Early Prediction of Hypertensive Diseases of Pregnancy by Using Combined Screening Methods in a Rural Population

INTRODUCTION

The most frequent medical issue during pregnancy is hypertension, which can complicate up to 10% to 15% of pregnancies worldwide. An estimated 14% of all maternal fatalities worldwide are thought to be caused by hypertensive disease of pregnancy, one of the main causes of maternal and fetal morbidity and mortality. Despite the fact that maternal mortality is substantially lower in high-income countries than in low- and middle-income countries, hypertension is still one of the leading causes of maternal death globally. Maternal mortality associated with hypertension fluctuated between 0.08 and 0.42 per 100,000 births between 2009 and 2015. In India, the estimated overall pooled prevalence of HDP was determined to be one out of 11 women, or 11% (95% CI, 5%-17%). Despite various government programs, there is still a high prevalence of hypertension, which calls for stakeholders and healthcare professionals to focus on providing both therapeutic and preventive care. The best solution is to concentrate more on the early detection of pregnancy-related hypertension and to guarantee its universal application so that proper care can be carried out to prevent maternal and fetal morbidity.

AIM

To estimate the predictive value of the combination of maternal characteristics, i.e., mean arterial pressure (MAP), biophysical evaluation (uterine artery Doppler), and biochemical markers (pregnancy-associated plasma protein A (PAPP-A)), in the first trimester of pregnancy for hypertensive diseases of pregnancy.

METHODOLOGY

It was a prospective observational study of longitudinal variety that took over 18 months in a tertiary care rural hospital. The number of women admitted to the hospital for labor care during 2019 was 5261. A total of 513 were diagnosed with hypertensive illnesses during pregnancy. At a prevalence rate of 10%, we calculated a sample size of 350 to achieve a sensitivity of 85% with an absolute error of 12.5% at a 95% CI. Maternal histories, such as age, education, socio-economic status, gravidity, and BMI, were taken along with three parameters, i.e., MAP, which was significant above 90 mmHg, uterine artery Doppler, which was taken significant above 1.69, and serum PAPP-A, which was significant at less than 0.69 ml/IU.

OBSERVATION AND RESULTS

We have found that the following are associated with the prediction of hypertension: among the maternal characteristics are advanced age >35 years, presence of body edema, and urine proteins along with MAP, uterine artery pulsatility index (UtA-PI), and PAPP-A are significant. The predictive accuracy of the combination of MAP, UtA-PI, and PAPP-A is also significant. We also found that there is a significant increase in cesarean sections and NICU admissions in hypertensive patients.

CONCLUSION

A combination of screening parameters, including MAP, UtA-PI, and PAPP-A, to predict early hypertensive disease of pregnancy is developed and tested.

Mean arterial pressure and mortality in patients with heart failure: a retrospective analysis of Zigong heart failure database

BACKGROUND

It is commonly observed that a higher target of mean arterial pressure (MAP) is in previous studies. This study assessed the association of MAP with short-term mortality in heart failure (HF) patients.

METHODS

A retrospective cohort study was conducted by using data from Hospitalized patients with heart failure: integrating electronic healthcare records and external outcome database (v1.2 ). The characteristic of patients was described by 3 groups of MAP: below 80 mmHg, 80-100 mmHg, and above 100 mmHg. Univariate and multivariate logistic regression analyses were used to assess the relevance between MAP and all-cause mortality within 28 days and 6 months. For assessing the effect of multiple variables on patient survival time, 28-day and 6-month, Kaplan-Meier survival analysis and Forest plot were performed.

RESULTS

The overall cohort comprised 2008 patients divided by MAP into 3 groups, each group had 344 (17.1%), 938 (46.7%), and 726 (36.2%) patients. Patients in MAP < 80 mmHg group had higher mortality than MAP 80-100 mmHg and MAP ≥ 100 mmHg in 28 days(3.8% versus 1.6% versus 1.2%) and in 6 months (4.9% versus 2.5% versus 2.3%). Univariate analysis showed that MAP as a continuous variate was associated with 28-day (OR was 0.98, 95% CIs: 0.96-0.99, P  = 0.011) and 6-month mortality (OR was 0.98, 95% CIs: 0.97-1, P  = 0.021) in HF patients. Model 4 put into multivariate logistic regression analyses showed MAP 80-100 mmHg (OR was 0.13, 95% CIs: 0.02-0.8, P  = 0.027) stably associated with 28-day and 6-month mortality after adjusted covariable. Kaplan-Meier survival curves revealed a higher survival rate in the MAP ≥ 80 mmHg group than in the MAP < 80 mmHg group. The forest plot showed the stable effect of MAP ≥ 80 mmHg compared with MAP < 80 mmHg, the interaction analysis had no statistical significance effect between the two groups of MAP and multi-variable.

CONCLUSION

It is indicated that MAP was independently associated with 28-day, 6-month all-cause mortality of HF patients, and compared with MAP < 80 mmHg, MAP ≥ 80 mmHg had a lower risk of 28-day, 6-month all-cause mortality of patients with HF.

Mean Arterial Pressure and Cerebral Hemodynamics Across The Lifespan: A Cross-Sectional Study From Human Connectome Project-Aging

BACKGROUND

Cerebral perfusion is directly affected by systemic blood pressure, which has been shown to be negatively correlated with cerebral blood flow (CBF). The impact of aging on these effects is not fully understood.

PURPOSE

To determine whether the relationship between mean arterial pressure (MAP) and cerebral hemodynamics persists throughout the lifespan.

STUDY TYPE

Retrospective, cross-sectional study.

POPULATION

Six hundred and sixty-nine participants from the Human Connectome Project-Aging ranging between 36 and 100+ years and without a major neurological disorder.

FIELD STRENGTH/SEQUENCE

Imaging data was acquired at 3.0 Tesla using a 32-channel head coil. CBF and arterial transit time (ATT) were measured by multi-delay pseudo-continuous arterial spin labeling.

