Rajdeep Khattar

Cardiovascular Outcome in White-Coat Versus Sustained Mild Hypertension A 10-Year Follow-Up Study

BACKGROUND The aim of this study was to compare the risk conferred by white-coat versus sustained mild hypertension for the development of cardiovascular disease. METHODS AND RESULTS Patients (n=479) who underwent 24-hour intra-arterial ambulatory blood pressure monitoring on the basis of a persistently elevated clinic systolic blood pressure of 140 to 180 mm Hg were followed up for the development of subsequent cardiovascular events during a 9.1+/-4. 2-year period. White-coat hypertension, defined as a clinic systolic blood pressure of 140 to 180 mm Hg associated with a 24-hour ambulatory systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg, was present in 126 patients, and the remainder had sustained mild hypertension. A subgroup of patients without complications underwent follow-up echocardiography and carotid ultrasound. White-coat hypertensives were younger (44+/-12 versus 52+/-10 years, respectively; P<0.001) and had a significantly lower incidence of cardiovascular events (1.32 versus 2.56 events per 100 patient-years, respectively; P<0.001) than sustained hypertensives. Multivariate analysis revealed age (P=0.002), sex (P=0.007), race (P=0.001), smoking (P=0.005), and the presence of white-coat hypertension (hazard ratio, 0.29; 95% CI, 0.09 to 0.90; P=0.04) to be independent predictors of subsequent cardiovascular events. Subgroup analysis in patients without complications revealed a lower incidence of left ventricular hypertrophy and lesser degrees of carotid hypertrophy in the white-coat group. CONCLUSIONS These findings indicate a relatively benign outcome in white-coat hypertension compared with sustained mild hypertension.

Prediction of Coronary and Cerebrovascular Morbidity and Mortality by Direct Continuous Ambulatory Blood Pressure Monitoring in Essential Hypertension

BACKGROUND The goal of this study was to assess the prognostic value of ambulatory versus clinic blood pressure measurement and to relate cardiovascular risk to ambulatory systolic and diastolic blood pressure levels. METHODS AND RESULTS The study population consisted of 688 patients 51+/-11 years of age who had undergone pretreatment 24-hour intra-arterial ambulatory blood pressure monitoring on the basis of elevated clinic blood pressure. A total of 157 first events were recorded during a 9.2+/-4.1-year follow-up period. The predictive value of a regression model containing age, sex, race, body mass index, smoking, diabetes mellitus, fasting cholesterol level, and previous history of cardiovascular disease was significantly improved by the addition of any ambulatory systolic or diastolic blood pressure parameter (whether 24-hour, daytime, or nighttime mean) or pulse pressure, whereas inclusion of baseline clinic blood pressure variables did not enhance the prediction of events. The most predictive models contained the ambulatory systolic blood pressure parameters. In the model containing 24-hour mean ambulatory systolic blood pressure (P=0.001), age (P<0.001), male sex (P<0.001), South Asian origin (P=0.008), diabetes mellitus (P=0. 05), and previous cardiovascular disease (P<0.001) were additional independent predictors of events. Whereas 24-hour ambulatory systolic blood pressure was linearly related to the incidence of both coronary and cerebrovascular events, 24-hour ambulatory diastolic blood pressure exhibited a positive linear relationship with cerebrovascular events but a curvilinear relationship with coronary events. CONCLUSIONS Ambulatory blood pressure is superior to clinic measurement for the assessment of cardiovascular risk; there is no reduction in coronary risk at lower levels of ambulatory diastolic blood pressure.

Carcinoid heart disease: presentation, diagnosis, and management

Tricuspid and pulmonary valve regurgitation usually occurs as a secondary phenomenon caused by dilatation of the valve ring secondary to right ventricular failure or pulmonary hypertension, respectively. Primary diseases of the tricuspid or pulmonary valves are uncommon, but the more likely causes might include congenital abnormalities, rheumatic heart disease, or infective endocarditis. Carcinoid heart disease is a rare, but interesting and important cause of intrinsic tricuspid and pulmonary valve disease leading to significant morbidity and mortality caused by right heart failure. When treated medically, and in appropriate cases surgically, significant benefits in overall quality of life and long term survival can be achieved. We review the current literature regarding the pathophysiological basis of the disease, the cardiovascular complications, and the currently available treatment strategies. Carcinoid tumours are rare neuroendocrine malignancies arising from neural crest amine precursor uptake decarboxylation cells. Approximately 90% of all carcinoid tumours are located in the gastrointestinal system of which the most common sites are the appendix and terminal ileum. Other less common sites include the bronchus and gonads. The most malignant of the carcinoid tumours tend to arise from the ileum and must be invasive or metastasise to produce the carcinoid syndrome which is characterised by facial flushing, intractable secretory diarrhoea, and bronchoconstriction. The incidence of carcinoid tumours is approximately 1 in 75 000 of the population1 of whom about 50% develop carcinoid syndrome. Once the carcinoid syndrome has developed, approximately 50% of these patients develop carcinoid heart disease which typically causes abnormalities of the right side of the heart. Usually, only carcinoid tumours that invade the liver result in pathological changes to the heart. The cardiac manifestations are caused by the paraneoplastic effects of vasoactive substances such as 5-hydroxytryptamine (5-HT or serotonin), histamine, tachykinins, and prostaglandins released by the malignant cells rather than any …

