Numerous studies addressed the predictive value of the nighttime blood pressure (BP) as captured by ambulatory monitoring. However, arbitrary cutoff limits in dichotomized analyses of continuous variables, data dredging across selected subgroups, extrapolation of cross-sectional studies to prospective outcomes, and lack of comprehensive adjustments for confounders make interpretation of the literature difficult. We reviewed prospective studies with total mortality or a composite cardiovascular end point as an outcome in relation to the level and the circadian profile of systolic BP. We analyzed studies in hypertensive patients (n=23 856) separately from those in individuals randomly recruited from populations (n=9641). We pooled summary statistics and individual subject data, respectively. In both patients and populations, in analyses in which nighttime BP was additionally adjusted for daytime BP and vice versa, nighttime BP was a stronger predictor than daytime BP. With adjustment for the 24-hour BP, both the night-to-day BP ratio and dipping status remained significant predictors of outcome but added little prognostic value over and beyond the 24-hour BP level. In the absence of conclusive evidence proving that nondipping is a reversible risk factor, the option whether or not to restore the diurnal blood pressure profile to a normal pattern should be left to the clinical judgment of doctors and should be individualized for each patient. Current guidelines on the interpretation of ambulatory BP recording need to be updated.

Predictive Role of the Nighttime Blood Pressure

RESEARCH into rheumatic heart disease has progressively yielded a series of important facts and a good deal that is still speculative. It has been shown that many tissues, especially vascular structures, throughout the body are injured in attacks of rheumatic fever, and that the most serious damage occurs in the heart, to the myocardium and to its valves. It is generally considered now to have been conclusively shown that infections of body tissues with type A hsemolytie streptococci play a causative and key role in the pathogenesis of this disease, but only a small proportion of human beings infected with type A streptococci develop rheumatic heart disease. It is also widely held that the rheumatic lesions in the myocardium, including the so-called Aschoff bodies, are non-myogenic lesions of the connective tissue and do not involve the heart muscle fibres. However, G. E. Murphy,' in a long and very detailed paper, subsequently reprinted as a monograph,\" has set out to demonstrate that this last-mentioned interpretation is not correct, and that it is the heart muscle and plain muscle fibres which are affected. He was able to produce typical cardiac changes in a small proportion of rabbits with multiple focal infections due to type A heemolytie streptococci, and these gave material for study at various stages of the cardiac changes. In addition, he made a detailed microscopic study of the hearts of over 100 patients who had died with active rheumatic heart disease and of the left atrial appendages removed from 150 other patients at the time of mitral commissurotomy. The histopathological findings are presented in considerable detail with 162 beautiful reproductions of coloured sections of cardiac tissue illustrating the points made in the text. A study of the text and the slides makes clear the author's claims that the changes in the myocardium, both in man and in rabbits, are really in the muscle cells and not in the fibrous tissue.

Rheumatic heart disease

Background— We assessed whether insufficient sleep is associated with prehypertension in healthy adolescents. Methods and Results— We undertook a cross-sectional analysis of 238 adolescents, all without sleep apnea or severe comorbidities. Participants underwent multiple-day wrist actigraphy at home to provide objective estimates of sleep patterns. In a clinical research facility, overnight polysomnography, anthropometry, and 9 blood pressure measurements over 2 days were made. Exposures were actigraphy-defined low weekday sleep efficiency, an objective measure of sleep quality (low sleep efficiency ≤85%), and short sleep duration (≤6.5 hours). The main outcome was prehypertension (≥90th percentile for age, sex, and height), with systolic and diastolic blood pressures as continuous measures as secondary outcomes. Prehypertension, low sleep efficiency, and short sleep duration occurred in 14%, 26%, and 11% of the sample, respectively. In unadjusted analyses, the odds of prehypertension increased 4.5-fold (...