ASSESSMENT

The relationships between cerebral hemodynamic parameters and MAP were evaluated globally in gray and white matter and regionally using surface-based analysis in the whole group, separately within different age groups (young: <60 years; younger-old: 60-79 years; oldest-old: ≥80 years).

STATISTICAL TESTS

Chi-squared, Kruskal-Wallis, ANOVA, Spearman rank correlation and linear regression models. The general linear model setup in FreeSurfer was used for surface-based analyses. P < 0.05 was considered significant.

RESULTS

Globally, there was a significant negative correlation between MAP and CBF in both gray (ρ = -0.275) and white matter (ρ = -0.117). This association was most prominent in the younger-old [gray matter CBF (β = -0.271); white matter CBF (β = -0.241)]. In surface-based analyses, CBF exhibited a widespread significant negative association with MAP throughout the brain, whereas a limited number of regions showed significant prolongation in ATT with higher MAP. The associations between regional CBF and MAP in the younger-old showed a different topographic pattern in comparison to young subjects.

DATA CONCLUSION

These observations further emphasize the importance of cardiovascular health in mid-to-late adulthood for healthy brain aging. The differences in the topographic pattern with aging indicate a spatially heterogeneous relationship between high blood pressure and CBF.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 3.

Combination Electroacupuncture and Guidelines Directed Medical Therapy Maintained Stability of Heart Rate and Mean Arterial Pressure in Heart Failure with Reduced Ejection Fraction

Background

Clinical studies have shown that electroacupuncture (EA) has therapeutic and modulatory effects on managing heart failure (HF) risk factors.

Objective

This study aimed to determine the impact of combination drugs and EA on chronic HF patients with reduced ejection fraction (HFrEF) to maintain a stable heart rate (HR) and mean arterial pressure (MAP).

Materials and Methods

This single-blind clinical randomized controlled trial included 42 patients with chronic HFrEF. The patients were divided into 3 groups: patients taking drugs and EA, patients taking drugs and sham EA (sham acupuncture [SA]), and patients taking drugs without EA. All patients underwent 16 sessions of therapy for 8 weeks.

Results

There was a significant difference in the average MAP based on therapy duration in the drugs + EA group, whereas there was no significant difference between drugs + SA and drugs without EA groups. There was a substantial difference between the average MAP in the drugs + EA group at the beginning of therapy compared with that at midtherapy (P < 0.05) and at the beginning of treatment and at the end of therapy (P < 0.05). There was no significant difference in the mean HR between the groups. Clinically, after 16 treatment sessions, patients receiving combined drugs and EA treatment presented with stable MAP and HR.

Conclusions

Drugs combined with EA maintained the stability of MAP and HR in patients with chronic HFrEF.

Additional predictors of the lower limit of cerebral autoregulation during cardiac surgery

OBJECTIVES

The lower limit of autoregulation (LLA) of cerebral blood flow was previously shown to vary directly with the Ambulatory Arterial Stiffness Index (AASI) redefined as 1-regression slope of DBP-versus-SBP readings invasively measured from the radial artery before the bypass. We aimed expanding the predictive capacity of the LLA with AASI by combining it with additional predictors and provide new indications whether mean arterial pressure (MAP) is above/below the LLA.

DESIGN AND METHOD

In 181 patients undergoing cardiac surgery, mean (SD) age 71 (8) years), we identified from the demographic, preoperative and intraoperative characteristics independent and statistically significant 'single predictors' of the LLA (including AASI). This was achieved using multivariate linear regression with a backward-elimination technique. The single predictors combined with 1-AASI generated new multiplicative and additive composite predictors of the LLA. Indicators for the MAP-to-LLA difference (DIF) were determined using DIF-versus-predictor plots. The odds ratio (OR) for the DIF sign (Outcome = 1 for DIF≤0) and predictor-minus-median sign (Exposure = 1 for Predictor  ≤ Median) were calculated using logistic regression.

RESULTS

BMI, 1-AASI and systolic coefficient of variation were identified single predictors that correlated similarly with the LLA ( r  = -0.26 to -0.27, P  < 0.001). The multiplicative and additive composite predictors displayed higher correlation with LLA ( r  = -0.41 and r  = -0.43, respectively, P  < 0.001) and improved LLA estimation. The adjusted OR for the composite predictors was nearly twice that of the single predictors.

CONCLUSION

The novel composite predictors may enhance the LLA estimation and the ability to maintain MAP in the cerebral autoregulatory range during cardiac surgery.

Predicting Hemodynamic Changes During Intra-Aortic Balloon Pump Support With a Longitudinal Evaluation

The use of intra-aortic balloon pump (IABP) has decreased in recent years due to negative outcome studies in cardiogenic shock complicating acute myocardial infarction, despite its favorable adverse-event profile. Acute hemodynamic response studies have identified potential super-responders with immediate improvements in cardiac index (CI) in heart failure patients. This single-center retrospective study aimed to predict CI and mean arterial pressure (MAP) changes throughout the entire duration of IABP support. The study analyzed 336 patients who received IABP between 2016 and 2022. Linear mixed-effect regression models were used to predict CI and MAP improvement during IABP support. The results showed that CI and MAP increases during the first days of support, and changes during IABP support varied with time and were associated with baseline parameters. Longitudinal CI change was associated with body surface area, baseline CI, baseline pulmonary artery pulsatility index, baseline need for pressors, and diabetes. Longitudinal MAP change was associated with baseline MAP, baseline heart rate, need for pressors, or inotropes. The study recommends considering these parameters when deciding if IABP is the most appropriate form of support for a specific patient. Further prospective studies are needed to validate the findings.

Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials

INTRODUCTION

Intraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure.