Longitudinal association of ambulatory pulse pressure with left ventricular mass and vascular hypertrophy in essential hypertension

Objective To determine the longitudinal relationship between clinic and ambulatory blood pressures and subsequent left ventricular and carotid artery structure. Design A retrospective follow-up study. Setting A large district general hospital in Harrow, UK. Patients One hundred and forty patients who had been subjected to 24 h ambulatory intra-arterial blood pressure monitoring on the basis of their having an elevated clinic blood pressure were followed up randomly a mean of 9.4 ± 3.4 years later. The ambulatory blood pressure parameters measured were the mean systolic, mean diastolic and mean pulse pressures. Follow-up variables assessed included the clinic blood pressure, body mass index, total cholesterol, number of years of follow-up, left ventricular mass index, carotid intima–media thickness and carotid artery cross-sectional area. Main outcome measures The left ventricular mass index, carotid intima–media thickness and carotid artery cross-sectional area. Results The mean pulse pressure and mean systolic blood pressure were correlated significantly with the left ventricular mass index (r = 0.46, P < 0.001 and r = 0.36, P < 0.001, respectively), carotid intima–media thickness (r = 0.45, P < 0.001 and r = 0.37, P < 0.001, respectively) and carotid artery cross-sectional area (r = 0.46, P < 0.001 and r = 0.41, P < 0.001, respectively). The mean pulse pressure was associated independently with all three outcome measures. In addition, the body mass index was an independent determinant of the left ventricular mass index, whereas the serum cholesterol level was associated independently with the carotid artery cross-sectional area; the number of years of follow-up was related independently to the left ventricular mass index and carotid intima–media thickness, but not to the cross-sectional area. Conclusions These findings suggest that ambulatory blood pressure monitoring can play a role in guiding the choice of doses in drug therapy to limit potential target organ damage.

Racial variation in cardiovascular morbidity and mortality in essential hypertension.

OBJECTIVES To perform a longitudinal comparison of morbidity and mortality among white, south Asian and Afro-Caribbean hypertensive patients in relation to baseline demographic characteristics and clinic and ambulatory blood pressure variables. DESIGN Observational follow up study. SETTING District general hospital and community setting in Harrow, England. PATIENTS 528 white, 106 south Asian, and 54 Afro-Caribbean subjects with essential hypertension who had undergone 24 hour ambulatory intra-arterial blood pressure monitoring. INTERVENTIONS Follow up for assessment of all cause morbidity and mortality over a mean (SD) of 9.2 (4.1) years. MAIN OUTCOME MEASURES Non-cardiovascular death, coronary death, cerebrovascular death, peripheral vascular death, non-fatal myocardial infarction, non-fatal stroke, coronary revascularisation. RESULTS South Asians had the highest all cause event rate of 3.46, compared with 2.50 (NS) and 0.90 (p = 0.002) events/100 patient-years for whites and Afro-Caribbeans, respectively. This was because of an excess of coronary events (2.86v 1.32 events/100 patient-years in south Asians v whites, respectively; p = 0.002). Age (p < 0.001), sex (p < 0.001), race (south Asians : whites, hazard ratio 1.79; p = 0.008), diabetes (p = 0.05), previous history of cardiovascular disease (p < 0.001), and 24 hour ambulatory systolic blood pressure (p = 0.006) were independent predictors of time to a first event. Clinic blood pressure did not provide additional prognostic information. CONCLUSIONS South Asian origin was an independent predictor of all cause events, mainly because of an excess of coronary events in this group. Ambulatory but not clinic blood pressure was of additional value in predicting subsequent morbidity and mortality.

Improved endocardial visualization with second harmonic imaging compared with fundamental two-dimensional echocardiographic imaging

BACKGROUND Endocardial visualization is suboptimal by fundamental imaging in at least 30% of patients. Second harmonic imaging was developed for visualization of myocardial contrast agents. We have hypothesized that endocardial visualization may improve with harmonic imaging compared with fundamental imaging. METHODS AND RESULTS Accordingly, 40 consecutive patients with poor endocardial visualization by conventional echocardiography in at least 1 left ventricular segment (22-segment model) in the 4 standard views randomly underwent fundamental and harmonic imaging without contrast. The images were separately and randomly analyzed by 2 observers. Endocardial visualization was scored as 0, not visualized; 1, poorly visible; and 2, well visualized. Endocardial visualization indexes were also calculated. More segments were assigned a score of 0 (P <. 001) and 1 (P <.001) by fundamental compared with harmonic imaging, whereas harmonic imaging demonstrated more segments with a score of 2 (P <.001) compared with fundamental imaging. Endocardial visualization indexes were significantly better by harmonic imaging in the parasternal long axis (P <.005), short axis (P <.001), and apical 4- (P <.0001) and 2-chamber views (P <.0001). Similar results were obtained by a second observer. Agreement between the 2 observers regarding improvement, deterioration, or no change in score between harmonic and fundamental imaging was 88% (kappa = 0. 76). Interobserver and intraobserver agreements for systolic wall thickening scores also significantly improved with harmonic compared with fundamental imaging (P <.001). CONCLUSION Second harmonic imaging is superior to fundamental imaging for endocardial visualization in patients with suboptimal fundamental imaging.