Sleep Quality and Elevated Blood Pressure in Adolescents

BACKGROUND\nModerately increased plasma concentrations of total homocysteine (tHcy) have been shown to be an important risk factor for vascular diseases. Two common polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene, the thermolabile C677T and a more recently reported A1298C polymorphism, may contribute to hyperhomocysteinemia.\n\n\nMETHODS\nUsing PCR and restriction fragment length polymorphism analysis, we studied the prevalence of the C677T and A1298C MTHFR genotypes and the combined effect of these polymorphisms on plasma tHcy concentrations, as measured by HPLC with fluorometric detection, both fasting and post-methionine load (PML), in 1238 individuals.\n\n\nRESULTS\nThe prevalences of the C677T and A1298C genotypes did not differ significantly in 772 individuals with documented coronary artery disease (CAD), 137 individuals with deep-vein thrombosis (DVT), and 329 individuals without documented vascular disease. Individuals homozygous for the 677T allele had significantly increased fasting tHcy, particularly in the presence of low folate, compared with individuals homozygous for the wild-type allele. Neither the 1298AC nor the 1298CC genotype was associated with significantly increased fasting or PML tHcy concentrations irrespective of serum folate. Of the nine combined MTHFR genotypes, six were present in >10% of the population. Of these, the difference in mean fasting tHcy reached statistical significance (P<0.005) only in individuals with the 677TT/1298AA genotype compared with individuals with the wild-type 677CC/1298AA genotype. Differences in mean fasting tHcy did not reach statistical significance in individuals heterozygous for both MTHFR variants. We detected two 677CT/1298CC and three 677TT/1298AC individuals; only one, an 677TT/1298AC individual, had increased tHcy (both fasting and PML). No individuals had the 677TT/1298CC genotype.\n\n\nCONCLUSIONS\nThe prevalences of the C677T and A1298C polymorphisms did not differ among individuals with CAD, DVT, or those without documented vascular disease. In contrast to the C677T polymorphism, the A1298C polymorphism is not associated with increased fasting tHcy. Although the two polymorphisms usually exist in trans configuration, crossover may occur rarely to form recombinant chromosomes.

C677T and A1298C polymorphisms of the methylenetetrahydrofolate reductase gene

Despite repeated calls to prohibit or limit conflicts of interests among authors and sponsors of clinical guidelines, the problem persists. Jeanne Lenzer investigates

https://www.bmj.com/content/bmj/346/bmj.f3830.full.pdf

Why we can’t trust clinical guidelines

Background. Sleep is a basic physiological process. Normal sleep yields decrease in sympathetic activity, blood pressure (BP) and heart rate. Those, who do not have expected decrease in their BP are considered “non‐dippers”. We aimed to determine if there was any association between the non‐dipping status and sleep quality, designed a cross‐sectional study, and enrolled and evaluated the sleep quality of relatively young patients with an initial diagnosis of hypertension. Methods. Seventy‐five consecutive patients, diagnosed to have stage 1 hypertension by their primary physicians, were referred to our study. Patients had newly diagnosed with stage 1 hypertension. Patients with a prior use of any anti‐hypertensive medication were not included. Eligible patients underwent the Pittsburgh Sleep Quality Index (PSQI), which has an established role in evaluating sleep disturbances. All patients underwent ambulatory BP monitoring. Results. There were 42 non‐dipper patients (mean age = 47.5±11.9 years, 24 male/18...

Sleep quality among relatively younger patients with initial diagnosis of hypertension: dippers versus non-dippers.

We examined the relationship between coronary flow rate and epicardial adipose tissue (EAT) in patients with slow coronary flow (SCF) and normal coronary arteries. The study included 40 consecutive patients with stable angina pectoris who had normal coronary arteries. All patients underwent echocardiography. To determine the SCF, thrombolysis in myocardial infarction (TIMI) frame count method was used. Half of the patients had SCF at least in 1 coronary artery. Thrombolysis in myocardial infarction frame counts, the mean TIMI frame count, and EAT thickness were significantly higher in patients with SCF. Slow coronary flow showed a significantly positive correlation with EAT thickness. Epicardial adipose tissue thickness was the only independent predictor of SCF. Our findings suggest that there is a significant correlation between the SCF and EAT. Therefore, echocardiographic EAT may become a predictor of subclinical atherosclerosis in patients with stable angina pectoris.

Echocardiographic Epicardial Adipose Tissue Predicts Subclinical Atherosclerosis: Epicardial adipose tissue and Atherosclerosis

The potential early predictive value of microalbuminuria (MA) in the estimation of atherosclerosis and the relation between the degree of urinary albumin excretion and the extent of coronary artery disease (CAD) were investigated. Patients (n = 159) with stable angina pectoris and angiographically significant stenosis in at least 1 of the major coronary arteries were included. Microalbuminuria was measured by immunoturbidimetry. The extent of coronary artery stenosis was graded using the Gensini score. The Gensini score was significantly greater in patients who had MA. Also, the Gensini increased by 0.15 units with 1 unit increase in MA. In the groups who had diabetes mellitus and hypertension, there was no correlation between MA and Gensini score. The results of the present study suggest that MA is associated with the severity of CAD independent of other cardiovascular risk factors.

