[National and international guidelines ignore significant cause of heart failure. Diastolic dysfunction is often the cause of heart failure in the elderly and in women]

Comparison of patients treated for chronic heart failure at a large hospital with patients included in major treatment studies published during the past ten years yielded important information. The former series was characterised by greater proportions of the elderly and of women than were the series recruited to the often cited ACE (angiotensin-converting enzyme) inhibitor studies. Although only patients with systolic dysfunction were recruited to the latter studies, a substantial body of evidence suggests the prevalence of severe heart failure among patients with normal systolic function to increase with increasing age. Thus, as many as 50 per cent of all elderly patients with chronic heart failure may have normal systolic function. In most cases, the heart failure is probably due to diastolic dysfunction, a condition that still lacks both a simple diagnostic procedure and a well-documented treatment.

Stroke was predicted by dimensions of quality of life in treated hypertensive men

BACKGROUND AND PURPOSE

Psychosocial factors have been suggested as risk factors for atherosclerotic disease. The purpose of the present study was to examine whether quality of life predicted strokes and acute coronary events in a prospective study.

METHODS

The study included 412 treated hypertensive men, aged 50 to 72 years, with >/=1 of the following: serum cholesterol >/=6.5 mmol/L, smoking, or diabetes mellitus. The Minor Symptoms Evaluation Profile (MSEP) was used to estimate quality of life at entry. Incidences of stroke and acute coronary events were recorded during follow-up. The median follow-up time was 6.6 years.

RESULTS

Sixty-four patients had an acute coronary event, and 37 had a stroke during the follow-up period. The Cox regression analyses revealed that the 3 dimensions of MSEP at entry were significant predictors of stroke. The relationship between low contentment at entry and the incidence of stroke during follow-up remained significant (relative risk=1.04; 95% CI, 1.01 to 1.06; P=0.003) even after adjustment for other potential cardiovascular risk factors. Vitality also remained an independent predictor for stroke after adjustment for these potential cardiovascular risk factors (relative risk=1.04; 95% CI, 1. 02 to 1.06; P<0.0001). There was no relationship between MSEP score at entry and myocardial infarction during follow-up.

CONCLUSIONS

An independent and significant association between reduced well-being at entry and future stroke was observed in hypertensive men at high cardiovascular risk. The causal relationship is not known, however.

Effects of acupuncture treatment on daily life activities and quality of life: a controlled, prospective, and randomized study of acute stroke patients

BACKGROUND AND PURPOSE

A number of studies have indicated that acupuncture might improve the functional recovery of stroke patients. These studies vary in inclusion criteria, sample size, and evaluation methods. The present study was designed to investigate whether electroacupuncture treatment favorably affects stroke patients' ability to perform daily life activities, their health-related quality of life, and their use of health care and social services.

METHODS

One hundred four consecutive patients >40 years of age admitted to hospital because of an acute stroke were randomized to 3 groups: deep, superficial, and no acupuncture treatment. The acupuncture treatment given by 4 physiotherapists started 4 to 10 days after randomization and was given twice a week for 10 weeks. All patients underwent conventional stroke rehabilitation as well. Two occupational therapists, blinded regarding the patients' allocation, evaluated the treatment effects. The assessments were performed 4 times during the first year after randomization by means of interviews and observations.

RESULTS

There were no differences between the groups with reference to changes in the neurological score and the Barthel and Sunnaas activities of daily living index scores after 3 and 12 months. Regarding the Nottingham Health Profile, the no acupuncture group had somewhat fewer mobility problems. No differences in health care and social services were found between the groups.

CONCLUSIONS

The present study does not give support to the previous studies, which indicates that acupuncture treatment may have a beneficial effect on acute stroke patients' ability to perform daily life activities, their health-related quality of life, and their use of health care and social services.

Feasibility of a nurse-monitored, outpatient-care programme for elderly patients with moderate-to-severe, chronic heart failure

AIMS

To evaluate the feasibility of a nurse-monitored, outpatient-care program for elderly patients previously hospitalized with chronic heart failure.