METHODS

We searched PubMed, Cochrane, and Embase up to June 2023 for studies comparing permissive (mean arterial pressure ≤60 mm Hg) with targeted (mean arterial pressure >60 mm Hg) intraoperative blood pressure management. Primary outcome was all-cause mortality at the longest follow-up available. Secondary outcomes were atrial fibrillation, myocardial infarction, acute kidney injury, delirium, stroke, number of patients requiring transfusion, time on mechanical ventilation, and length of hospital stay.

RESULTS

We included 10 randomised trials including a total of 9359 patients. Mortality was similar between permissive and targeted blood pressure management groups (89/4644 [1.9%] vs 99/4643 [2.1%], odds ratio 0.88, 95% confidence interval [CI], 0.65-1.18, P=0.38, I2=0% with nine studies included). Atrial fibrillation (102/3896 [2.6%] vs 130/3887 [3.3%] odds ratio 0.71, 95% CI 0.53-0.96, P=0.03, I2=0%), and length of hospital stay (mean difference -0.20 days, 95% CI -0.26 to -0.13, P<0.001, I2=0%) were reduced in the permissive management group. No significant differences were found in subgroup analysis for cardiac and noncardiac surgery.

CONCLUSION

Pooled randomised evidence shows that a target intraoperative mean arterial pressure ≤60 mm Hg is not associated with increased mortality; nevertheless it is surprisingly associated with a reduced rate of atrial fibrillation and of length of hospital stay.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42023393725.

Glycosylated fibronectin improves first-trimester prediction of pre-eclampsia

OBJECTIVE

To determine whether maternal serum glycosylated fibronectin (GlyFn) level in the first trimester increases the sensitivity of the Fetal Medicine Foundation (FMF) triple test, which incorporates mean arterial pressure, uterine artery pulsatility index and placental growth factor, when screening for pre-eclampsia (PE) in an Asian population.

METHODS

This was a nested case-control study of Chinese women with a singleton pregnancy who were screened for PE at 11-13 weeks' gestation as part of a non-intervention study between December 2016 and June 2018. GlyFn levels were measured retrospectively in archived serum from 1685 pregnancies, including 101 with PE, using an enzyme-linked immunosorbent assay (ELISA), and from 448 pregnancies, including 101 with PE, using a point-of-care (POC) device. Concordance between ELISA and POC tests was assessed using Lin's correlation coefficient and Passing-Bablok and Bland-Altman analyses. GlyFn was transformed into multiples of the median (MoM) to adjust for maternal and pregnancy characteristics. GlyFn MoM was compared between PE and non-PE pregnancies, and the association between GlyFn MoM and gestational age at delivery with PE was assessed. Risk for developing PE was estimated using the FMF competing-risks model. Screening performance for preterm and any-onset PE using different biomarker combinations was quantified by area under the receiver-operating-characteristics curve (AUC) and detection rate (DR) at a 10% fixed false-positive rate (FPR). Differences in AUC between biomarker combinations were compared using the DeLong test.

RESULTS

The concordance correlation coefficient between ELISA and POC measurements was 0.86 (95% CI, 0.83-0.88). Passing-Bablok analysis indicated proportional bias (slope, 1.08 (95% CI, 1.04-1.14)), with POC GlyFn being significantly higher compared with ELISA GlyFn. ELISA GlyFn in non-PE pregnancies was independent of gestational age at screening (P = 0.11), but significantly dependent on maternal age (P < 0.003), weight (P < 0.0002), height (P = 0.001), parity (P < 0.02) and smoking status (P = 0.002). Compared with non-PE pregnancies, median GlyFn MoM using ELISA and POC testing was elevated significantly in those with preterm PE (1.23 vs 1.00; P < 0.0001 and 1.18 vs 1.00; P < 0.0001, respectively) and those with term PE (1.26 vs 1.00; P < 0.0001 and 1.22 vs 1.00; P < 0.0001, respectively). GlyFn MoM was not correlated with gestational age at delivery with PE (P = 0.989). Adding GlyFn to the FMF triple test for preterm PE increased significantly the AUC from 0.859 to 0.896 (P = 0.012) and increased the DR at 10% FPR from 64.9% (95% CI, 48.7-81.1%) to 82.9% (95% CI, 66.4-93.4%). The corresponding DRs at 10% FPR for any-onset PE were 52.5% (95% CI, 42.3-62.5%) and 65.4% (95% CI, 55.2-74.5%), respectively.

CONCLUSIONS

Adding GlyFn to the FMF triple test increased the screening sensitivity for both preterm and any-onset PE in an Asian population. Prospective non-intervention studies are needed to confirm these initial findings. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Screening for pre-eclampsia by maternal serum glycosylated fibronectin at 11-13 weeks' gestation

OBJECTIVE

To examine the performance of screening for preterm and term pre-eclampsia (PE) at 11-13 weeks' gestation by maternal factors and combinations of maternal serum glycosylated fibronectin (GlyFn), mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF).

METHODS

This was a case-control study in which maternal serum GlyFn was measured using a point-of-care device in stored samples from a non-intervention screening study of singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. In the same samples, PlGF was measured by time-resolved fluorometry. We used samples from women who delivered with PE at < 37 weeks' gestation (n = 100), PE at ≥ 37 weeks (n = 100), gestational hypertension (GH) at < 37 weeks (n = 100), GH at ≥ 37 weeks (n = 100) and 1000 normotensive controls with no pregnancy complications. In all cases, MAP and UtA-PI had been measured during the routine 11-13-week visit. Levels of GlyFn were transformed to multiples of the expected median (MoM) values after adjusting for maternal demographic characteristics and elements of medical history. Similarly, the measured values of MAP, UtA-PI and PlGF were converted to MoMs. The competing-risks model was used to combine the prior distribution of gestational age at delivery with PE, obtained from maternal characteristics, with various combinations of biomarker MoM values to derive the patient-specific risks of delivery with PE or GH at < 37 and ≥ 37 weeks' gestation. Screening performance was estimated by examining the area under the receiver-operating-characteristics curve (AUC) and detection rate (DR) at 10% fixed false-positive rate (FPR).

