Renan Oliveira Vaz-de-Melo

Hypertensive crisis: clinical–epidemiological profile

Hypertensive crisis (HC) stands out as one type of acute elevation in blood pressure (BP) and can manifest as hypertensive emergency (HE—with target-organ damage (TOD)) or hypertensive urgency (HU—without TOD), usually accompanied by levels of diastolic BP ⩾120u2009mmu2009Hg. The aim of this study was to characterize the clinical–epidemiological profile of HC over the course of 1 year in a university reference hospital and perform a review of the literature. The study was a cross-sectional study, conducted over a period of 1 year (2006) in 362 patients who presented for treatment at the emergency hospital with HC, as described above. Among all patients examined, 231 individuals met the criteria for HE and 131 met the criteria for HU. Patients with HE were older (P<0.001) and more sedentary (P=0.026) than those with HU. Furthermore, fewer HE patients than HU patients had previously undergone antihypertensive treatment (P=0.006). The groups did not differ regarding BP levels, gender, smoking or body mass index. Dyspnea (41.1%), thoracic pain (37.2%) and neurological deficit (27.2%) were common signs/symptoms in those with HE. Meanwhile, in the group with HU, we most frequently found headache (42.0%), thoracic pain (41.2%) and dyspnea (34.3%). Among the forms of HE, we most frequently observed acute lung edema (30.7%), myocardial infarction/unstable angina (25.1%), and ischemic (22.9%) and hemorrhagic (14.8%) stroke. HC is a clinical entity associated with high morbidity in the emergency room. Individuals with HE are older and sedentary and have lower rates of antihypertensive treatment. Adequate control of BP should be pursued as a way to avoid this severe complication of hypertension.

Fatores associados ao aumento no índice de incremento de pressão radial em indivíduos hipertensos

BACKGROUNDnArterial stiffness is a variable predictor of morbidity and mortality and a possible marker of vascular injury. Its non-invasive assessment by radial tonometry and analysis of the augmentation index (r-AI) allows identifying patients exposed to higher cardiovascular risk.nnnOBJECTIVEnTo analyze the influence of r-AI on clinical-biochemical variables and its influence on the prevalence of target-organ damage in hypertensive patients.nnnMETHODSn140 consecutive hypertensive patients, followed-up in an outpatient clinic, were analyzed in a cross-sectional study. Blood pressure (BP) levels and r-AI were obtained by applanation tonometry of the radial artery (HEM-9000AI, Onrom). The patients were allocated into r-AI tertiles (r-AI < 85%; 85< r-AI < 97%; r-AI > 97%).nnnRESULTSnThe sample was predominantly composed of women (56.4%), mean age of 61.7 ± 11.7 years and body mass index 29.6 ± 6.1 Kg/m². The highest tertile showed higher proportion of women (p = 0.001), higher systolic BP (p = 0.001) and pulse pressure (p = 0.014), and lower weight (p = 0.044), height (p < 0.001) and heart rate (p < 0.001). Multivariate analysis demonstrated that weight (β = -0.001, p = 0.017), heart rate (β = -0.001, p = 0.007) and central pressure (β = 0.015, p < 0.001) correlated independently with r-AI. In logistic regression analyses, the 3rd r-AI tertile was associated to lower levels of diabetes (DM) (OR = 0.41; 95% CI 0.17-0.97; p = 0.042).nnnCONCLUSIONnThis study demonstrated that weight, heart rate and central BP were independently related to r-AI.

