[Aortic valve replacement for the patient with Osler-Rendu-Weber disease]

Osler Rendu-Weber (O-R W) disease (hereditary haemorrhagic telangiectasia) is characterized by an anormality of the peripheral blood vessels which often causes recurrent epistaxis. We presented a case of aortic valve replacement for the patient with O-R-W disease. A 75-year-old woman diagnosed as O-R-W disease with chest pain and dyspnea was admitted. Preoperative transthoratic echocardiography showed severe aortic valve stenosis (AS) with a pressure gradient (from left ventricle to ascending aorta) of 72.5 mmHg. Urgent aortic valve replacement (AVR) was performed after preoperative hormonal (estrogen-progesterone) therapy, that might be effective for bleeding from vascular ectasia. No hemorrhagic tendency was recognized and the postoperative course was uneventful.

[Surgical treatment for the patient with atrial septal defect and Andersen syndrome]

An 18-year-old girl with atrial septal defect and Andersen syndrome is reported. Andersen syndrome was described as a hereditary disease characterized by periodic paralysis, prolongation of the QT interval with ventricular arrhythmia and characteristic physical features including low set ear and micrognathia. We successfully performed cardiac operation for this rare associated malformation.

[Norwood procedure after colostomy; report of a case]

We encountered a baby who was diagnosed with anal atresia, interruption of aortic arch (type B), aortic stenosis, mitral stenosis, single atrium, large ventricular septal defects, aberrant origin right subclavian artery. We operated on him using the Norwood procedure after a colostomy. Aortic arch was reconstructed by interposing with an 8 mm graft and the right ventricular-pulmonary artery (RV-PA) conduit was chosen for pulmonary flow. We closed the sternum 6 days after the Norwood procedure. We extubated him 16 days after delayed sternal closure. There was no trouble with his stoma and no sign of infection. The postoperative echocardiography didn't show the finding which left pulmonary artery was stenotic, but the lung perfusion schintigraphy revealed an imbalance in the distribution of lung perfusion. He was discharged 70 days after undergoing the Norwood procedure.

[Successful repair of supravalvular aortic stenosis using Steinberg 3 sinuses reconstruction; report of a case]

Steinberg method is a modification of Doty extended aortoplasty for supravalvular aortic stenosis (SAS). This modification entails placement of an additional patch in the left coronary sinus. A 3-year-old boy was diagnosed as SAS with aortic valvular stenosis. He was noticed a systolic murmur from 1 month after his birth. Echocardiography showed left ventricular hypertrophy, and pressure gradient of 80 mmHg was measured between the ascending aorta and the left ventricle. Cardiac catheterization revealed severe aortic stenosis at the sino-tubular (ST) junction. We adopted Steinberg 3 sinuses reconstruction. After this operation, there was no pressure gradient at ST junction although aortic valvular stenosis remained and mild aortic valve regurgitation newly developed. As this method can produce a symmetric aortic root, it may reduce aortic valve deformity especially on the left coronary cusp.

[Surgical treatment for postinfarction ventricular septal perforation]

Between November 1985 and April 2003, surgical treatment for ventricular septal perforation (VSP) after acute myocardial infarction was performed in 16 patients. Patients were divided into 2 groups by method of operation. One group is infarct exclusion technique (n = 10). The other group is trans right ventricular (RV) approach (n = 6). No significant differences were observed between 2 groups in preoperative states. Operative death rate was high in both groups. Five patients (50%) were died in infarct exclusion group, 4 patients (67%) in trans RV group. Infarct exclusion technique needed longer extracorporeal circulation time (201 +/- 33 min) than trans RV approach (170 +/- 32 min). Although trans RV approach is attractive for its simplicity, 3 cases died of rupture of remained left ventricle infarction area. On the other hand, there were no mortality cases caused by left ventricle rupture in infarct exclusion technique group. As this result, we select infarct exclusion technique as a surgical correction for VSP.

