Theo Thien

Plasma metanephrines in the diagnosis of pheochromocytoma.

Pheochromocytoma is a tumor of chromaffin cells that usually presents as hypertension. The tumor has potentially life-threatening consequences if it is not promptly diagnosed, located, and removed. Evidence of excessive production of catecholamines is essential for diagnosis of the tumor. Traditional tests have relied on measurements of the 24-hour urinary excretion of catecholamines (norepinephrine and epinephrine) or of the products of catecholamine metabolism [1-4]. Because of the common problems of incompleteness and inconvenience associated with 24-hour urine collections, clinicians have long sought a diagnostic test based on sampling of antecubital venous blood. Measurements of plasma catecholamines are useful in this respect [4, 5]. However, patients with a pheochromocytoma can have plasma concentrations of catecholamines that fall within the range of those in patients with essential hypertension [4, 6] (that is, false-negative results). In addition, emotional distress or pathologic conditions other than pheochromocytoma (such as heart failure) can produce abnormally high catecholamine concentrations [7, 8] (that is, false-positive results). Glucagon stimulation and clonidine suppression testing can enhance the accuracy of plasma catecholamine determinations in the diagnosis of pheochromocytoma [9, 10]. These tests, however, can still yield false-negative or false-positive results [9-11]; they also require considerable time and effort. The search has continued for a single simple, highly sensitive and specific blood test with which to confirm the presence of the tumor in patients with pheochromocytoma. We studied the diagnostic accuracy of tests for specific catecholamine metabolites for this purpose, notably the metanephrinesnormetanephrine and metanephrine. An understanding of why plasma metanephrines may be particularly useful for diagnosis of pheochromocytoma requires an understanding of catecholamine metabolism. Norepinephrine and epinephrine are first metabolized intraneuronally by deamination to dihydroxyphenylglycol or extraneuronally by o-methylation to the metanephrines [12]. Because most dihydroxyphenylglycol is formed from norepinephrine leaking from neuronal stores and little is formed from circulating catecholamines [13, 14], plasma levels of this metabolite are relatively insensitive to the release of catecholamines into the circulation from a pheochromocytoma [6, 15]. The formation of most methoxyhydroxyphenylglycol from dihydroxyphenylglycol [14] and the formation of most vanillylmandelic acid from methoxyhydroxyphenylglycol within the liver [16] explains why a test for vanillylmandelic acid is also a poorer marker for pheochromocytoma than other tests [17]. In contrast, preferential metabolism of circulating catecholamines compared with neuronal catecholamines by extraneuronal pathways [14] suggests that the metanephrinesas extraneuronal metabolitesmay provide good markers for release of catecholamines from a pheochromocytoma. Furthermore, substantial production of metanephrines within adrenal tissue [18] suggests that metanephrines may be produced within the tumor itself. In humans, metanephrines are extensively sulfate-conjugated [18, 19]. Assays of metanephrines in urine depend on measurements after deconjugation to free metanephrines [19] so that measurements represent the sum of free and conjugated metabolites (total metanephrines). In contrast, good sensitivity of the assay for plasma metanephrines [20] enables measurements of both free and total metanephrines. We compared the sensitivity, specificity, and positive and negative predictive values of tests for plasma free and total metanephrines with those of tests for plasma catecholamines and urinary total metanephrines. Study participants included a relatively large sample of patients with pheochromocytoma, patients with essential hypertension or secondary hypertension from causes other than pheochromocytoma, and patients with either heart failure or angina pectoris in whom sympathetically mediated catecholamine release would be expected to be increased. Methods Patients Fifty-two patients with a histologically proven pheochromocytoma were studied. Thirty patients were studied retrospectively, and 22 were studied before the final diagnosis was made. The pheochromocytoma was benign in 39 patients and malignant in 13. Sixty-seven healthy, normotensive persons and 51 patients with essential hypertension served as a reference group. Blood samples were obtained from 23 patients with secondary hypertension (12 patients with renal artery stenosis, 2 with kidney disease, 1 with Cushing disease, 1 with primary hyperaldosteronism, and 7 with cyclosporine-induced hypertension) and from 50 patients with either heart failure or angina pectoris. The age, sex, and specialty center where the patients were studied for each of the five groups are shown in Table 1. Except for the few patients who were being