METHODS AND RESULTS

Patients with chronic heart failure hospitalized in the medical wards were screened to find those eligible for a randomized study to compare the effect of a nurse-monitored, outpatient-care programme aiming at symptom management, with conventional care. The inclusion criteria were patients classified in New York Heart Association classes III-IV, age 65 years, and eligibility for an outpatient follow-up programme. The total in-hospital population of patients discharged with a heart-failure diagnosis was surveyed. Eighty-nine per cent of all the hospitalized patients (n=1541) were 65 years old. Of these, 69% (n=1058) were treated in the medical wards which were screened. The study criteria were met by 158 patients (15%). No visits to the nurse occurred in 23 cases among the 79 patients randomized to the structured-care group (29%), mainly on account of death or fatigue. The numbers of hospitalizations and hospital days did not differ between the structured-care and the usual-care groups.

CONCLUSIONS

Given the selection criteria and the outline of the interventions, the outpatient, nurse-monitored, symptom-management programme was not feasible for the majority of these elderly patients with moderate-to-severe, chronic heart failure, mainly because of the small proportion of eligible patients and the high drop-out rate. Management of these patients would have to be more adjusted to their home situation.

Prothrombin fragment 1+2 is a risk factor for myocardial infarction in treated hypertensive men

BACKGROUND

Haemostatic factors may play a part in the development of acute coronary heart disease.

OBJECTIVE

To evaluate as predictors of major coronary events (fatal and non-fatal myocardial infarctions and sudden death) levels of fibrinogen, von Willebrand factor, prothrombin fragment 1+2, thrombin-antithrombin complex, plasminogen activator inhibitor activity and C-reactive protein.

METHODS

We studied 131 men, aged 56-77 years, with treated hypertension and at least one additional cardiovascular risk factor (hypercholesterolaemia, diabetes mellitus or smoking). These patients were recruited from a continuing risk factor intervention study. The mean observation time was 3.0 years.

RESULTS

Fourteen patients died and 16 had a major coronary event during the follow-up period. After adjustments for other risk factors, levels of prothrombin fragment 1+2 and C-reactive protein were independent predictors of major coronary events. The other measured haemostatic variables were not significantly associated with major coronary events during follow-up. Fibrinogen and prothrombin fragment 1+2 levels were independent predictors for mortality.

CONCLUSIONS

Among treated hypertensive men, levels of prothrombin fragment 1+2 and C-reactive protein were independent predictors of major coronary events.

Mortality rates in treated hypertensive men with additional risk factors are high but can be reduced: a randomized intervention study

The aim was to examine the feasibility and efficacy of a multifactorial risk factor intervention program in hypertensive patients at high cardiovascular risk. Treated hypertensive men, aged 50 to 72 years, with at least one of the following: serum cholesterol concentration > or = 6.5 mmol/L, diabetes mellitus, or smoking were randomized to multifactorial risk factor intervention (n = 253) or usual care (n = 255). The specific intervention was based on group meetings to encourage a lipid lowering diet and smoking cessation. Cholestyramine, nicotinic acid, fibrates, and later statins were used either as single drug therapy or in combination, following agreed guidelines in patients in whom the nonpharmacological intervention was judged to be insufficient. Usual care was given according to clinical practice. The median follow-up time was 6.6 years. Sixty-four patients (25.1%) died in the usual care group, compared with 41 patients (16.2%) in the intervention group (P = .016; 95% confidence interval, relative risk 0.42 to 0.92). The overall risk for fatal and nonfatal cardiovascular events was 29% lower in the intervention group than in the usual care group (P = .041). Relative to usual care, the intervention program lowered mean in-trial serum concentrations of total cholesterol (6.3%, P < .0001), LDL cholesterol (9.1%, P < .0001), and blood glucose (0.2 mmol/L, P < .05). Among smokers, at entry, cotinine-adjusted quit rates were 28% in the intervention group and 11% in the usual care group (P = .012) after 3 years. This study illustrates the very high cardiovascular risk in hypertensive patients 50 to 72 years of age with additional risk factors. The results indicate, however, that the gloomy prognosis may be improved by a dedicated risk factor intervention program.