Human growth hormone induces SOCS3 and CIS mRNA increase in the hypothalamic neurons of hypophysectomized rats

The activation of the growth hormone (GH) receptor is followed by activation of the JAK2-STAT system in peripheral tissues, which in turn induces the expression of suppressors of cytokine signaling (SOCS) and/or cytokine-inducible SH2 protein (CIS) to achieve the attenuation of the signaling. To examine whether GH involves the SOCS/CIS system as intracellular negative regulators in the hypothalamus, we observed the effects of human GH on the gene expression of SOCS/CIS in the rat hypothalamus. The mRNAs of CIS, SOCS2, and SOCS3 in the hypothalamus of hypophysectomized male rats were examined by Northern analysis following the intravenous administration of recombinant human GH (hGH), 50 microg/100 g BW. The SOCS3 and CIS mRNAs were increased transiently with maximum expression at 1 h after hGH administration. The intravenous hGH did not induce SOCS2 mRNA expression in the hypothalamus. In situ hybridization demonstrated the increase of SOCS3 and CIS mRNAs in the arcuate nucleus after hGH administration, and the increase of SOCS3 mRNA in the periventricular nucleus. The hGH applied to primary cultured hypothalamic neurons at 500 ng/ml induced transient increase of SOCS3 and CIS mRNAs, but not SOCS2 mRNA. The results show that hGH acts directly on the neurons in the hypothalamus, and increases SOCS3 and CIS mRNAs, suggesting that these negative regulators may be involved in the mechanism that turns off the hGH action in the hypothalamic neurons.

Binding affinity of bunazosin, dorzolamide, and timolol to synthetic melanin

PURPOSE

The purpose of this study was to compare the binding affinity of bunazosin and dorzolamide to synthetic melanin relative to that of timolol.

METHODS

Synthetic melanin was prepared from dopa by the action of tyrosinase. Timolol, dorzolamide, and bunazosin were incubated separately at a concentration of 10(-4) M in 2 ml of 0.066 M phosphate buffer containing 5 mg of synthetic melanin. After centrifugation, the absorbance of each free drug in the supernatant was measured at its optimum wavelength. The percentage of each drug bound to melanin was calculated directly from the change in absorbance relative to the initial value.

RESULTS

The increase in the binding rates of all three drugs seemed to reach a plateau after 30 min. After incubating for 60 min, the binding rate of timolol was 22.2% +/- 4.9%, bunazosin 36.3% +/- 2.5%, and dorzolamide 8.5% +/- 1.9%. There were statistically significant differences between the binding rates of each drug.

CONCLUSIONS

Under our study conditions, the order of binding affinity of these ocular hypotensive agents to synthetic melanin seems to be as follows: bunazosin>timolol>dorzolamide.

Atomic force microscope of drug-DNA interaction

We have been investigated the possibility of B-Z transition in ZnTMPyP-DNA interaction based on the observation of spectroscopic data. In this study, we found drastic change in the AFM image of supercoiled plasmid DNA when it was interacted with TMPyPs indicating that the considerable amount of unwinding of double helix or B-Z transition is induced by the drug-DNA interaction. Such phenomena were not observed for other cationic drugs examined.

[Total aortic arch replacement with a right femur neck fracture on chronic renal dialysis; report of a successful case]

Although recent operative outcome for aortic arch aneurysm has been improved by various newly-devised assistant measures, satisfactory results have not been obtained in cases with serious preoperative complications, such as chronic renal failure. We present here an operative case of a 67-year-old woman on chronic hemodialysis with a calcified aortic arch aneurysm and a right femur neck fracture. First, we performed femur head replacement under careful hemodynamic control. After her mobilization was achieved, total aortic arch replacement was performed in "arch-first technique" using deep hypothermia plus retrograde cerebral perfusion in consideration of her calcified vessels. Her postoperative course was uneventful. We believe that early mobilization was a key for her recovery, because it was useful to prevent postoperative complications such as pulmonary infection and atelectasis. Our experience suggested that meticulous management throughout the whole perioperative course is very important for total aortic arch replacement in such complicated cases.

[Surgical treatment for giant ascending aorta-arch aneurysm coexisted with DeBakey type II dissection on elderly women: report of a case]

A 78-year-old woman was admitted to our hospital after computed tomography (CT) had revealed in her the presence of a giant ascending aorta-arch aneurysm. This aneurysm was about 8 cm in diameter and associated with DeBakey type II dissection. Aortography showed the same condition as the CT view with the entry on the ascending aorta. The ascending aortaarch was replaced with a Hemashield 24 mm, by using deep-hypothermic selective cerebral perfusion and the open distal method. There were no complications during her peripostoperative state and no evidence of leakage and remnant dissection on CT and aortography. This is a rare case in which thoracic aortic aneurysm coexisted with dissection. In this case of severe atherosclerosis, deep-hypothermic selective cerebral perfusion and the open distal method provided effective treatment.