Pulmonary artery dissection: an emerging cardiovascular complication in surviving patients with chronic pulmonary hypertension.

Pulmonary arterial dissection is an extremely rare and usually lethal complication of chronic pulmonary hypertension. The condition usually manifests as cardiogenic shock or sudden death and is therefore typically diagnosed at postmortem examination rather than during life. However, recent isolated reports have described pulmonary artery dissection in surviving patients. The first case of pulmonary artery dissection in a surviving patient with cor pulmonale caused by chronic obstructive pulmonary disease is presented. The aetiology, pathophysiology, and clinical presentation of pulmonary artery dissection are reviewed and factors that may aid diagnosis during life are discussed.

Non-cardiac surgery and antiplatelet therapy following coronary artery stenting

Coronary artery stenting is increasingly used as a treatment for coronary artery disease. A period of antiplatelet therapy is mandatory following coronary stenting, in order to minimise the risk of stent thrombosis. About 5% of patients who undergo coronary stenting will require non-cardiac surgery within 12 months, and the management of antiplatelet therapy in this setting is complex, requiring a balance between the risks of both operative haemorrhage and stent thrombosis. The available evidence to guide decision-making in the management of antiplatelet therapy in this setting is reviewed.

Carotid intima-media thickness: ultrasound measurement, prognostic value and role in clinical practice.

Ultrasound measurement of carotid intima–media thickness (IMT) has become a valuable tool for detecting and monitoring progression of atherosclerosis and recently published recommendations provide guidance for proper standardisation of these measurements. Important determinants of carotid IMT include age, gender, systolic blood pressure, diabetes mellitus and serum cholesterol levels. Many studies have shown carotid IMT to correlate with the severity of coronary atherosclerosis assessed by CT coronary calcification scores, coronary angiography and intravascular ultrasound. Consistent with its correlation with cardiovascular risk factors and coronary artery disease, a meta-analysis of large observational studies has shown carotid IMT to be a strong predictor of future cardiovascular events. Moreover, in patients with established coronary artery disease a reduction in carotid IMT has been shown to translate into a reduction in future cardiovascular events. Consensus statements now also recommend carotid IMT measurements to further refine the prognostic assessment of patients traditionally considered to be at an intermediate risk of cardiovascular disease.

Tricuspid regurgitation: contemporary management of a neglected valvular lesion

Right-sided cardiac valvular disease has traditionally been considered less clinically important than mitral or aortic valve pathology. However, detectable tricuspid regurgitation (TR) is common and recent data suggest that significant TR can lead to functional impairment and reduced survival, particularly in patients with concomitant left-sided valvular disease. The tricuspid valve is a complex anatomical structure and advances in three dimensional echocardiography and cardiac MRI have contributed to a greater understanding of tricuspid valve pathology. These imaging techniques are invaluable in determining the aetiology and severity of TR, and provide an assessment of right ventricular function and pulmonary artery pressure. TR is more prevalent in women and those with a history of myocardial infarction and heart failure. It also occurs in about 10% of patients with rheumatic heart disease. Chronic severe TR may have a prolonged clinical course culminating in the development of fatigue and poor exercise tolerance due to a reduced cardiac output. Approximately 90% of cases of TR are secondary to either pulmonary hypertension or intrinsic right ventricular pathology and about 10% are due to primary tricuspid valve disease. Primary causes such as Ebsteins anomaly, rheumatic disease, myxomatous changes, carcinoid syndrome, endomyocardial fibrosis, and degenerative disease have characteristic morphological features readily identifiable by echocardiography. Ascertaining an accurate right ventricular systolic pressure is important in separating primary from secondary causes as significant TR with a pressure <40 mm Hg implies intrinsic valve disease. Cardiac MRI may be indicated in those with inadequate echocardiographic images and is also the gold standard for the evaluation of right ventricular function and morphology. The assessment of leaflet morphology, annular dimensions, and pulmonary artery pressure are particularly important for determining subsequent management. Along with appropriate treatment of the underlying cause of TR and pulmonary hypertension, management guidelines indicate a move towards more aggressive treatment of TR. In those undergoing left-sided valve surgery, tricuspid valve repair is universally recommended in the presence of severe coexistent TR; in those with isolated severe TR, surgery is recommended in the presence of symptoms or progressive right ventricular dilatation or dysfunction.