclusiones Existe una perdida del ritmo nictemeral mas frecuente, asi como presiones del pulso mas elevadas, entre los pacientes con diabetes mellitus tipo 2 que presentan nefropatia.

Quiz Page August 2012 : A Man With Nephrotic Syndrome and a Mediastinal Mass

m CLINICAL PRESENTATION A 34-year-old man with no relevant medical history presented with chest pain. Chest computed tomography and radiographs showed an anterior mediastinal mass (Fig 1), and a biopsy performed through mediastinoscopy confirmed the diagnosis of lymphocytic thymoma World Health Organization grade IV. He underwent surgical treatment with thymectomy, pleuropericardiectomy, and left pneumonectomy. No adjuvant therapies were indicated at the time. Thirty-one months after the initial diagnosis, the patient was admitted with nephrotic-range proteinuria (protein excretion, 14 g/24 h) and anasarca (weight gain, 16 kg). Laboratory investigations showed normal kidney function (serum creatinine, 0.7 mg/dL [61.88 mol/L]; estimated lomerular filtration rate 60 mL/min/1.73 m [ 1 mL/s/1.73 m] calculated using the Modifiation of Diet in Renal Disease [MDRD] Study quation), hypoalbuminemia (albumin, 1.5 g/dL 15 g/L]), and hypercholesterolemia (choleserol, 384 mg/dL [9.93 mmol/L]). Results of erologic and complement tests, including antiuclear antibody, antineutrophil cytoplasmic anibody, cryoglobulinemia, C3, C4, and immunolobulin, were negative. Viral markers for epatitis B, hepatitis C, and human immunodefiiency virus (HIV) also were negative. Kidney ltrasound was normal, and a percutaneous kidey biopsy was performed (Fig 2).

Is Persistent Office Hypertension in Treated Hypertensive Patients a Benign Condition

Arterial stiffness is a powerful and independent risk factor for cardiovascular (CV) disease. Its prognostic value is added to others including hypertension. The estimation of both stiffness and blood pressure (BP) can provide advantages in individual CV risk determination. “Out-of-office” BP has a better CV prognostic value than office BP in hypertensive patients. This is a common knowledge; however, it is unclear how clinicians use this information in their decision-making. In untreated hypertensive patients at baseline, some authors have shown that those with white-coat hypertension (WCH) according to ambulatory BP monitoring (ABPM) have similar CV risk to normotensive patients. However, other cohort studies with longer follow-up periods have shown that the CV risk of patients with WCH according to ABPM or home BP monitoring (HBPM) is intermediate between normotension and sustained hypertension or even higher. There are some factors to consider when discussing these discordant results. First is the rate of detection of subclinical vascular disease in patients diagnosed withWCH.When a patient has subclinical vascular disease, the diagnosis of WCH is not possible. For this reason, it is important to perform the appropriate search of subclinical vascular disease. If not, CV morbidity and mortality can be influenced. Second, patients identified as having WCH have a different profile according to out-of-office BP measurements (ABPM or HBPM). Patients with normal BP by bothmeasurements have a lower basal CV risk than those who have normal values according to only one measurement. According to the above, hypertensive patients in whom normal out-of-office BP required by both techniques, ABPM and HBPM, have an incidence of CV events similar to that of normotensive patients, while those with one of the two measures high and the other normal have an intermediate CV risk among normotensive and sustained hypertensive patients. When these out-of-office measurements apply to the monitoring of treated hypertensive patients, it seems that both are useful and reliable. When a patient has outof-office BP controlled according to any one of the measures, ABPM orHBPM, CV risk is independent of BP measurement in the office. The work by Barochiner and colleagues published in this issue of the Journal shows that hypertensive patients with persistent office hypertension (high BP in the office and normal HBPM) have greater arterial stiffness, measured by pulse wave velocity, than those with sustained normotension. Previously, Cuspidi and colleagues showed similar findings with both ABPM and HBPM in treated hypertensive patients in relation to left ventricular hypertrophy.The conclusion is that this condition (persistent office hypertension) is perhaps not so benign, as is the case ofWCH in untreated hypertensive patients. The study discussed has limitations that require caution in interpreting its results, particularly referring to the BP measurement types: office BP was obtained with only one determination; the inter-arm BP difference was not determined when it was known that one inter-arm BP difference exceeding 10 mm Hg was associated with greater CV risk; and this study used only HBPM for out-of-office BP measurement, not both ABPM and HBPM. Nevertheless, the relationship between rigidity and BP are physiological and conceptually complex. In the estimation of arterial stiffness and carotid-femoral pulse wave velocity, it is not possible to differentiate which part is directly attributable to BP level. Spronck and colleagues found that carotid tonometry builds pressure curves throughout the cardiac cycle to measure stiffness, as the average 10 mm Hg of systolic BP change resulted in a variation of 1 m/s of pulse wave velocity. Although Barochiner and colleagues compared HBPM vs office BP, and not the physiopathological role of BP in arterial stiffness, establishing the status of persistent office hypertension with only one BP office measurement may have caused misclassification of patients in this category. More longitudinal studies are needed to improve the usefulness of out-of-office BP in the management of treated hypertensive patients. There are several questions regarding this issue. First, is normal BP according to ABPM or HBPM while on treatment enough to consider the patient well controlled? Second, should both techniques be required or also the addition of office BP to consider the patient well controlled? Finally, are the currently accepted cutoff values the most appropriate for monitoring hypertensive patients? Pending further studies to answer these questions, the use of ABPM or HBPM has an important place in the management of hypertensive patients; however, decision-making in the treatment of hypertensive patients must be accompanied by appropriate monitoring of the development and Address for Correspondence: Gabriel Coll-de-Tuero, MD, PhD, USR Girona, dIAP, Maluquer Salvador, 11 17002 Girona, Spain E-mail: gabriel.coll@ias.scs.es

Quiz Page August 2010

i i u p m l e 49-year-old woman presented ith a 2-day history of severe abominal pain, nausea, and vomitng. Her history included paranoid elusions and herniated lumbar iscs, for which 16 months prior he underwent decompressive lamiectomy and diskectomy, with fuion of L5-S1. Topiramate therapy as started for neuropathy at a dose f 150 mg twice daily. Other mediations included olanzapine, atorvatatin, aspirin, and esomeprazole. he was evaluated 3 days before his presentation for a 3-week hisory of paranoid delusions. Workup esults included the following values: erum sodium, 139 mEq/L (139 mol/L); potassium, 3.4 mEq/L 3.4 mmol/L); chloride, 110 mEq/L v