RESULTS

The maternal characteristics and elements of medical history with a significant effect on the measurement of GlyFn were maternal age, weight, height, race, smoking status and history of PE. In pregnancies that developed PE, GlyFn MoM was increased and the deviation from normal decreased with increasing gestational age at delivery. The DR and AUC of screening for delivery with PE at < 37 weeks' gestation by maternal factors alone were 50% and 0.834, respectively, and these increased to 80% and 0.949, respectively, when maternal risk factors were combined with MAP, UtA-PI and PlGF (triple test). The performance of the triple test was similar to that of screening by a combination of maternal factors, MAP, UtA-PI and GlyFn (DR, 79%; AUC, 0.946) and that of screening by a combination of maternal factors, MAP, PlGF and GlyFn (DR, 81%; AUC, 0.932). The performance of screening for delivery with PE at ≥ 37 weeks' gestation was poor; the DR for screening by maternal factors alone was 35% and increased to only 39% with use of the triple test. Similar results were obtained when GlyFn replaced PlGF or UtA-PI in the triple test. The DR of screening for GH with delivery at < 37 and ≥ 37 weeks' gestation by maternal factors alone was 34% and 25%, respectively, and increased to 54% and 31%, respectively, with use of the triple test. Similar results were obtained when GlyFn replaced PlGF or UtA-PI in the triple test.

CONCLUSIONS

GlyFn is a potentially useful biomarker in first-trimester screening for preterm PE, but the findings of this case-control study need to be validated by prospective screening studies. The performance of screening for term PE or GH at 11 + 0 to 13 + 6 weeks' gestation by any combination of biomarkers is poor. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Effect of cerebral oxygen saturation monitoring in patients undergoing superficial temporal anterior-middle cerebral artery anastomosis for ischemic Moyamoya disease: a prospective cohort study

Objective

Regional cerebral oxygen saturation (rSO2) is linked with blood pressure. This study evaluated the influence of perioperative rSO2 monitoring on the prognosis of ischemic Moyamoya disease (MMD) patients undergoing anastomosis surgery.

Methods

In this prospective cohort, patients with unilateral ischemic MMD of Suzuki stage ≥3 were included. The decision of rSO2 was made by the clinician and the patient. The rSO2 group maintained intraoperative rSO2 levels through the modulation of blood pressure, inhaled oxygen concentration, carbon dioxide in arterial blood, and red blood cell transfusion. The non-rSO2 group used conventional anesthesia practices. Perioperative mean arterial pressure (MAP), rSO2 values, neurological complications, and postoperative results were assessed.

Results

A total of 75 eligible patients were categorized into a rSO2 monitoring group (n = 30) and a non-rSO2 monitoring group (n = 45). For the rSO2 group, the preoperative rSO2 was significantly lower on the affected side (P < 0.05). After anastomosis, this value notably increased (P = 0.01). A moderate relationship was observed between perioperative rSO2 and MAP before, during, and after surgery, with correlation coefficients (r) of 0.536, 0.502, and 0.592 (P < 0.05). Post-surgery MAP levels differed between the groups, with the rSO2 group showing decreased levels compared to pre-surgery and the non-rOS2 group displaying elevated levels. Notably, the rSO2 group reported shorter hospitalizations and decreased neurological complications. Patients with a hypertension history found postoperative MAP influencing hospital stay duration.

Conclusion

Perioperative rSO2 surveillance enhanced cerebral perfusion and minimized postoperative complications in ischemic MMD patients. Thus, rSO2 monitoring is advocated for MMD patients undergoing vascular anastomosis.

Accuracy of placental growth factor alone or in combination with soluble fms-like tyrosine kinase-1 or maternal factors in detecting preeclampsia in asymptomatic women in the second and third trimesters: a systematic review and meta-analysis

OBJECTIVE

This study aimed to: (1) identify all relevant studies reporting on the diagnostic accuracy of maternal circulating placental growth factor) alone or as a ratio with soluble fms-like tyrosine kinase-1), and of placental growth factor-based models (placental growth factor combined with maternal factors±other biomarkers) in the second or third trimester to predict subsequent development of preeclampsia in asymptomatic women; (2) estimate a hierarchical summary receiver-operating characteristic curve for studies reporting on the same test but different thresholds, gestational ages, and populations; and (3) select the best method to screen for preeclampsia in asymptomatic women during the second and third trimester of pregnancy by comparing the diagnostic accuracy of each method.

DATA SOURCES

A systematic search was performed through MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform databases from January 1, 1985 to April 15, 2021.

STUDY ELIGIBILITY CRITERIA

Studies including asymptomatic singleton pregnant women at >18 weeks' gestation with risk of developing preeclampsia were evaluated. We included only cohort or cross-sectional test accuracy studies reporting on preeclampsia outcome, allowing tabulation of 2×2 tables, with follow-up available for >85%, and evaluating performance of placental growth factor alone, soluble fms-like tyrosine kinase-1- placental growth factor ratio, or placental growth factor-based models. The study protocol was registered on the International Prospective Register Of Systematic Reviews (CRD 42020162460).

METHODS

Because of considerable intra- and interstudy heterogeneity, we computed the hierarchical summary receiver-operating characteristic plots and derived diagnostic odds ratios, β, θi, and Λ for each method to compare performances. The quality of the included studies was evaluated by the QUADAS-2 tool.