Nebivolol reduces central blood pressure in stage I hypertensive patients: experimental single cohort study

CONTEXT AND OBJECTIVESnAssessment of central blood pressure (BP) has grown substantially over recent years because evidence has shown that central BP is more relevant to cardiovascular outcomes than peripheral BP. Thus, different classes of antihypertensive drugs have different effects on central BP despite similar reductions in brachial BP. The aim of this study was to investigate the effect of nebivolol, a β-blocker with vasodilator properties, on the biochemical and hemodynamic parameters of hypertensive patients.nnnDESIGN AND SETTINGnExperimental single cohort study conducted in the outpatient clinic of a university hospital.nnnMETHODSnTwenty-six patients were recruited. All of them underwent biochemical and hemodynamic evaluation (BP, heart rate (HR), central BP and augmentation index) before and after 3 months of using nebivolol.nnnRESULTSn88.5% of the patients were male; their mean age was 49.7 ± 9.3 years and most of them were overweight (29.6 ± 3.1 kg/m2) with large abdominal waist (102.1 ± 7.2 cm). There were significant decreases in peripheral systolic BP (P = 0.0020), diastolic BP (P = 0.0049), HR (P < 0.0001) and central BP (129.9 ± 12.3 versus 122.3 ± 10.3 mmHg; P = 0.0083) after treatment, in comparison with the baseline values. There was no statistical difference in the augmentation index or in the biochemical parameters, from before to after the treatment.nnnCONCLUSIONSnNebivolol use seems to be associated with significant reduction of central BP in stage I hypertensive patients, in addition to reductions in brachial systolic and diastolic BP.

Ausência de descenso noturno se associa a acidente vascular cerebral e infarto do miocárdio

BACKGROUNDnThe arterial hypertension varies in according to the circadian cycle, presenting physiologic fall of blood pressure (BP) during sleep (dipping). The absence of this fall or its increase associates to higher incidence of target-organ damages.nnnOBJECTIVEnTo analyze the prevalence of dipping in hypertensive individuals, to correlate dipping to the blood pressure levels, clinic, and socio-demographic factors, and biochemical characteristics and to associate it cardiovascular events (stroke and myocardial infarction).nnnMETHODSnHypertensive individuals were submitted to the ambulatory blood pressure monitoring. Presence of dipper was defined as fall >10% of the systolic BP of the day for sleep.nnnRESULTSn163 evaluated patients were divided in dippers (D, n=53) and nondippers (ND, n=110). Between the groups there was not significant difference to the age, sex, race, time of hypertension, glycemia, LDL-cholesterol, total cholesterol, triglycerides, schooling, smoking, and history of diabetes. D presented BP higher than the ND during the day and lower during sleep. ND had higher body mass index (BMI) (p=0.0377), lower level of HDL-cholesterol (p=0.0189), and higher pulse pressure during sleep (p=0.0025). History of stroke alone (p=0,046) and combined with myocardial infarction (p=0.032) were more frequent in nondippers individuals. In the logistic regression, only ND was associated independently with stroke or myocardial infarction.nnnCONCLUSIONnND was associated in an independent way with the target-organ damages analyzed, what demonstrates its importance and strengthens the necessity of more aggressive treatment with objective to reach BP goals e, consequently, to prevent the development of new cardiologic and cerebrovascular events.FUNDAMENTO: A pressao arterial (PA) varia de acordo com o ciclo circadiano, apresentando quedas fisiologicas durante o sono (descenso noturno - DN). A ausencia dessa queda se associa a maior incidencia de lesoes em orgaos-alvo. OBJETIVO: Analisar a prevalencia de DN em individuos hipertensos, correlacionar DN aos niveis pressoricos, variaveis clinicas, fatores sociodemograficos e bioquimicos e associa-lo a eventos cardiovasculares (acidente vascular cerebral - AVC e infarto agudo do miocardio - IAM). METODOS: Foram avaliados 163 hipertensos, submetidos a monitorizacao ambulatorial da pressao arterial. DN foi definido como queda >10% da PA sistolica do periodo da vigilia para o de sono. RESULTADOS: Os pacientes foram divididos em grupos dipper (D) e nao dipper (ND). Nao houve diferenca significante entre os grupos quanto a idade, sexo, raca, tempo de hipertensao, glicemia, LDL-colesterol, colesterol total, triglicerides, escolaridade, tabagismo, historia de diabetes. Grupo dipper apresentou PA superior a ND durante a vigilia e inferior durante o sono. Grupo ND cursou com maior indice de massa corporea (IMC) (p=0,0377), menor HDL-colesterol (p=0,0189) e maior pressao de pulso durante o sono (p=0,0025). Historia de AVC ou IAM foram mais frequentes em ND. A regressao logistica, apenas a ausencia de descenso noturno associou-se independentemente a AVC ou IAM. CONCLUSAO: A ausencia de DN associou-se de maneira independente as lesoes em orgaos-alvo analisadas, o que demonstra a sua importância e reforca a necessidade de tratamento mais agressivo com objetivo de se atingir as metas pressoricas e, consequentemente, evitar o desenvolvimento de novos eventos cardiocerebrovasculares.Correspondencia: Renan Oliveira Vaz de Melo • Rua Professor Enjolrras Vampré, 201/44 Bloco 3 Vila Santa Cândida 15091-290 São José do Rio Preto, SP Brasil E-mail: renanovmelo@gmail.com Artículo recibido el 15/10/08; revisado recibido el 01/02/09; aceptado el 15/05/09. Resumen Fundamento: La presión arterial (PA) varía de acuerdo al ciclo circadiano, presentando descensos fisiológicos durante el sueño (descenso nocturno DN). La ausencia de ese descenso se asocia a mayor incidencia de lesiones en órganos blanco.