Usefulness of microalbuminuria in predicting cardiovascular mortality in treated hypertensive men with and without diabetes mellitus. Risk Factor Intervention Study Group

In the present study we report on the predictive power of microalbuminuria for total and cardiovascular mortality in a prospective study (mean follow up 6.3 years) of treated hypertensive men, aged 50 to 72 years, with (n = 94) and without (n = 345) maturity onset diabetes mellitus. Thirty-three (35.1%) of the hypertensive patients with diabetes mellitus died during the follow-up period compared with 57 patients (16.5%) in the hypertensive group without diabetes mellitus (p <0.0002). In those with diabetes mellitus and hypertension, a log-rank test revealed a lower cardiovascular mortality in the normoalbuminuric group compared with both the microalbuminuric (p = 0.035) and the macroalbuminuric group (p = 0.002). The logarithm of urinary albumin excretion was a predictor of both total (p = 0.009) and cardiovascular (p = 0.001) mortality during the follow-up period using Cox regression analysis. This relation remained significant even after adjustment for other risk factors. HbA1c was also an independent predictor of total and cardiovascular mortality. In patients without diabetes mellitus, the small group of patients with macroalbuminuria had a markedly increased cardiovascular mortality compared with both the microalbuminuric (p <0.0001) and the normoalbuminuric groups (p <0.0001). No difference was observed between the normoalbuminuric and the microalbuminuric groups. Smoking at entry and concomitant cardiovascular disease at entry were independent predictors of cardiovascular mortality in these patients. We conclude that microalbuminuria was an independent predictor for cardiovascular mortality in treated hypertensive men with maturity onset diabetes mellitus. Macroalbuminuria, but not microalbuminuria, predicted cardiovascular mortality in nondiabetic treated hypertensive men.

Multifactorial treatment of hypertensive men at high cardiovascular risk and low-density lipoprotein cholesterol affinity to human arterial proteoglycans

The purpose of this work was to examine in an open, randomized parallel-group study whether an intervention programme directed towards hypercholesterolaemia, smoking and diabetes mellitus in treated hypertensive men was associated with less complex formation between low-density lipoprotein (LDL) and human arterial proteoglycans than was the case with usual care. The intervention consisted mainly of non-pharmacological treatment, but drug therapy could be instituted to achieve the treatment goals in the intervention group. The intervention programme was associated with a significant reduction in body mass index, and 46% of the patients were on lipid-lowering medication at the follow-up examination. The net differences were (intervention--usual care): change in serum LDL-cholesterol, -0.48 mmol L-1 (95% confidence interval -0.84 to -0.11 mmol L-1), precipitated LDL-cholesterol, -5.5 micrograms (95% CI -9.0 to -1.1 micrograms). The latter remained after adjustment for the difference in serum LDL-cholesterol between groups. Our conclusion is that the multifactorial risk factor treatment programme was associated with a reduced tendency of LDL to form complexes with human arterial proteoglycans.

Risk factors that predict development of microalbuminuria in treated hypertensive men. The Risk Factor Intervention Study Group