RESULTS

The search identified 2028 citations, from which we selected 474 studies for detailed assessment of the full texts. Finally, 100 published studies met the eligibility criteria for qualitative and 32 for quantitative syntheses. Twenty-three studies reported on performance of placental growth factor testing for the prediction of preeclampsia in the second trimester, including 16 (with 27 entries) that reported on placental growth factor test alone, 9 (with 19 entries) that reported on the soluble fms-like tyrosine kinase-1-placental growth factor ratio, and 6 (16 entries) that reported on placental growth factor-based models. Fourteen studies reported on performance of placental growth factor testing for the prediction of preeclampsia in the third trimester, including 10 (with 18 entries) that reported on placental growth factor test alone, 8 (with 12 entries) that reported on soluble fms-like tyrosine kinase-1-placental growth factor ratio, and 7 (with 12 entries) that reported on placental growth factor-based models. For the second trimester, Placental growth factor-based models achieved the highest diagnostic odds ratio for the prediction of early preeclampsia in the total population compared with placental growth factor alone and soluble fms-like tyrosine kinase-1-placental growth factor ratio (placental growth factor-based models, 63.20; 95% confidence interval, 37.62-106.16 vs soluble fms-like tyrosine kinase-1-placental growth factor ratio, 6.96; 95% confidence interval, 1.76-27.61 vs placental growth factor alone, 5.62; 95% confidence interval, 3.04-10.38); placental growth factor-based models had higher diagnostic odds ratio than placental growth factor alone for the identification of any-onset preeclampsia in the unselected population (28.45; 95% confidence interval, 13.52-59.85 vs 7.09; 95% confidence interval, 3.74-13.41). For the third trimester, Placental growth factor-based models achieved prediction for any-onset preeclampsia that was significantly better than that of placental growth factor alone but similar to that of soluble fms-like tyrosine kinase-1-placental growth factor ratio (placental growth factor-based models, 27.12; 95% confidence interval, 21.67-33.94 vs placental growth factor alone, 10.31; 95% confidence interval, 7.41-14.35 vs soluble fms-like tyrosine kinase-1-placental growth factor ratio, 14.94; 95% confidence interval, 9.42-23.70).

CONCLUSION

Placental growth factor with maternal factors ± other biomarkers determined in the second trimester achieved the best predictive performance for early preeclampsia in the total population. However, in the third trimester, placental growth factor-based models had predictive performance for any-onset preeclampsia that was better than that of placental growth factor alone but similar to that of soluble fms-like tyrosine kinase-1-placental growth factor ratio. Through this meta-analysis, we have identified a large number of very heterogeneous studies. Therefore, there is an urgent need to develop standardized research using the same models that combine serum placental growth factor with maternal factors ± other biomarkers to accurately predict preeclampsia. Identification of patients at risk might be beneficial for intensive monitoring and timing delivery.

Investigation of the Optimum Baseline Blood Pressure for Spinal Anesthesia to Guide Vasopressor Management for Elective Cesarean Delivery: A Case-Control Design

BACKGROUND

Current guidelines recommend prophylactic vasopressor administration during spinal anesthesia for cesarean delivery to maintain intraoperative blood pressure above 90% of the baseline value. We sought to determine the optimum baseline mean arterial pressure (MAP) reading to guide the management of spinal hypotension.

METHODS

We performed a secondary analysis of data collected from normotensive patients presenting for elective cesarean delivery in a tertiary care institution from October 2018 to August 2020. We compared the magnitude of hypotension in patients who reported nausea versus those who did not, using a case-control design. Baseline MAPs at last office visit, morning of surgery, or operating room (pre-spinal) were determined. We calculated the duration and degree of hypotension using the area under the curve (AUC) when the MAP of the respective patient was below 90% of each baseline.

RESULTS

The patients who experienced nausea (n=45) had longer and more profound periods of hypotension than those who did not develop nausea (n=240). A comparison of AUC using MAP baseline at the last office visit or on the morning of surgery showed a statistically significant between-group difference, P=0.02, and P=0.005, respectively, and no significant between-group difference when 90% of the MAP baseline in the operating room was used.

CONCLUSIONS

Patients had the highest preoperative MAP in the operating room and the AUC was similar for those with and without nausea when the pre-spinal MAP baseline was used. Therefore, maintaining higher intraoperative blood pressure using individual pre-spinal MAP as baseline should reduce intraoperative maternal nausea.

Correlation Between Mean Arterial Pressure and Capillary Refill Time in Patients with Septic Shock: A Systematic Review and Meta-analysis

Background: The initial hemodynamic goal during septic shock resuscitation is to achieve a mean arterial pressure (MAP) above 65 mm Hg, although this does not assure a normal tissue perfusion. Capillary refill time (CRT), a marker of skin blood flow, has been validated as a marker of the reperfusion process. The aim of the study was to explore the relationship between MAP and CRT in patients in septic shock. Methods: We systematically reviewed studies which reported CRT and MAP in septic shock patients. Authors of eligible studies were asked to provide necessary data for performing a meta-correlation of Spearman's rank correlation coefficients. Subgroup analyses were performed, including studies of good quality and studies with higher/lower norepinephrine doses. Results: We identified 10 studies, comprising 917 patients. There were 5 studies considered to be of good quality. A meta-correlation showed a statistically significant but poor negative correlation between MAP and CRT (R = -0.158, range -0.221 to -0.093, P < .001, I2 = 0.0%). Subgroup analysis of best-quality studies gave similar results (R = -0.201, range -0.282 to -0.116, P < .001, I2 = 0.0%). In subanalysis concerning norepinephrine doses, no significant correlations were found. Conclusions: In patients with septic shock, there is poor inverse correlation between MAP and CRT. MAP > 65 mm Hg does not guarantee normalization of CRT.Registration code: PROSPERO: CRD42022355996. Registered on 5 September 2022.

Prediction of hypertensive disorders after screening at 36 weeks' gestation: comparison of angiogenic markers with competing-risks model

OBJECTIVE

To compare the performance at 35 + 0 to 36 + 6 weeks' gestation of screening for delivery with pre-eclampsia (PE) at various timepoints, using one of three approaches: placental growth factor (PlGF) concentration, soluble fms-like tyrosine kinase-1 (sFlt-1) to PlGF concentration ratio, or the competing-risks model, which combines maternal risk factors with biomarkers to estimate patient-specific risk.