treated with phenoxybenzamine, no patients with pheochromocytoma had been receiving medication for at least 2 weeks at the time of blood sampling. No patients with essential hypertension had been receiving medication for at least 2 weeks at the time of blood sampling. Medications taken by the other patient groups included digoxin, calcium channel blockers, diuretics, acetylsalicylic acid, dipyridamole, and cyclosporine. Procedures used in our study were approved by the hospital ethics committee or intramural research board of each of the three centers where patients were studied. Table 1. Patient Characteristics* Blood and Urine Samples All patients refrained from ingesting methylxanthine-containing food products and from smoking after midnight on the day before blood sampling. Blood was collected from an indwelling catheter in an antecubital vein after the patients had rested supine for 20 minutes. In 39 patients with heart failure and 15 with secondary hypertension, arterial blood was obtained through an indwelling arm arterial catheter. Blood samples were collected into precooled tubes containing heparin or EGTA and glutathione and were centrifuged within 30 minutes to separate the plasma, which was stored frozen until assayed. All plasma catecholamine and urinary metanephrine assays were done within 2 weeks of sample collection. Seven of the 52 pheochromocytoma samples were assayed for plasma metanephrines after being stored at 80C for more than 2 years (range, 2 to 8 years), whereas the remaining 45 samples were assayed within 2 years of collection (22 samples within 4 weeks). In 46 of the 52 patients with pheochromocytoma, a 24-hour urine collection was obtained, with 30 mL of 6-M hydrochloric acid used as a preservative. Analytic Methods Plasma metanephrines were assayed at the National Institutes of Health (NIH) using liquid chromatography with electrochemical detection [20]. Concentrations of total metanephrines (the sum of concentrations of free and sulfoconjugated metanephrines) were measured after incubation of 0.25 mL of plasma with 0.1 units of sulfatase (Sigma Chemical Company, St. Louis, Missouri) at 37 C for 30 minutes. The detection limits were 0.013 nmol/L for normetanephrine and 0.019 nmol/L for metanephrine. At a plasma normetanephrine concentration of 0.31 nmol/L and a metanephrine concentration of 0.21 nmol/L, the interassay coefficients of variation were 12.2% for normetanephrine and 11.2% for metanephrine. As previously reported [20], the presence of acetaminophen in samples of plasma can substantially interfere with measurements of plasma normetanephrine concentrations. Therefore, this analgesic must not be used by patients for several days before blood samples are collected. No analytic interference of various other drugs with this assay has been shown [20]. Plasma catecholamines were assayed using liquid chromatography. Electrochemical detection was used for quantification at the NIH [21], and fluorometric detection was used at St. Radboud University Hospital, Nijmegen, the Netherlands [22]. At the NIH, the detection limits were 0.006 nmol/L for norepinephrine and 0.010 nmol/L for epinephrine. At a plasma norepinephrine concentration of 2.4 nmol/L and an epinephrine concentration of 0.39 nmol/L, the interassay coefficients of variation were 6.5% for norepinephrine and 11.4% for epinephrine. At St. Radboud University Hospital, the detection limits for norepinephrine and epinephrine were 0.002 nmol/L and 0.003 nmol/L, respectively. At plasma concentrations of 1.02 nmol/L for norepinephrine and 0.15 nmol/L for epinephrine, interassay coefficients of variation were 8.5% for norepinephrine and 7.2% for epinephrine. Urinary concentrations of metanephrines were measured according to a previously described method [23]; the upper reference limit of the normal range for the 24-hour urinary output of metanephrines was 6.8 mol/d. Data Analysis Because plasma concentrations of catecholamines and metanephrines were not normally distributed, only medians and ranges are presented for these concentrations. Differences in plasma concentrations of metanephrines and catecholamines among patients with pheochromocytoma and other groups were tested using the Kruskal-Wallis test. We assessed relations among variables using the Spearman rank correlation coefficient. Normal distributions of plasma concentrations of catecholamines and metanephrines were obtained after logarithmic transformation of the data. Thus, upper reference limits, defined as the 97.5th percentile, were determined after logarithmic transformation of individual values for the combined data from normotensive persons and those with essential hypertension (118 persons). The 97.5th percentiles were calculated from the antilogarithm of the mean plus 2 standard deviations of the transformed data. A false-negative result of a test for plasma metanephrines in a patient with pheochromocytoma was defined as plasma concentrations of both normetanephrines and metanephrines that were