The aim of this prospective study was to investigate the risk factors for development of microalbuminuria in treated hypertensive men with and without diabetes mellitus. Two hundred and ninety-seven treated hypertensive men, aged fifty to seventy-two years, with at least one of the following: serum cholesterol > or = 6.5 mmol/L, smoking, or diabetes mellitus, were included in the study. Patients with elevated overnight urinary albumin excretion (> 17 mg/12 hr) were excluded. Urinary albumin excretion (UAE), blood pressure, and various well-established risk factor levels were measured. Two hundred thirteen nondiabetic patients and 40 patients with diabetes mellitus completed the three-year follow-up. Development of microalbuminuria was more prevalent in those with diabetes mellitus at baseline compared with the group without diabetes mellitus, 25% and 10.3%, respectively (P = 0.02). Nondiabetic patients who developed microalbuminuria had higher UAE. 10.2 mg +/- 3.7 and 5.7 +/- 3.2, respectively (P < 0.0001), and higher systolic blood pressure 160 mm Hg +/- 27 and 152 +/- 17, respectively (P = 0.043), at baseline compared with whose who remained normoalbuminuric. In the group with diabetes mellitus, a higher UAE, 9.8 +/- 2.7 and 7.1 +/- 3.6, respectively (P = 0.036), at baseline was observed in whose who developed microalbuminuria compared with whose who remained normoalbuminuric. In conclusion, concomitant diabetes mellitus significantly increased the risk for development of microalbuminuria during the three-year follow-up in treated hypertensive men. Patients who progressed to microalbuminuria had higher UAE at baseline, but still within the normoalbuminuric range, compared with thosewho remained normoalbuminuric. Systolic blood pressure at baseline was higher in those who progressed to microalbuminuria, although reaching statistically significance only in the larger nondiabetic group.

Atherosclerotic disease in the femoral artery in hypertensive patients at high cardiovascular risk. The value of ultrasonographic assessment of intima-media thickness and plaque occurrence. Risk Intervention Study (RIS) Group

The aim of the present investigation was to examine the occurrence of ultrasound-assessed morphological changes in the right common femoral artery and relate these findings to the ankle-arm index and to symptoms of lower-extremity arterial disease in hypertensive men at high cardiovascular risk (n = 143). Comparisons were made with a healthy reference group consisting of age-matched men at low risk (n = 46). The results showed that it was possible to obtain high-quality measurements of intima-media thickness in about 80% of all men and that the intraobserver variability was satisfactory (14%). A normal mean intima-media thickness was defined, using data from the low-risk group. Plaque occurrence and mean intima-media thickness in the right common femoral artery were significantly associated with ankle-arm index both in the right and left leg. There were more and larger plaques, as well as thicker mean and maximum intima-media complexes, in the high-risk group than in the low-risk group. In the high-risk group, 11% suffered from symptoms of right lower-extremity artery disease, 20% had an ankle-arm index < or= 0.9, 62% had moderate or large plaques (compared with 28% in the low-risk group, P < .001), and 77% had an enlarged intima-media complex. The cumulative frequency of signs of atherosclerosis in the right leg was 81% among the 110 patients in whom complete results from all examinations were available. Our conclusion is that ultrasound measurement of the intima-media thickness of the common femoral artery is a valuable method to evaluate morphological changes related to atherosclerotic disease in the lower extremity.

Negative feelings (discontent) predict progress of intima-media thickness of the common carotid artery in treated hypertensive men at high cardiovascular risk

A number of psychosocial factors have been identified as cardiovascular risk factors. The purpose of the present study was to examine, in a prospective study, whether quality of life, as measured by the minor symptoms evaluation profile, was associated with progression of the intima-media thickness in the common carotid artery in a group of treated hypertensive men at high risk of cardiovascular disease (n = 97). Patients with any cardiovascular disease (myocardial infarction, angina pectoris, intermittent claudication, or stroke) at entry felt significantly more discontent, compared with patients without signs or symptoms of cardiovascular disease. The change in maximum intima-media thickness during the follow-up period was associated with discontent at entry (r = 0.23, P = .03). The relationship between the change in maximum intima-media thickness and discontent at entry remained significant (P = .02) after adjusting for serum-cholesterol and concomitant cardiovascular disease. In conclusion, discontent in treated hypertensive men at high cardiovascular risk was significantly and independently associated with an increase in maximum intima-media thickness in the common carotid artery. This finding suggests that the experience of well-being may influence the atherosclerotic process.