Absence of nocturnal dipping is associated with stroke and myocardium infarction

BACKGROUNDnThe arterial hypertension varies in according to the circadian cycle, presenting physiologic fall of blood pressure (BP) during sleep (dipping). The absence of this fall or its increase associates to higher incidence of target-organ damages.nnnOBJECTIVEnTo analyze the prevalence of dipping in hypertensive individuals, to correlate dipping to the blood pressure levels, clinic, and socio-demographic factors, and biochemical characteristics and to associate it cardiovascular events (stroke and myocardial infarction).nnnMETHODSnHypertensive individuals were submitted to the ambulatory blood pressure monitoring. Presence of dipper was defined as fall >10% of the systolic BP of the day for sleep.nnnRESULTSn163 evaluated patients were divided in dippers (D, n=53) and nondippers (ND, n=110). Between the groups there was not significant difference to the age, sex, race, time of hypertension, glycemia, LDL-cholesterol, total cholesterol, triglycerides, schooling, smoking, and history of diabetes. D presented BP higher than the ND during the day and lower during sleep. ND had higher body mass index (BMI) (p=0.0377), lower level of HDL-cholesterol (p=0.0189), and higher pulse pressure during sleep (p=0.0025). History of stroke alone (p=0,046) and combined with myocardial infarction (p=0.032) were more frequent in nondippers individuals. In the logistic regression, only ND was associated independently with stroke or myocardial infarction.nnnCONCLUSIONnND was associated in an independent way with the target-organ damages analyzed, what demonstrates its importance and strengthens the necessity of more aggressive treatment with objective to reach BP goals e, consequently, to prevent the development of new cardiologic and cerebrovascular events.FUNDAMENTO: A pressao arterial (PA) varia de acordo com o ciclo circadiano, apresentando quedas fisiologicas durante o sono (descenso noturno - DN). A ausencia dessa queda se associa a maior incidencia de lesoes em orgaos-alvo. OBJETIVO: Analisar a prevalencia de DN em individuos hipertensos, correlacionar DN aos niveis pressoricos, variaveis clinicas, fatores sociodemograficos e bioquimicos e associa-lo a eventos cardiovasculares (acidente vascular cerebral - AVC e infarto agudo do miocardio - IAM). METODOS: Foram avaliados 163 hipertensos, submetidos a monitorizacao ambulatorial da pressao arterial. DN foi definido como queda >10% da PA sistolica do periodo da vigilia para o de sono. RESULTADOS: Os pacientes foram divididos em grupos dipper (D) e nao dipper (ND). Nao houve diferenca significante entre os grupos quanto a idade, sexo, raca, tempo de hipertensao, glicemia, LDL-colesterol, colesterol total, triglicerides, escolaridade, tabagismo, historia de diabetes. Grupo dipper apresentou PA superior a ND durante a vigilia e inferior durante o sono. Grupo ND cursou com maior indice de massa corporea (IMC) (p=0,0377), menor HDL-colesterol (p=0,0189) e maior pressao de pulso durante o sono (p=0,0025). Historia de AVC ou IAM foram mais frequentes em ND. A regressao logistica, apenas a ausencia de descenso noturno associou-se independentemente a AVC ou IAM. CONCLUSAO: A ausencia de DN associou-se de maneira independente as lesoes em orgaos-alvo analisadas, o que demonstra a sua importância e reforca a necessidade de tratamento mais agressivo com objetivo de se atingir as metas pressoricas e, consequentemente, evitar o desenvolvimento de novos eventos cardiocerebrovasculares.Correspondencia: Renan Oliveira Vaz de Melo • Rua Professor Enjolrras Vampré, 201/44 Bloco 3 Vila Santa Cândida 15091-290 São José do Rio Preto, SP Brasil E-mail: renanovmelo@gmail.com Artículo recibido el 15/10/08; revisado recibido el 01/02/09; aceptado el 15/05/09. Resumen Fundamento: La presión arterial (PA) varía de acuerdo al ciclo circadiano, presentando descensos fisiológicos durante el sueño (descenso nocturno DN). La ausencia de ese descenso se asocia a mayor incidencia de lesiones en órganos blanco.