CAFFEINE AND THEOPHYLLINE ATTENUATE ADENOSINE-INDUCED VASODILATION IN HUMANS

In this study the local vasoactive effects of adenosine were explored in the human forearm. Adenosine (15 μg/100 ml forearm/min) infused into the brachial artery (n = 6) increased forearm blood flow by 572% ± 140%, versus −0.5% ± 5.8% during placebo infusion (p < 0.01). Lower adenosine infusion rates (5 μg/100 ml forearm/min, three times) induced forearm blood flow increments to 330% ± 94%, 339% ± 67% and 330% ± 79%, respectively (n = 8). These forearm blood flow responses were reduced (p = 0.02) during concomitant intra‐arterial infusion of two doses of caffeine (30 and 90 μg/100 ml forearm/min) to 150% ± 45% and 98% ± 28%, respectively. Theophylline (30 μg/100 ml forearm/min; n = 6) also significantly attenuated the adenosine‐induced increase in forearm blood flow. Enprofylline (30 μg/100 ml forearm/min), a related xanthine with a low affinity to adenosine receptors in vitro, did not change the response to adenosine. Nonspecific vasodilation by sodium nitroprusside infusion (50 ng/100 ml forearm/min) was not inhibited by caffeine compared with placebo (forearm blood flow responses were 202% ±21% versus 216% ± 40%; n = 6). This study demonstrated that caffeine and theophylline specifically reduce adenosine‐induced vasodilation in humans, supporting the existence of functional human vascular adenosine receptors.

Endothelium-Dependent Vascular Relaxation in Patients With Type I Diabetes

The endothelium plays an important role in the regulation of vascular tone. Although animal data show evidence for an impaired endothelium-dependent vasodilation in diabetes, human in vivo data are scarce. We investigated 11 type I diabetic patients and 11 matched healthy control subjects. The diabetic patients were selected on their relatively poor metabolic regulation (HbA1c > 8.5%), but none showed signs of microvascular complications. In all subjects, we recorded the forearm vasodilator responses to three different stimuli: 1) 5 min of forearm ischemia to obtain a maximal vasodilator response; 2) infusion of MCh into the brachial artery (dosages: 0.03–0.3–1.0 μg · min−1 · 100 ml−1 forearm volume) to evaluate endothelium-dependent vasodilation; and 3) intra-arterial infusion of SNP (dosages: 0.06–0.2–0.6 ng · min−1 · 100 ml−1) to evaluate endotheliumindependent vasodiiation. The diabetic patients had their usual subcutaneous insulin dose and breakfast 90 min before the start of the test. Baseline levels of BP and FBF were similar in both groups. The PORH response was similar in both groups, with a percentage fall in FVR of 92 ± 1% in diabetic patients and 94 ± 1% in control subjects. In the control subjects, MCh infusions exerted a dose-dependent vasodilator response with a maximal fall in the FVR of 90 ± 2%. The highest dose of SNP induced a fall in FVR of 81 ± 6% in this group. In diabetic patients, thepercentage decrements in FVR during the several dosages of MCh and SNP were similar when compared with the control group. We conclude that chronic hyperglycemia, as occurred in our patients with uncomplicated diabetes mellitus, does not impair endothelium-dependent vasodilation in vivo.

Self-measurement of blood pressure at home reduces the need for antihypertensive drugs: a randomized, controlled trial.