Multiple risk intervention in high-risk hypertensive patients. A 3-year ultrasound study of intima-media thickness and plaques in the carotid artery. Risk Intervention Study (RIS) Group

In spite of optimal blood pressure control, available data indicate that the risk of coronary heart disease remains high in many patients with hypertension. Multifactorial risk intervention programs have therefore been advocated. The aim of the present randomized study was to analyze whether a favorable change in risk factors caused by a comprehensive risk factor modification program (focused mainly on nonpharmacological intervention) might beneficially affect ultrasound-assessed far-wall common carotid intima-media thickness or plaques in the carotid artery in high-risk hypertensive patients (n=81) in comparison with those undergoing usual care (n=83). A further aim was to analyze whether risk factors measured at baseline or follow-up were related to the change recorded in intima-media thickness during follow-up. The results showed in the intervention group a favorable change in LDL cholesterol (-9%), in smoking habits (32% of smokers quit smoking), and in HbA1c (-17% in patients with diabetes mellitus) over the 3.5-year observation period. However, no difference between the two randomization groups could be observed for far-wall common carotid intima-media thickness or plaque status during follow-up. Of all tested potential risk factors, only fasting insulin at baseline (available in nondiabetic patients) was significantly related to the change in mean intima-media thickness during follow-up (r=.25, n=92, P<.01). The relationship (negative) between follow-up serum HDL and change in mean intima-media thickness during the preceding follow-up was of borderline significance. Patients with moderate to large plaques in the carotid artery region at baseline had a significantly larger increase in common carotid artery intima-media thickness during follow-up than patients with no or only small plaques. The results are disappointing and may indicate that either the change in risk factors occurred too late in life or a considerably larger change in concomitant risk factors than we observed is needed to favorably affect intima-media thickness during an observation period of around 3 years in high-risk hypertensive patients.

Femoral artery wall morphology, hemostatic factors and intermittent claudication: ultrasound study in men at high and low risk for atherosclerotic disease

The aim of this study was to examine whether there was a relationship between ultrasound-assessed morphology of the femoral artery wall and hemostatic factors, and whether these factors were associated with intermittent claudication. One hundred and thirty men at high cardiovascular risk and 51 men at low risk were examined. The subjects (high- and low-risk) with moderate/large plaque (n = 96) had higher fibrinogen, thrombin/antithrombin complex and von Willebrand factor, compared to subjects with small/no plaque. The maximum intima-media thickness of the femoral artery was significantly associated with fibrinogen. These associations were independent of current smoking habits. Clinical atherosclerosis was associated with fibrinogen, von Willebrand factor, thrombin/antithrombin complex, plasminogen activator inhibitor activity, mean and maximum intima-media thickness and plaque status of the femoral artery. In conclusion, fibrinogen, von Willebrand factor and thrombin/antithrombin complex were related to plaque occurrence in the femoral artery. Clinical atherosclerosis was associated with fibrinogen, von Willebrand factor, thrombin/antithrombin complex and plasminogen activator inhibitor activity.

A randomized study of quality of life during multiple risk factor intervention in treated hypertensive men at high cardiovascular risk

OBJECTIVE

To examine the effect on quality of life in hypertensive men of a multiple risk factor intervention programme compared with that of usual care.

DESIGN

A prospective, open, randomized, parallel-group study with allocation either to a comprehensive multiple risk factor modification programme or to usual care.

SETTING

An outpatient clinic in a city hospital.

PATIENTS

Five hundred and eight treated hypertensive men, aged 50-72 years, with at least one of the following: serum cholesterol > or = 6.5 mmol/l, smoking habit or diabetes mellitus.

INTERVENTION

Nutritional advice, behavioural treatment principles and drug therapy.

MAIN OUTCOME MEASURES

Minor symptoms evaluation profile (MSEP) was used to measure change in quality of life.