La ausencia de descenso nocturno de la presión arterial se asocia a accidente cerebrovascular e infarto de miocardio

BACKGROUNDnThe arterial hypertension varies in according to the circadian cycle, presenting physiologic fall of blood pressure (BP) during sleep (dipping). The absence of this fall or its increase associates to higher incidence of target-organ damages.nnnOBJECTIVEnTo analyze the prevalence of dipping in hypertensive individuals, to correlate dipping to the blood pressure levels, clinic, and socio-demographic factors, and biochemical characteristics and to associate it cardiovascular events (stroke and myocardial infarction).nnnMETHODSnHypertensive individuals were submitted to the ambulatory blood pressure monitoring. Presence of dipper was defined as fall >10% of the systolic BP of the day for sleep.nnnRESULTSn163 evaluated patients were divided in dippers (D, n=53) and nondippers (ND, n=110). Between the groups there was not significant difference to the age, sex, race, time of hypertension, glycemia, LDL-cholesterol, total cholesterol, triglycerides, schooling, smoking, and history of diabetes. D presented BP higher than the ND during the day and lower during sleep. ND had higher body mass index (BMI) (p=0.0377), lower level of HDL-cholesterol (p=0.0189), and higher pulse pressure during sleep (p=0.0025). History of stroke alone (p=0,046) and combined with myocardial infarction (p=0.032) were more frequent in nondippers individuals. In the logistic regression, only ND was associated independently with stroke or myocardial infarction.nnnCONCLUSIONnND was associated in an independent way with the target-organ damages analyzed, what demonstrates its importance and strengthens the necessity of more aggressive treatment with objective to reach BP goals e, consequently, to prevent the development of new cardiologic and cerebrovascular events.FUNDAMENTO: A pressao arterial (PA) varia de acordo com o ciclo circadiano, apresentando quedas fisiologicas durante o sono (descenso noturno - DN). A ausencia dessa queda se associa a maior incidencia de lesoes em orgaos-alvo. OBJETIVO: Analisar a prevalencia de DN em individuos hipertensos, correlacionar DN aos niveis pressoricos, variaveis clinicas, fatores sociodemograficos e bioquimicos e associa-lo a eventos cardiovasculares (acidente vascular cerebral - AVC e infarto agudo do miocardio - IAM). METODOS: Foram avaliados 163 hipertensos, submetidos a monitorizacao ambulatorial da pressao arterial. DN foi definido como queda >10% da PA sistolica do periodo da vigilia para o de sono. RESULTADOS: Os pacientes foram divididos em grupos dipper (D) e nao dipper (ND). Nao houve diferenca significante entre os grupos quanto a idade, sexo, raca, tempo de hipertensao, glicemia, LDL-colesterol, colesterol total, triglicerides, escolaridade, tabagismo, historia de diabetes. Grupo dipper apresentou PA superior a ND durante a vigilia e inferior durante o sono. Grupo ND cursou com maior indice de massa corporea (IMC) (p=0,0377), menor HDL-colesterol (p=0,0189) e maior pressao de pulso durante o sono (p=0,0025). Historia de AVC ou IAM foram mais frequentes em ND. A regressao logistica, apenas a ausencia de descenso noturno associou-se independentemente a AVC ou IAM. CONCLUSAO: A ausencia de DN associou-se de maneira independente as lesoes em orgaos-alvo analisadas, o que demonstra a sua importância e reforca a necessidade de tratamento mais agressivo com objetivo de se atingir as metas pressoricas e, consequentemente, evitar o desenvolvimento de novos eventos cardiocerebrovasculares.Correspondencia: Renan Oliveira Vaz de Melo • Rua Professor Enjolrras Vampré, 201/44 Bloco 3 Vila Santa Cândida 15091-290 São José do Rio Preto, SP Brasil E-mail: renanovmelo@gmail.com Artículo recibido el 15/10/08; revisado recibido el 01/02/09; aceptado el 15/05/09. Resumen Fundamento: La presión arterial (PA) varía de acuerdo al ciclo circadiano, presentando descensos fisiológicos durante el sueño (descenso nocturno DN). La ausencia de ese descenso se asocia a mayor incidencia de lesiones en órganos blanco.