Quantitative assessment of right ventricular structural abnormalities by right ventricular polar mapping of single photon emission computed tomogram

The identification of right ventricular (RV) abnormalities is clinically important in the evaluation of arrhythmogenic substrates in right ventricular-originated ventricular tachycardia (RVT). The purpose of this study was to determine the diagnostic benefit of quantitative analysis in RV single photon emission computed tomography (SPECT) imaging with (99m)Tc-tetrofosmin/sestamibi in patients with RVT. Thirty patients with RVT (15 with idiopathic RVT and 15 with arrhythmogenic right ventricular cardiomyopathy (ARVC)) were compared with 27 control subjects (including 11 with right bundle branch block) with regard to the semiquantitative RV uptake score in each of six segments and the quantitative RV extent score in polar coordinate map displays by SPECT imaging. The RV total score and RV extent score were compared with the RV global function. Perfusion abnormalities were more frequently detected (P = 0.0001) in the ARVC group (59/90, 65.6%) than in the idiopathic RVT group (4/90, 4.4%) or controls (1/162, 0.6%). The RV extent score in the ARVC group (53.0 +/- 24.8) was significantly higher than that in the idiopathic RVT group (8.4 +/- 10.1) or controls (1.2 +/- 4.9). The RV extent score correlated well with the regional RV perfusion score (P < 0.0001) and with the RV ejection fraction (P < 0.0001). Non-invasive RV perfusion mapping using a (99m)Tc-labelled tracer is useful for the quantitative evaluation of RV substrates in patients with ARVC.

Differential expression of multiple isoforms of the ELKS mRNAs involved in a papillary thyroid carcinoma

A novel gene, ELKS, whose 5' portion was fused to the RET gene, was found in a papillary thyroid carcinoma. A cDNA of this gene obtained from a human-brain cDNA library revealed that it encoded a peptide of 948 amino acids, termed ELKSalpha. We identified four other isoforms, which encoded ELKSbeta, ELKSgamma, ELKSdelta, and ELKSepsilon proteins consisting, respectively, of 992, 720, 1088, and 1116 amino acid residues. Analysis of the gene structure revealed that the isoforms were generated by alternative splicing. Isoforms beta, gamma, delta, and epsilon all contain an optional exon (exon14a), but ELKSgamma, -delta, and -epsilon lack exon 1b. ELKSgamma lacks exons 3 to 6. ELKSdelta and -epsilon lack exons 12 and 17; ELKSepsilon contains an optional exon (exon 6a). Analysis by RT-PCR suggested that ELKSalpha and ELKSbeta mRNAs are abundant in the brain, ELKSdelta and ELKSepsilon mRNAs predominate in testis and thyroid, and ELKSepsilon mRNA predominates in other tissues. To prove whether the fusion of different ELKS isoforms to RET (between ELKS coiled-coil domains and the RET kinase domain) could produce chimeric proteins that could be autophosphorylated, we synthesized ELKSgamma-RET, ELKSdelta-RET, and ELKSepsilon-RET fusion proteins in vitro. Immunoblotting with anti-ELKS, anti-RET, and anti-phosphotyrosine antibodies demonstrated that the chimeric proteins were constitutively phosphorylated at tyrosine residues, whereas native RET protein was not. These results indicate that the ELKS gene is alternatively spliced, and that every type of ELKS-RET chimeric protein having oligomerization domains can activate RET's cytoplasmic tyrosine kinase.

Validation of quantitative gated single photon emission computed tomography and an automated scoring system for the assessment of regional left ventricular systolic function