RESULTS

The intervention programme led to sustained effects on lifestyle-related variables such as hypercholesterolaemia, body mass index and smoking habits, whereas diastolic blood pressure and HbA1c remained unchanged. The change in the MSEP during follow-up did not differ between the intervention and the usual care groups. There was a close relationship between the measurements of the three MSEP dimensions at baseline and at follow-up (P < 0.0001). None of the potential risk factors measured at entry was significantly associated with change in the three MSEP dimensions during follow-up.

CONCLUSION

The multiple risk factor intervention programme directed towards smoking habits, hypercholesterolaemia and the metabolic control of diabetes mellitus in treated hypertensive men at high cardiovascular risk was not associated with an impaired quality of life compared with that in a control group. The method used, the MSEP, has previously been found to be a reliable method with good validity, and this study's results provide further evidence of its validity.

Carotid artery wall intima-media thickness is associated with insulin-mediated glucose disposal in men at high and low coronary risk

BACKGROUND AND PURPOSE

The aim of this investigation was to examine the relationship between insulin sensitivity and intima-media thickness in the common carotid artery.

METHODS

Ultrasound examinations of the common carotid artery and hyperinsulinemic euglycemic clamp examinations were performed in a group (n = 25) of men aged 57 to 77 years at high risk for atherosclerotic disease (hypertension and at least one of the following factors: hypercholesterolemia and/or smoking) and in an age-matched low-risk group (n = 23) with no cardiovascular risk factors. Subjects with cardiovascular disease or diabetes mellitus were excluded.

RESULTS

A significant negative relationship between insulin sensitivity index and common carotid maximum intima-media thickness was observed in both the high-risk group (r = -.45, P < .05) and in the low-risk group (r = -.59, P < .01).

CONCLUSIONS

Our results suggest that an increase in intimamedia thickness, as a possible expression of early atherosclerosis, is negatively related to insulin sensitivity.

Urinary albumin excretion is associated with the intima-media thickness of the carotid artery in hypertensive males with non-insulin-dependent diabetes mellitus

OBJECTIVE

To examine the relationship between urinary albumin excretion and ultrasonographically assessed morphology of the common carotid artery in hypertensive men with and without non-insulin-dependent diabetes mellitus.

DESIGN

Cross-sectional study.

SETTING

An outpatient clinic in a city hospital.

PATIENTS

Hypertensive male patients (n = 25) with non-insulin-dependent diabetes mellitus and non-diabetic hypertensive male patients (n = 94) aged 50-72 years, randomly selected from a larger study group.

MAIN OUTCOME MEASURES

Overnight urinary albumin excretion and B-mode ultrasound examinations of the carotid artery.

RESULTS

Among the diabetic patients the logarithm of the overnight urinary albumin excretion was independently and significantly associated with the common carotid artery intima-media thickness, which was also true after adjustment for concomitant cardiovascular disease. In the non-diabetic group there was no association between intima-media thickness and urinary albumin excretion. No relationship between the occurrence of plaque and urinary albumin excretion was observed in any of the study groups. The results were reproducible at a re-examination after 3 years using the same methods.

CONCLUSION

Among the hypertensive men with non-insulin-dependent diabetes mellitus, an independent and significant relationship, reproducible after 3 years, was found between urinary albumin excretion and the intima-media thickness of the common carotid artery. No such relationship was found in the group of non-diabetic hypertensive males.