Microalbuminuria is Associated With the Severity of Coronary Artery Disease Independently of Other Cardiovascular Risk Factors

Background: Heart failure (HF) is a fatal disease. Plasma osmolality with individual impacts of sodium, blood urea nitrogen (BUN), and glucose has not been studied prognostically in patients with HF. Aim: This study aims to investigate the impact of serum osmolality on clinical endpoints in HF patients. Methods: A total of 509 patients (383 males, 126 females) with HF with reduced ejection fraction in three HF centres were retrospectively analysed between January 2007 and December 2013. Follow-up data were completed for 496 patients. Plasma osmolality was calculated as (2 × Na) + (BUN/2.8) + (Glucose/18). Quartiles of plasma osmolality were produced, and the possible relationship between plasma osmolality and cardiovascular mortality was investigated. Results: The mean follow-up was 25 ± 22 months. The mean age was 56.5 ± 17.3 years with a mean EF of 26 ± 8%. The mean levels of plasma osmolality were as follows in the quartiles: 1st % = 280 ± 6, 2nd % = 288 ± 1, 3rd % = 293 ± 2 (95% confidence interval [CI] 292.72–293.3), and 4th % = 301 ± 5 mOsm/kg. The EF and B-type natriuretic peptide levels were similar in the four quartiles. Univariate and multivariate analyses in the Cox proportional hazard model revealed a significantly higher rate of mortality in the patients with hypo-osmolality. The Kaplan-Meier plot showed graded mortality curves with the 1st quartile having the worst prognosis, followed by the 4th quartile and the 2nd quartile, while the 3rd quartile was shown to have the best prognosis. Conclusions: Our study results suggest that normal plasma osmolality is between 275 and 295 mOsm/kg. However, being close to the upper limit of normal range (292–293 mOsm/kg) seems to be the optimal plasma osmolality level in terms of cardiovascular prognosis in patients with HF.

/pdf/plasma-osmolality-predicts-mortality-in-patients-with-heart-2jnn8emlhz.pdf

Plasma osmolality predicts mortality in patients with heart failure with reduced ejection fraction

Objective : In this study, 12 patients who were diagnosed as having cardiac tumours and were operated on in the Department of Cardiovascular Surgery following referral from the Department of Cardiology were enrolled between January 1995 and October 2007.
Methods : The symptoms, clinical findings, diagnostic methods, localisation of masses and surgical applications were recorded retrospectively.
Results : There were 10 female (83%) and two (17%) male patients; their ages ranged from 35 to 70 years (mean 68.7 years). Twelve patients were diagnosed with myxomas, nine of which were located within the left atrium and three in the right atrium. The most common symptoms at clinical presentation were those associated with heart failure or embolisation. Diagnosis of the tumours was made by echocardiography in all patients. The masses were completely resected in eight patients and the interatrial septae were partially excised with mass resection in two patients. The defect was reconstructed with a pericardial patch in one of the patients, and primarily reconstructed in the other. We carried out debridement with mass resection in another case. Femoro-popliteal aorto-iliac thrombo-endarterectomy was performed with mass resection in a further case.
Conclusion : Atrial myxomas are the most common primary cardiac tumours. They can cause valvular or inflow-outflow tract obstruction, thrombo-embolism, arrhythmias, or pericardial disorders. Most atrial myxomas are benign but due to non-specific symptoms, early diagnosis may be a challenge and they must be removed by surgical resection. Diagnosis and follow up with the collaboration of cardiology and cardiovascular surgery departments is important for meticulous care of these patients.

Oguzhan Yucel

Papers

Sleep quality among relatively younger patients with initial diagnosis of hypertension: dippers versus non-dippers.

Echocardiographic Epicardial Adipose Tissue Predicts Subclinical Atherosclerosis: Epicardial adipose tissue and Atherosclerosis

Microalbuminuria is Associated With the Severity of Coronary Artery Disease Independently of Other Cardiovascular Risk Factors

Plasma osmolality predicts mortality in patients with heart failure with reduced ejection fraction

Diagnosis and follow up of patients with primary cardiac tumours: a single-centre experience of myxomas.