Renin Angiotensin System Blockage Associates with Insertion/Deletion Polymorphism of Angiotensin-Converting Enzyme in Patients with Hypertensive Emergency

Hypertensive crisis (HC) stands out as a form of acute elevation of blood pressure (BP). It can manifest itself as hypertensive emergency (HE) or hypertensive urgency (HU), which is usually accompanied with levels of diastolic BP ≥120 mmHg. Angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism may influence manifestations of HC. Thus, this study evaluated the influence of ACE I/D polymorphism in individuals with HC. A total of 187 patients admitted with HC (HU [n=69] and HE [n=118]) and 75 normotensive individuals were included in the study. Peripheral blood was drawn for a biochemical and genetic analysis of the ACE I/D polymorphism by Polymerase Chain Reaction. HC group showed higher systolic BP, body mass index (BMI), glycemia, creatinine, and lower high-density lipoprotein (HDL) cholesterol compared with normotensive individuals. The use of renin-angiotensin system (RAS) blockers was more frequent in the HU group than in the HE group (p=0.020). The II genotype was more predominant in normotensive and HU individuals than among HE individuals (18.7%, 11.6%, and 2.5%, respectively; p=0.004). Higher BMI and glycemia were associated with HC in the logistic regression model. ACE II genotype (odds ratio [OR] 0.14; 95% confidence interval [CI] 0.04-0.51) and HDL cholesterol were protective for the development of HE. ACE II genotype was present in the HU group, compared with the HE group (OR 0.18; 95% CI 0.04-0.88). This study shows an association between the low prevalence of ACE I/D polymorphism II genotype and a greater occurrence of HE in Brazilian individuals. The lower blockage of RAS, which was detected in the HE group, may interact with the low frequency of II genotype, conferring an increased risk for HE.

Urinary albumin excretion regression in hypertensive individuals

[1] Kawada T. Serum C reactive protein and carotid intima–media thickness. Int J Cardiol Mar 3