Does microalbuminuria predict cardiovascular events in nondiabetic men with treated hypertension? Risk Factor Intervention Study Group

The aim of this study was to investigate the predictive value of microalbuminuria (overnight urinary albumin excretion rate 17 to 100 mg/12 h) as a risk factor for future major cardiovascular events in nondiabetic patients with treated hypertension in a prospective study with follow-up time of 3.3 years. Overnight urinary albumin excretion was measured in 345 nondiabetic treated hypertensive men, aged 50 to 72 years, either with a serum cholesterol of > or = 6.5 mmol/L or smokers, or both. Cardiovascular morbidity was closely recorded during the follow-up period. At entry, microalbuminuria was found in 84 patients (24.3%) and 12 patients had macroalbuminuria (3.5%). During the follow-up period there were no differences in new cardiovascular events between patients with microalbuminuria and those with normoalbuminuria. However, an increase in the risk of future major cardiovascular events occurred in patients with urinary albumin excretion above 100 mg/12 h (macroalbuminuria). In a Cox regression analysis urinary albumin excretion was not associated with the incidence of future major cardiovascular events unless a more detailed approach was used, showing that this was the case for urinary albumin excretion above 100 mg/12 h (macroalbuminuria). Calculations with an alternative definition of microalbuminuria and mortality as end-point did not change the principal result. In conclusion, microalbuminuria does not seem to be a predictor of future mortality and cardiovascular morbidity in nondiabetic men with treated hypertension and at high risk of coronary heart disease. However, macroalbuminuria was associated with future major cardiovascular events in this group of patients.

Microalbuminuria, insulin sensitivity and haemostatic factors in non-diabetic treated hypertensive men. Risk Factor Intervention Study Group

OBJECTIVE

To examine whether microalbuminuria in non-diabetic, treated hypertensive men is associated with insulin resistance and measures of endothelial function, thrombogenesis and fibrinolysis.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinic in city hospital.

PATIENTS

Ninety-two treated hypertensive men, aged 57-77 years, either with a serum cholesterol of > or = 6.5 mmol L-1 or smokers, or both. Patients with diabetes mellitus or overnight urinary albumin excretion of > 100 mg 12 h-1 were excluded.

MAIN OUTCOME MEASURES

Overnight urinary albumin excretion, insulin-mediated glucose disposal (hyperinsulinaemic euglycaemic clamp), blood glucose and plasma insulin during oral glucose tolerance test, fibrinogen, von Willebrand factor and plasminogen activator inhibitor activity.

RESULTS

Microalbuminuric patients had increased blood glucose concentrations during the oral glucose tolerance test and higher plasma fibrinogen levels compared with the normoalbuminuric patients. In a randomly selected subgroup (n = 36), insulin-mediated glucose disposal was lower in microalbuminuric than in normoalbuminuric patients, and an inverse relationship between insulin sensitivity and albuminuria (r = -0.37; P = 0.028) was found. This relationship was not significant after adjustment for body-mass index (P = 0.098). In the univariate analyses including all patients, albuminuria was associated with blood glucose, serum creatinine, body-mass index, systolic blood pressure, fibrinogen, von Willebrand factor and cholesterol (negatively). In a multiple regression analysis, only the body-mass index was independently related to urinary albumin excretion.

CONCLUSIONS

Microalbuminuria was associated with insulin resistance but obesity was a confounding factor. Relationships between microalbuminuria and fibrinogen as well as von Willebrand factor were found, but only in univariate analysis.

The cost-effectiveness of a cardiovascular multiple-risk-factor intervention programme in treated hypertensive men

OBJECTIVES

The aim of this study was to carry out a cost-effectiveness analysis of a multifactorial intervention programme in treated hypertensive patients.

DESIGN

A cost-effectiveness analysis based on 3 years of follow-up in an open, randomized, parallel-group study with allocation either to a comprehensive, multiple-risk factor modification programme or to conventional treatment.

SETTING

An outpatient clinic of a city hospital.

SUBJECTS

Inclusion criteria were: male sex, age 50-72 (mean 66.4) years, treated hypertension and at least one of the following: serum cholesterol > or = 6.5 mmol L-1, and/or smoking and/or diabetes mellitus. A total of 508 patients were included in the study.

INTERVENTIONS

Advice given to individuals, and group meetings based on nutritional advice and behavioural treatment principles. If necessary, drug therapy could be instituted to achieve the treatment goals in the intervention group: serum total cholesterol of < 6.0 mmol L-1, no smoking, HbAlc < 6.0% and diastolic blood pressure < 90 mmHg in both groups.