Despite its ability to quantify regional perfusion and function, there is no established method for quantification of regional perfusion and function by myocardial gated single photon emission computed tomography (SPECT). The aim of this study was to establish a quantitative index for regional perfusion and systolic function assessment using gated SPECT. Myocardial SPECT was performed at rest using (99m)Tc sestamibi with 8-frame gating in 62 consecutive patients. In addition to computation of left ventricular ejection fraction (LVEF), a new computerized method for quantifying, displaying and automatically grading regional data was developed. Regional function was quantified as wall motion, regional EF, and imaged based, count based, and normalized per cent wall thickenings (%WTs). Regional perfusion was assessed as a relative per cent peak count. Data were displayed on a 25-segmented polar map and automatically graded with a 5-point scale, and then summed scores were calculated. These quantitative parameters were compared to data from radionuclide ventriculography (RNV) and contrast left ventriculography. Gated SPECT had high reproducibilities for calculating global and regional ejection fractions and %WT indices (r=0.811-0.984, P<0.0001), but measurement of wall motion was less reproducible (r=0.555, SEE=7.9, P<0.011). LVEF estimated by gated SPECT and summed perfusion scores correlated closely (P<0.0001) with angiographic LVEF. Among the summed function indices that correlated closely with LVEF, normalized %WT had the closest correlations with LVEF estimated by RNV (r=0.657, P<0.0001) and by gated SPECT (r=0.778, P<0.0001). Assessment by visual reviewing of cine-mode playback or by normalized %WT had greater overall sensitivity, specificity, and positive and negative predictive values for detecting impaired regional function among the functional parameters: 71%, 79%, 63% and 84% for cine format analysis, and 78%, 73%, 59% and 87% for normalized %WT, respectively. Thus, besides LVEF, quantitative gated SPECT can provide reproducible and reliable quantitative data on regional perfusion and function. Automated summed scores obtained by gated SPECT can reflect integrated abnormalities of regional perfusion and function of the left ventricle. Both visual analyses by cine-mode display and a functional map of normalized wall thickening have greater diagnostic values for detecting regional function deficit related to coronary artery disease.

The role of the hypothalamic nitric oxide in the pressor responses elicited by acute environmental stress in awake rats

We quantitatively investigated the change in nitric oxide (NO) in the hypothalamic paraventricular nucleus (PVN) and its effect on cardiovascular regulation during shaker stress (SS) using brain microdialysis in awake rats. Male Wistar rats were fed either N(G)-nitro-L-arginine methyl ester (L-NAME, 0.7 g/L) or tap water for 2 weeks. Two days after implantation of an arterial catheter and guide shaft, a microdialysis probe was placed to perfuse the PVN with degassed Ringer solution at 2 microl/min in awake normotensive Wistar (CONTROL) and chronic L-NAME-treated hypertensive rats. After the rat was placed in a plastic cage set on a shaker, the blood pressure and heart rate was monitored and 10-min SS was loaded at a frequency of 200 cycles/min. Dialysate samples were analyzed by NO analyzer (based on the Griess reaction) every 10 min, and NOx (NO(2)(-) + NO(3)(-)) was measured. Plasma NOx was also measured before and after SS. Pressor responses elicited by SS were significantly greater in L-NAME-treated rats than in the CONTROL. Although NOx in the PVN dialysate were increased by SS in the CONTROL, these responses were attenuated in chronic L-NAME-treated rats. Resting plasma NOx were higher in the CONTROL than in L-NAME-treated rats. SS elicited no difference between two groups in plasma NOx. These results indicated that NO within the PVN, but not in systemic circulation, may play a role on the attenuation of the pressor responses elicited by SS. The dysfunction of NO release within the PVN may, in part, play a role in the exaggerated pressor responses in acute environmental stress.

[Surgical treatment of Marfan syndrome; analysis of the patients required multiple surgical interventions]

Without treatment, the life expectancy of patients with Marfan syndrome is reduced by the associated cardiovascular abnormalities. In this study, we reviewed our experience of the patients with Marfan syndrome who required multiple surgical interventions to identify the optimal treatment for these patients. Between January 1986 and December 2000, 44 patients with Marfan syndrome were operated on at Shizuoka City Hospital (SCH). Among them, 10 patients (22.7%) underwent multiple surgical interventions. There were 5 male and 5 female patients with a mean age of 40.6 +/- 16.1 years at the initial surgery. Only one patient was operated on at another hospital for his first, second, and third operations. His fourth operation was carried out at SCH. The remaining 9 patients underwent a total of 14 additional surgical procedures at SCH. Computed tomography (CT) scans were taken every 6 months postoperatively, and aortic diameter greater than 60 mm was considered as the indication for the additional surgery. There were no early death and one late death. The causes of additional surgery were enlargement of true aneurysm in 6, enlargement of residual dissection in 4, new dissection in 4, false aneurysm at the coronary anastomosis of Bentall procedure in 1. In 9 patients, both ascending and descending aorta were replaced. Among these 9 patients, only 3 patients underwent total arch replacement, and remaining 6 patients had their arch left in place with or without dissection. Our current strategy of the treatment of Marfan patients with acute type A dissection is total arch replacement with an elephant trunk at the initial emergent surgery.