It is still uncertain whether one can safely base treatment decisions on self-measurement of blood pressure. In the present study, we investigated whether antihypertensive treatment based on self-measurement of blood pressure leads to the use of less medication without the loss of blood pressure control. We randomly assigned 430 hypertensive patients to receive treatment either on the basis of self-measured pressures (n=216) or office pressures (OPs; n=214). During 1-year follow-up, blood pressure was measured by office measurement (10 visits), ambulatory monitoring (start and end), and self-measurement (8 times, self-pressure group only). In addition, drug use, associated costs, and degree of target organ damage (echocardiography and microalbuminuria) were assessed. The self-pressure group used less medication than the OP group (1.47 versus 2.48 drug steps; P<0.001) with lower costs (

Circulatory effects of coffee in relation to the pharmacokinetics of caffeine

3222 versus

Evidence for an antagonism between caffeine and adenosine in the human cardiovascular system.

4420 per 100 patients per month; P<0.001) but without significant differences in systolic and diastolic OP values (1.6/1.0 mm Hg; P=0.25/0.20), in changes in left ventricular mass index (-6.5 g/m(2) versus -5.6 g/m(2); P=0.72), or in median urinary microalbumin concentration (-1.7 versus -1.5 mg per 24 hours; P=0.87). Nevertheless, 24-hour ambulatory blood pressure values at the end of the trial were higher in the self-pressure than in the OP group: 125.9 versus 123.8 mm Hg (P<0.05) for systolic and 77.2 versus 76.1 mm Hg (P<0.05) for diastolic blood pressure. These data show that self-measurement leads to less medication use than office blood pressure measurement without leading to significant differences in OP values or target organ damage. Ambulatory values, however, remain slightly elevated for the self-pressure group.

Thiazide-Induced Vasodilation in Humans Is Mediated by Potassium Channel Activation

Drinking coffee results in an increase in blood pressure (BP) after an interval of caffeine abstinence. During chronic caffeine intake this pressor response disappears and adaptation to the circulatory effects of caffeine develops. This study was designed to determine whether a pressor response to coffee occurs during chronic caffeine intake if low basal plasma caffeine levels are achieved by a period of caffeine abstinence, defined by individual plasma caffeine half-life. In 8 normotensive subjects, circulatory measurements were studied after ingestion of coffee in 2 strengths, decaffeinated coffee and hot water after a caffeine abstinence of 4.5 times individual caffeine half-life. These measurements were compared to the same protocol without intervention. Coffee of both strengths resulted in a similar increase in BP (diastolic BP +/- 15%). The coffee-induced increase in forearm blood flow and plasma epinephrine levels were less pronounced. Decaffeinated coffee induced a smaller increase of diastolic BP, and after water, no changes were observed. Additionally, a negative correlation was found between the coffee-induced BP increase and basal plasma caffeine level in a group of 30 normotensive subjects (r = -0.71, p less than 0.001). During chronic caffeine intake, subjects with short plasma caffeine half-life are exposed to a pressor response after drinking coffee, despite the phenomenon of adaptation.

Direct vascular effects of furosemide in humans

A randomized, double-blind and placebo-eon-trolled study was performed in 10 normotensive male subjects to analyze a possible antagonism between caffeine and adenosine with respect to their effects on the cardiovascular system in humans. Caffeine alone. 250 mg intravenously (i.v.). increased blood pressure by 9/12 mm Hg. and resulted in a fall of heart rate (HR) of 3 beats/ min. Plasma epinephrine (E) rose by 1149? after caffeine. Adenosine alone, in an increasing dose of 0.04–0.16 mg/kg/min, induced an increase in systolic blood pressure (SBP) (17 mm Hg). and HR (33 beats/min). a moderate fall in diastolic blood pressure (DBP) (-4 mm Hg). and no change of mean arterial pressure (MAP). At the highest adenosine infusion rate, forearm blood How. Skin temperature (ST), and transcutaneous oxygen tension were lowered, whereas plasma (nor)epinephrine was increased 227.2 and 215.9%, respectively. Adenosine infusion after caffeine induced comparable effects, but the fractional adenosine-induced changes of SBP. HR, plasma catecholamines, plasma renin activity (PRA), and aldosterone all were significantly reduced by previous administration of caffeine. Our results indicate an antagonism between caffeine and adenosine in humans, which may support the suggestion that some circulatory effects of caffeine are caused by an interaction with endogenous adenosine.