METHODS

This was a prospective observational study of women attending for a routine hospital visit at 35 + 0 to 36 + 6 weeks' gestation at one of two maternity hospitals in England between 2016 and 2022. During the visit, maternal demographic characteristics and medical history were recorded and serum PlGF, serum sFlt-1 and mean arterial pressure (MAP) were measured. Detection rates (DRs) were evaluated for delivery with PE (defined as per American College of Obstetricians and Gynecologists 2019 criteria) within 1 week, within 2 weeks or at any time after screening, using the following strategies: (i) low PlGF (< 10th percentile); (ii) high sFlt-1/PlGF ratio (> 90th percentile); or (iii) the competing-risks model, in which maternal factors were combined with multiples of the median values of PlGF ('single test'), PlGF and sFlt-1 ('double test') or PlGF, sFlt-1 and MAP ('triple test'). Risk cut-offs corresponded to a screen-positive rate of 10%. DRs were compared between tests.

RESULTS

Of 34 782 pregnancies, 831 (2.4%) developed PE. In screening for delivery with PE at any time from assessment, the DR at 10% screen-positive rate was 47% by low PlGF alone, 54% by the single test, 55% by high sFlt-1/PlGF ratio, 61% by the double test and 68% by the triple test. In screening for delivery with PE within 2 weeks from assessment, the respective values were 67%, 74%, 74%, 80% and 87%. In screening for delivery with PE within 1 week from assessment, the respective values were 77%, 81%, 85%, 88% and 91%. For prediction of PE at any time, the DR was significantly higher with the triple test compared to PlGF alone or the sFlt-1/PlGF ratio, with a DR difference (95% CI) of 20.1% (16.7-23.0%) and 12.4% (9.7-15.3%), respectively. Similar results were seen for prediction of PE within 2 weeks (20.6% (14.9-26.8%) and 12.9% (7.7-17.5%), respectively) and prediction of PE within 1 week (13.5% (5.4-21.6%) and 5.4% (0.0-10.8%), respectively). The double test was superior to the sFlt-1/PlGF ratio and the single test was superior to PlGF alone in the prediction of PE within 2 weeks and at any time from assessment, but not within 1 week of assessment.

CONCLUSION

At 35 + 0 to 36 + 6 weeks' gestation, the performance of screening for PE by the competing-risks model triple test is superior to that of PlGF alone or the sFlt-1/PlGF ratio for the development of disease within 1 week, within 2 weeks and at any time from screening. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Symptoms in Hypertensive Patients Presented to the Emergency Medical Service: A Comprehensive Retrospective Analysis in Clinical Settings

BACKGROUND

Hypertension is a prevalent condition with a variety of accompanying symptoms. Gender differences, specific blood pressure readings, and early signs of organ complications present intricate interplays in hypertensive individuals.

OBJECTIVE

This study aimed to investigate the relationship between hypertension and its accompanying symptoms, emphasizing gender-specific differences and potential indicators of organ complications.

METHODS

Data from 2002 participants were analyzed from a retrospective study, focusing on the presentation of symptoms, blood pressure values, and potential organ complications associated with these symptoms.

RESULTS

Of the participants, 68.8% were women with an average age of 69. Women were, on average, 8 years older than men. The average systolic blood pressure (SBP) was 188 mmHg. High-blood pressure was accompanied by symptoms in 84.9% of participants. Among those with an SBP > 180 mmHg, headaches were reported by 24.7%, and dizziness by 15.7%. Interestingly, as SBP increased, heart palpitations reports diminished with a mere 4.8% of those with SBP > 180 mmHg noting this symptom. Younger men exhibited increased chest pain and heart palpitations, while younger women more commonly reported headaches and nausea/vomiting. A significant relationship was identified between pulse pressure (PP) and symptoms, with dizziness in women and chest pain/discomfort in men being most pronounced.

CONCLUSIONS

The study underlines the importance of in-depth research on hypertensive individuals for improved symptom recognition and management. The data highlight the gender and age-specific symptom presentations and their correlation with blood pressure metrics, suggesting a need for patient-specific intervention strategies.

Non-Invasive Estimation of Central Systolic Blood Pressure by Radial Tonometry: A Simplified Approach

BACKROUND

Central systolic blood pressure (cSBP) provides valuable clinical and physiological information. A recent invasive study showed that cSBP can be reliably estimated from mean (MBP) and diastolic (DBP) blood pressure. In this non-invasive study, we compared cSBP calculated using a Direct Central Blood Pressure estimation (DCBP = MBP2/DBP) with cSBP estimated by radial tonometry.

METHODS

Consecutive patients referred for cardiovascular assessment and prevention were prospectively included. Using applanation tonometry with SphygmoCor device, cSBP was estimated using an inbuilt generalized transfer function derived from radial pressure waveform, which was calibrated to oscillometric brachial SBP and DBP. The time-averaged MBP was calculated from the radial pulse waveform. The minimum acceptable error (DCBP-cSBP) was set at ≤5 (mean) and ≤8 mmHg (SD).

RESULTS

We included 160 patients (58 years, 54%men). The cSBP was 123.1 ± 18.3 mmHg (range 86-181 mmHg). The (DCBP-cSBP) error was -1.4 ± 4.9 mmHg. There was a linear relationship between cSBP and DCBP (R2 = 0.93). Forty-seven patients (29%) had cSBP values ≥ 130 mmHg, and a DCBP value > 126 mmHg exhibited a sensitivity of 91.5% and specificity of 94.7% in discriminating this threshold (Youden index = 0.86; AUC = 0.965).

CONCLUSIONS

Using the DCBP formula, radial tonometry allows for the robust estimation of cSBP without the need for a generalized transfer function. This finding may have implications for risk stratification.

