White coat hypertension and carotid atherosclerosis

To investigate further the relationship between atherosclerotic vascular disease and blood pressure, and the phenomenon of white coat hypertension, we performed a cross-sectional study of patients referred for carotid Doppler scanning, to determine the relationship between ambulatory blood pressure monitoring (ABPM) and carotid atherosclerosis. We studied 79 patients (51 men, 28 women) undergoing Doppler ultrasound examination of the carotid arteries: 44 (56%) had evidence of carotid atherosclerosis on Doppler ultrasound examination ("disease group"), whilst 35 (44%) had normal carotid arteries ("controls"). "Adequate" ABPM recordings, defined by > 90% of recordings over the 24 h, were available in 51 patients (30 positive, 21 negative). There were no significant differences in mean daytime, mean night-time or mean 24 h ABPM recordings between those with and without carotid atherosclerosis. Mean manual clinic systolic blood pressure was significantly greater in those with carotid atherosclerosis than in controls (146.7 +/- 25.2 vs 131.1 +/- 35 mmHg, p < 0.005). In patients with carotid atherosclerosis, the first systolic blood pressure ABPM recording was not significantly different from the mean manual clinic recording (mean difference -1.5 mmHg, 95% confidence interval (CI) -7.9 to 4.8 mmHg). The initial diastolic blood pressure ABPM recording was significantly higher than the mean manual recording. Carotid atherosclerosis was identified in 53% of normotensive controls compared with 56% of white coat hypertensives and 75% of persistent hypertensives. One-third (9/27) of the patients with normal carotid arteries did not have nocturnal dipping ("non-dippers") compared with 50% (12/24) of the atherosclerotic patients. This study suggests that carotid atherosclerosis may be associated with white coat hypertension. Our study adds to the body of evidence that white coat hypertension is associated with end-organ damage and is not simply a benign disease. Such patients should be screened for other cardiovascular risk factors and should be monitored for the development of persistent hypertension.

Pyrexia, anaemia and acute renal failure secondary to omeprazole

We present the case of a 77-year-old woman who initially presented with pyrexia of unknown origin, anaemia and mild renal impairment. When her omeprazole was stopped she improved rapidly. When omeprazole was re-started she developed fever and acute renal failure, which again settled quickly on discontinuation of omeprazole. This case demonstrates how drugs can cause severe multisystem disorders that may appear to be infective or inflammatory.

Association of atherogenic low-density lipoprotein subfractions with carotid atherosclerosis

Patients with carotid atherosclerosis are at increased risk of both stroke and ischaemic heart disease. Low-density lipoprotein (LDL) is a heterogeneous group of particles, with small, dense particles being more atherogenic. We studied 79 patients (51 men, mean +/- SD age 62.4 +/- 11.7 years) referred for Doppler ultrasound assessment of the carotid arteries. Evidence of carotid atherosclerosis, defined as the presence of atherosclerotic plaque, stenosis or occlusion in one or more of the six carotid artery segments examined, was found in 44 patients (56%). LDL subfractions were analysed by disc polyacrylamide gel electrophoresis with prior ultracentrifugation of serum to remove chylomicrons. This method produces a LDL score; the higher the score, the greater the proportion of the more atherogenic LDL subfractions. Mean LDL score was significantly higher in diseased patients (mean +/- SD, 1.56 +/- 0.61) than the normal group (1.26 +/- 0.65) (t = 2.12, p = 0.037). There was no significant association between LDL score and severity of carotid artery stenosis. Age (adjusted odds ratio 1.09, 95% CI 1.03-1.15) and smoking history (2.09, 95% CI 1.10-3.98) predicted carotid atherosclerosis in logistic regression analysis, with LDL score achieving borderline significance (2.20, 95% CI 0.91-5.29). Small, dense LDL subfractions are associated with carotid atherosclerosis and may be a modifiable risk factor for stroke as well as ischaemic heart disease.

Beta-blockers in heart failure--a cardioprotective therapy?

Heart failure remains a major cause of morbidity and mortality despite optimum treatment with angiotensin-converting enzyme inhibitors and diuretics. Meta-analysis of recent placebo-controlled, randomized trials suggest that treatment with beta-blockers may significantly reduce mortality by 35%.