Blood Pressure Measurement Method and Inter-Arm Differences: A Meta-Analysis

-Hydrochlorothiazide and indapamide are thought to exert their hypotensive efficacy through a combined vasodilator and diuretic effect, but in vivo evidence for a direct vascular effect is lacking. The presence and mechanism of a direct vascular action of hydrochlorothiazide in vivo in humans were examined and compared with those of the thiazide-like drug indapamide. Forearm vasodilator responses to infusion of placebo and increasing doses of hydrochlorothiazide (8, 25, and 75 microg. min-1. dL-1) into the brachial artery were recorded by venous occlusion plethysmography. Dose-response curves were repeated after local tetraethylammonium (TEA) administration to determine the role of potassium channel activation and, in patients with the Gitelman syndrome, to determine the role of the thiazide-sensitive Na-Cl cotransporter in the vasodilator effect of hydrochlorothiazide. Vascular effects of hydrochlorothiazide were compared with those of indapamide in both normotensive (mean arterial pressure, 85+/-7 mm Hg) and hypertensive (mean arterial pressure, 124+/-16 mm Hg) subjects. At the highest infusion rate, local plasma concentrations of hydrochlorothiazide averaged 11.0+/-1.6 microg/mL, and those of indapamide averaged 7. 2+/-1.5 microg/mL. In contrast to indapamide, hydrochlorothiazide showed a direct vascular effect (maximal vasodilation, 55+/-14%; P=0. 013), which was inhibited by TEA (maximal vasodilation after TEA, 13+/-10%; P=0.02). The response was not dependent on blood pressure and was similar in patients with Gitelman syndrome, indicating that absence of the Na-Cl cotransporter does not alter the vasodilatory effect of hydrochlorothiazide. The vasodilator effect of hydrochlorothiazide in the human forearm is small and only occurs at high concentrations. The mechanism of action is not mediated by inhibition of vascular Na-Cl cotransport but involves vascular potassium channel activation. In contrast, indapamide does not exert any direct vasoactivity in the forearm vascular bed.

The post-thrombotic syndrome: incidence and prognostic value of non-invasive venous examinations in a six-year follow-up study

BACKGROUND In humans, hemodynamic changes observed within minutes after systemic administration of furosemide are often referred to as direct vasoactivity. However, these immediate changes do not per se imply a direct vascular effect. We examined the genuine direct vascular effects of furosemide on the human forearm vascular bed and dorsal hand vein. METHODS AND RESULTS Forearm blood flow in response to infusion of increasing dosages of furosemide into the brachial artery was recorded by venous occlusion plethysmography. Local plasma concentrations of furosemide reached a maximum of 234+/-40 microg/mL during the highest infused dose but did not significantly affect the ratio of flow in the infused/noninfused arms. Venous distensibility of a dorsal hand vein was measured with a linear variable differential transformer. During precontraction with norepinephrine, five increasing dosages of furosemide (1 to 100 microg/min) were administered locally. Additional experiments using local administration of indomethacin or N(G)-monomethyl-L-arginine (L-NMMA) were carried out to determine whether effects were dependent on local prostaglandin or nitric oxide synthesis, respectively. Also, the effects of systemic administration of furosemide were examined. Local administration of furosemide led to a dose-dependent venorelaxation of 18+/-6% at the first to 72+/-16% at the last dose. Indomethacin almost completely abolished furosemide-induced venorelaxation, whereas L-NMMA had no effect. Systemic administration of furosemide resulted in a time-dependent increase of hand vein distensibility, reaching 45+/-11% after 8 minutes. CONCLUSIONS Furosemide does not exert any direct arterial vasoactivity in the human forearm, even at supratherapeutic concentrations. In contrast, at concentrations estimated to be in the therapeutic range, we observed a dose-dependent direct venodilator effect on the dorsal hand vein that appears to be mediated by local vascular prostaglandin synthesis.