Blood Pressure Goals in Critically Ill Patients

Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.

OCE-205, a Selective V1a Partial Agonist, Reduces Portal Pressure in Rat Models of Portal Hypertension

Purpose

Management of decompensated cirrhosis may include the use of vasoconstrictors that can lead to serious adverse events. OCE-205 was designed as a highly selective V1a receptor partial agonist, intended to have a wider therapeutic window than full vasopressin agonists.

Methods

We aimed to characterize the activity of OCE-205 treatment in two rat models of portal hypertension (PHT). For both models, OCE-205 was administered as a subcutaneous bolus injection. Thirty male Wistar rats were fed a methionine/choline-deficient (MCD) diet to model PHT. Animals received OCE-205 (10, 25, 100, or 500 µg/kg) or intra-arterial terlipressin (100 µg/kg). In a more severe model of PHT, 11 male Sprague Dawley rats had the common bile duct surgically ligated (BDL) and received OCE-205. Portal pressure (PP) and mean arterial pressure (MAP) were measured.

Results

For PP in the MCD model, MAP increased while PP decreased in rats treated with OCE-205 or terlipressin; the peak changes to MAP were 14.7 and 33.5 mmHg, respectively. Changes in MAP began to plateau after 10 min in the OCE-205 groups, whereas in the terlipressin group, MAP rapidly increased and peaked after 20 min. Across all treatment groups in the BDL model, a dose-related decrease from baseline in PP was observed following OCE-205, plateauing as the dose increased. In all treatment groups, PP change remained negative throughout the 30-min testing period. In both PHT rat models, a reduction in PP was coupled to an increase in MAP, with both plateauing in dose-response curves.

Conclusion

Data support OCE-205 as a promising candidate for further development.

Institutional Protocol Number

Procedures were approved by the Ferring Research Institute (FRI) Institutional Animal Care and Use Committee on July 13, 2011, under protocol FRI-07-0002.

Cerebrospinal Fluid Drainage in Patients with Acute Spinal Cord Injury: A Multi-Center Randomized Controlled Trial

OBJECTIVE

The secondary phase of spinal cord injury (SCI) is characterized by ischemic injury. Spinal cord perfusion pressure (SCPP), calculated as the difference between mean arterial pressure (MAP) and intrathecal pressure (ITP), has arisen as a therapeutic target for improving outcomes. Cerebrospinal fluid drainage (CSFD) may reduce ITP and thereby increase SCPP. Randomized controlled trial to evaluate the safety and feasibility of CSFD to improve SCPP and outcomes after acute SCI.

METHODS

Inclusion criteria included acute cervical SCI within 24 hours of presentation. All patients received lumbar drain placement and appropriate decompressive surgery. Patients randomized to the control group received MAP elevation only. Patients in the experimental group received MAP elevation and CSFD to achieve ITP < 10 mmHg for 5 days. ITP and MAP were recorded hourly. Adverse events were documented and patients underwent functional assessments at enrollment, 72 hours, 90 days, and 180 days post-injury.

RESULTS

Eleven patients were enrolled; 4 were randomized to receive CSFD. CSFD patients had a mean ITP of 5.3±2.5 mmHg vs 15±3.0 mmHg in the control group. SCPP improved significantly, from 77±4.5 mmHg in the control group to 101±6.3 mmHg in the CSFD group (p<0.01). Total motor scores improved by 15±8.4 and 57±24 points in the control and CSFD groups, respectively, over 180 days. No adverse events were attributable to CSFD.

CONCLUSIONS

CSFD is a safe, effective mechanism for reducing ITP and improving SCPP in the acute period post-SCI. The favorable safety profile and preliminary efficacy should help drive recruitment in future studies.

ASPRE trial: effects of aspirin on mean arterial blood pressure and uterine artery pulsatility index trajectories in pregnancy

OBJECTIVES

The mechanism by which aspirin prevents pre-eclampsia is poorly understood, and its effects on biomarkers throughout pregnancy are unknown. We aimed to investigate the effects of aspirin on mean arterial pressure (MAP) and mean uterine artery pulsatility index (UtA-PI) using repeated measures from women at increased risk of preterm pre-eclampsia.

METHODS

This was a longitudinal secondary analysis of the Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Pre-eclampsia Prevention (ASPRE) trial using repeated measures of MAP and UtA-PI. In the trial, 1620 women at increased risk of preterm pre-eclampsia were identified using the Fetal Medicine Foundation algorithm at 11 + 0 to 13 + 6 weeks, of whom 798 were randomly assigned to receive 150 mg/day aspirin and 822 were assigned to receive placebo daily from 11-14 weeks to 36 weeks of gestation or delivery, whichever came first. MAP and UtA-PI were measured at baseline and follow-up visits at 19-24, 32-34 and 36 weeks of gestation. Generalized additive mixed models with treatment by gestational age interaction terms were used to investigate the effects of aspirin on MAP and UtA-PI trajectories over time.

RESULTS

Among 798 participants in the aspirin group and 822 in the placebo group, there were 5951 MAP and 5942 UtA-PI measurements. Trajectories of raw and multiples of the median (MoM) values of MAP did not differ significantly between the two groups (MAP MoM analysis: P-value for treatment by gestational age interaction, 0.340). In contrast, trajectories of raw and MoM values of UtA-PI showed a significantly steeper decline in the aspirin group than in the placebo group, with the difference mainly driven by a more pronounced reduction before 20 weeks of gestation (UtA-PI MoM analysis: P-value for treatment by gestational age interaction, 0.006).