Microinjection of dihydrotestosterone into the medial preoptic area produces male-like pattern of growth hormone secretion in ovariectomized female rats

The pattern of growth hormone (GH) secretion is sexually dimorphic in rats. We have previously shown that the secretory pattern in adult ovariectomized (OVX) female rats is masculinized by the administration of a single dose of dihydrotestosterone (DHT), a nonaromatizable androgen. To investigate the primary site of action of DHT in the brain, a small amount of DHT was injected directly into a defined area of the brain, and the blood GH profile was observed for 18 h in conscious adult OVX female rats. The bilateral direct injection of 1 microg DHT into the medial preoptic area (MPA) produced a male-like secretory pattern of GH in OVX rats. The masculinizing effects became apparent at 9 h after injection, from which time the episodic GH secretion was produced regularly at intervals of about 150 min, the amplitude of the peak increased and baseline levels were lowered. These parameters, analyzed during 9-18 h after DHT injection, were not different from those in adult male rats. On the contrary, microinjection of DHT into the bed nucleus of the stria terminalis, the hypothalamic periventricular nucleus, or the hypothalamic arcuate-ventromedial nucleus did not affect the secretory pattern of GH. The data indicate that DHT primarily acts on cells in the MPA through androgen receptors and modulates the secretion of somatostatin and/or GH-releasing hormone secondarily to masculinize the GH secretory pattern in OVX rats.

[Long-term results after surgery for aortic arch nondissection aneurysm]

Between 1990 and August 2001, 109 patients were treated surgically for nondissection fusiform or saccular aortic arch aneurysm. Fifteen patients were emergent. There were 89 male and 20 female patients (mean 71.7 +/- 6, range 49 to 84). Eight patients underwent hemiarch replacement, 57 total arch replacement, 44 distal arch replacement, which were performed with the aid of hypothermic extracorporeal circulation with antegrade selective cerebral perfusion or retrograde cerebral perfusion. The early mortality was 8.5% with elective operations and 53.3% with emergent operations. The incidence of post operative permanent neurological dysfunction was 12.8% with elective operations and 46.7% with emergent operations. The 5-year and 10-year survival rate including in-hospital deaths was 52 +/- 6% and 29 +/- 9%. The 5-year event free rate was 89 +/- 5%.

[A case of emergency coronary artery bypass graft for the patient using chronic hemodialysis, where in blood volume was measurable in the perioperative period]

An emergency coronary artery bypass graft (CABG) was given to a 66 year-old patient due to acute myocardial infarction (AMI). Circulating blood volume (BV) was measured to study in the perioperative period. Three coronary artery bypasses were made under cardiopulmonary bypass, being managed by ultrafiltration when the pump-oxygenator was in action and by peritoneal dialysis in the early postoperative period. Preoperative BV reduced immediately after the operation. It showed an increasing trend 4 hours after the operation, but after that BV reduced from that before the operation while water balance was kept positive. Cardiac output after the operation was higher than before. It suggested that in this patient using hemodialysis BV levels turned to be lower compared with that before the operation, as excessive water leaked out of the blood vessel, although water balance was kept positive due to improved cardiac functions after the operation.

Antiinflammatory effect of heparin-coated circuits with leukocyte-depleting filters in coronary bypass surgery

Cardiac surgery with cardiopulmonary bypass is associated with a systemic inflammatory response. We examined combined use of heparin coating of the cardiopulmonary bypass circuit and a leukocyte-depleting arterial line filter to reduce this response. Thirty patients were allocated randomly to equal groups with a conventional circuit and arterial line filter (C group), a heparin-coated circuit with a conventional filter (H group), or a heparin-coated circuit with a leukocyte-depleting arterial line filter (HF group). Cytokines and respiratory function were repeatedly measured perioperatively. Plasma interleukin (IL)-6 concentrations in the HF group were lower than in the C group immediately following bypass and operation, at 4 h, and 12 h (p < 0.05). Plasma IL-8 was lower in the HF group than in the C group at 4 h (p < 0.05). The respiratory index was lower immediately after bypass in the HF group than the C group (0.61 +/- 0.2 versus 1.05 +/- 0.4, p < 0.05). Heparin-coated circuits with leukocyte-depleting filters decrease inflammatory responses and improve pulmonary function during operation.