CONCLUSIONS

In women at increased risk of preterm pre-eclampsia, 150 mg/day aspirin initiated in the first trimester does not affect MAP but is associated with a significant decrease in mean UtA-PI, particularly before 20 weeks of gestation. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Early Fluid Balance Is Associated with 90-Day Mortality in Patients Receiving Continuous Renal Replacement Therapy

Continuous renal replacement therapy (CRRT) is widely used to control fluid balance, but the optimal fluid balance to improve the prognosis of patients remains debated. Appropriate fluid management may depend on hemodynamic status. We investigated the association between 90-day mortality and fluid balance/mean arterial pressure (MAP) in patients receiving CRRT. This single-center retrospective study was conducted between May 2018 and March 2021. Based on the cumulative fluid balance at 72 h after initiation of CRRT, the cases were divided into negative (< 0 mL) and positive (> 0 mL) fluid balance groups. Ninety-day mortality was higher in the positive fluid balance group (p=0.009). At 4 h before and after CRRT initiation, the mean MAP was lower in the positive fluid balance group (p<0.05). After multivariate cox adjustment, 72-h positive fluid balance was independently associated with 90-day mortality (p=0.004). In addition, the cumulative fluid balance was associated with 90-day mortality (p<0.05) in cases without shock, high APACHE II score, sepsis, dialysis dependence, or vasopressor use. A 72-h positive fluid balance was associated with 90-day mortality in patients receiving CRRT.

A Randomized Control Trial to Compare Hemodynamic Parameters of Patients Undergoing Percutaneous Nephrolithotomy Under Combined Spinal-Epidural and General Anesthesia in a Tertiary Hospital

Background and Aim

Percutaneous nephrolithotomy (PCNL) under epidural anesthesia has been reported to have few advantages over general anesthesia, like lower postoperative pain and less need for analgesics. There are limited studies on PCNL being performed under neuraxial anesthesia in supine position. Hence the present study was conceived to compare hemodynamic parameters in patients undergoing percutaneous nephrolithotomy (PCNL) in the supine position under combined spinal-epidural with general anesthesia (GA).

Material and Methods

A prospective, randomized control trial was conducted among 90 patients who were posted to undergo elective percutaneous nephrolithotomy in the the supine position, after obtaining Institutional Ethical Committee (IEC) approval and CTRI (Clinical Trial Registry - India) registration. Patients were randomly allotted to undergo surgery either under general anesthesia (group GA) or combined spinal epidural anesthesia (group CSE) by computer-generated random number method. Hemodynamic parameters, postoperative analgesic requirement and incidence of blood transfusion were recorded and analyzed.

Results

There was no significant difference between the two groups with respect to gender, ASA grade, surgery duration, calculus size and pulse rate. There was a statistically significant reduction in mean arterial pressure from 5 to 50 minutes of surgery and less incidence of blood transfusion in patients in the CSE group. Patients who underwent PCNL in the supine position under CSE required lesser analgesics postoperatively compared to those under general anesthesia.

Conclusion

Combined spinal epidural analgesia can be used as an alternative to general anesthesia for patients undergoing PCNL in the supine position in view of less MAP and reduced postoperative analgesic and blood transfusion requirement.

Flow down gradients: the problem of pressure in this physiology core concept

The core concepts of physiology, as first published in this journal in 2011, not only provide a noteworthy teaching approach but also encourage reflection on the fundamentals of physiology. Unfortunately, a fundamental flaw has crept into the core concept of flow down gradients. Fluids do not generally flow from high to low pressure, as claimed, but only because of a specific pressure difference, that is, the perfusion pressure. This is related to a problem that is widespread in physiology, from which even the core concepts are not free, namely, the description of mean arterial pressure (MAP) solely by means of Ohm's law of circulation, although this law actually describes perfusion pressure. Both pressures can be numerically approximately equal in the physiological case, but conceptually they remain different in principle. We solved this problem using the extended Bernoulli equation (a combination of Ohm's law and the simple Bernoulli equation). Thereafter, MAP depends on the following pressure components, all of which are essential for a basic understanding of circulation: perfusion, central venous, gravitational, and dynamic pressures. These pressures also have great pathophysiological and clinical importance, which we exemplify here. Towards the end of this paper, we provide recommendations that should be considered in teaching, whether it is a beginner or advanced course. We address physiology teachers who are open to critical constructive improvements in their teaching, especially in hemodynamics. In particular, we encourage the authors of the flow down gradients core concept to improve and refine its "unpacking."

Systolic blood pressure in acute ischemic stroke and impact on clinical outcomes

CONTEXT

Stroke is one of the largest healthcare burdens in the United States and globally. It continues to be one of the leading causes of morbidity and mortality. Patients with acute ischemic stroke (AIS) often present with elevated blood pressure (BP).

OBJECTIVES

The objective of our study was to evaluate the association of systolic blood pressure (SBP) in the emergency department (ED) with stroke severity in patients with AIS.

METHODS

This observational study was conducted at an ED with an annual census of 80,000 visits, approximately half (400) of which are for AIS. The cohort consisted of adult patients who presented to the ED within 24 h of stroke symptom onset. BP was measured at triage by a nurse blinded to the study. Stroke severity was measured utilizing the National Institutes of Health Stroke Scale (NIHSS). Statistical analyses were performed utilizing JMP 14.0. This study was approved by our medical school's institutional review board.

RESULTS

Patients with higher SBP had significantly lower NIHSS scores (p=0.0038). This association was significant even after adjusting for age and gender. By contrast, diastolic blood pressure (DBP) did not appear to impact stroke severity. There was no difference in the DBP values between men and women. Higher SBP was also significantly associated with being discharged home as well as being less likely to die in the hospital or discharged to hospice. The DBP did not demonstrate this association. Neither the SDP nor the DBP were significantly associated with the hospital length of stay (LOS). In multivariate models that included age, gender, basal metabolic index (BMI), comorbidities, and ED presentation, elevated SBP was associated with better prognosis.

CONCLUSIONS

In this cohort of patients presenting with stroke-like symptoms to the ED, higher SBP was associated with lower stroke severity and higher rates of being discharged to home rather than hospice or death.