Assessment of underlying etiology and cardiac sympathetic innervation to identify patients at high risk of cardiac death

Cardiac (123)I-labeled metaiodobenzylguanidine (MIBG) activity has significant incremental prognostic value, but the difference between the long-term prognostic value of MIBG imaging for ischemic cardiomyopathies and the long-term prognostic value of MIBG imaging for idiopathic cardiomyopathies is not clear. This study aimed to determine whether assessment of cardiac (123)I-MIBG activities in ischemic and idiopathic cardiomyopathies have equally prognostic values and whether the kinetics are different because of the underlying etiologies.

METHODS

After quantitative (123)I-MIBG imaging, 76 ischemic and 56 idiopathic cardiomyopathy patients were prospectively followed up for 54 mo. In addition to conventional parameters, cardiac (123)I-MIBG activity was quantified as a heart-to-mediastinum ratio (H/M) for early and late images and the washout kinetics were calculated using tomographic imaging. The data were compared with those obtained from 16 healthy volunteers.

RESULTS

During follow-up, 29 deaths from heart failure, 11 sudden cardiac deaths, 2 deaths from arrhythmia, and 5 deaths from acute myocardial infarction were documented. Multivariate discriminant analysis using the Cox proportional hazards model showed that, in comparison with other variables, late H/M was the most powerful independent predictor of a lethal clinical outcome in ischemic (Wald chi(2) = 18.6502; P = 0.0000) and idiopathic (Wald chi(2) = 5.3394; P = 0.0208) groups. When patients with left ventricular ejection fraction (LVEF) < 40% were considered, late H/M had the greatest statistical power in both groups. Kaplan-Meier analysis showed late H/M to have an identical threshold (1.82) for both groups for identifying patients at risk of cardiac death. Likewise, when analysis was restricted to patients with an LVEF < 40%, the upper cutoff value of late H/M was 1.50 (P = 0.0358; log rank = 4.41) for ischemic patients and 2.02 (P = 0.0050; log rank = 7.86) for idiopathic patients. For patients with an LVEF < 40% and a late H/M less than the identified threshold of late H/M, the annual rate of cardiac death was greatest, 18.2%/y for the ischemic group and 11.9%/y for the idiopathic group.

CONCLUSION

Cardiac (123)I-MIBG activity has the most powerful independent long-term prognostic value for both ischemic cardiomyopathy patients and idiopathic cardiomyopathy patients, indicating that both disease processes have common pathophysiologic and prognostic implications of impaired cardiac sympathetic innervation. Although combined testing of cardiac function and (123)I-MIBG activity is most likely to identify patients at increased risk of cardiac death, the underlying etiology of cardiac dysfunction may affect the threshold of (123)I-MIBG activity for the differentiation of high-risk patients.

Reduction of white coat effect by cilnidipine in essential hypertension

Stress elevates blood pressure (BP) by increased sympathetic nerve activity. Cilnidipine, a novel dihydropyridine calcium antagonist that has inhibitory actions on N-type as well as L-type voltage-dependent calcium channels, has been reported to attenuate the cold stress-induced increase in plasma norepinephrine and BP in rats. Because white coat effect is associated with an enhanced pressor response to mental stress, we postulated that cilnidipine would attenuate white coat effect in patients with essential hypertension. Sixty-one consecutive outpatients (50 men, 11 women) with essential hypertension were studied prospectively. Twenty-nine patients were treated with either cilnidipine (n = 15) or nifedipine, a representative L-type voltage-dependent calcium antagonist (n = 14). Gender, age, body mass index, duration of hypertension, target organ damage of hypertension, and BP and heart rate (HR) were not significantly different between cilnidipine and nifedipine groups, and both systolic (SBP) and diastolic BP (DBP) were significantly decreased after treatment in both groups. White coat effects on systolic and DBP and HR were not significantly different between groups before antihypertensive treatment. Cilnidipine, but not nifedipine, significantly reduced white coat effects on SBP and HR. Furthermore, white coat effects on systolic BP and HR were significantly lower after treatment in the cilnidipine group compared with the nifedipine group. These data suggest that cilnidipine may reduce white coat effect in hypertensive patients by N-type calcium channel antagonism.