MAIN OUTCOME MEASURE

Incremental cost per life-year gained of the intervention programme.

RESULTS

The cost per life-year gained was SEK 4000 in an estimation based on the observed risk reduction and ranged between SEK 62,000 and SEK 163,000 in three estimations based on the risk factor changes.

CONCLUSIONS

The analysis indicates that the intervention programme is cost-effective in the studied patient population.

Carotid artery wall morphology, haemostatic factors and cardiovascular disease. An ultrasound study in men at high and low risk for atherosclerotic disease

The aim of this study was to examine whether there was a relationship between haemostatic factors and ultrasound-assessed morphology of the common carotid artery and cardiovascular disease in 57- to 77-year-old men at high risk for atherosclerotic disease (hypertension and at least one of the following risk factors: hypercholesterolaemia, smoking, diabetes mellitus). They were divided into one group with (n = 59) and one group without (n = 70) manifest cardiovascular disease. An age-matched reference group with no cardiovascular risk factors was used as a comparison (n = 51). Significant associations, independent of smoking, were found between plasma fibrinogen and both the maximal intima-media thickness and the occurrence of plaque in the high-risk group. High-risk patients with clinical signs of cardiovascular disease had higher levels of plasma fibrinogen and prothrombin 1 + 2 fragment compared with both high-risk patients without concomitant cardiovascular disease and low-risk subjects. Plasminogen activator inhibitor, von Willebrand factor and thrombin/antithrombin complex were increased in the high-risk group with signs of cardiovascular disease in comparison with the low-risk group. In conclusion the results indicate that plasma fibrinogen may be operative in the development of atherosclerosis. Clinical signs of cardiovascular disease were associated with increased plasma levels of fibrinogen, von Willebrand factor, plasminogen activator inhibitor, thrombin/antithrombin complex and prothrombin 1 + 2 fragment.

The efficacy of multiple risk factor intervention in treated hypertensive men during long-term follow up. Risk Factor Intervention Study Group

OBJECTIVE

To examine the feasibility and efficacy of a multifactorial intervention programme directed towards hypercholesterolaemia, smoking, and diabetes mellitus in treated hypertensive patients after more than 3 years' follow-up and to describe the incidence of cardiovascular complications.

DESIGN

Open, randomized, parallel-group study with allocation either to a comprehensive multiple risk factor modification programme or to usual care.

SETTING

Outpatient clinic in a city hospital.

PATIENTS

A total of 508 male patients with treated hypertension, aged 50-72 years, with at least one of the following: serum cholesterol > or = 6.5 mmol L-1, smoking or diabetes mellitus.

INTERVENTION

Individually given advice and group meetings based on nutritional advice and behavioral treatment principles. Drug therapy could be instituted to achieve the treatment goals in the intervention group: serum total cholesterol below 6.0 mmol L-1, no smoking, and HbA1c below 6.0%. Diastolic blood pressure below 90 mmHg was the treatment goal in both groups.

MAIN OUTCOME MEASUREMENTS

Serum cholesterol, HbA1c, diastolic blood pressure, smoking. Cardiovascular end-points were recorded.

RESULTS

The net changes were (change intervention--change usual care): serum cholesterol -5.0% (95% confidence interval, -7.6 to -2.3%), 17.6% more stopped smoking (P = 0.04); diastolic blood pressure and HbA1c remained unchanged. The incidence of stroke was lower in the intervention group compared with the usual-care group: 2.0 and 6.7%, respectively (P = 0.017).

CONCLUSION

The intervention programme was comparatively successful with regards to the effects on hypercholesterolaemia and smoking habits. An unexpected decrease in the stroke incidence was observed in the intervention group compared with the usual-care group.

Is carbohydrate-deficient transferrin in serum useful for detecting excessive alcohol consumption in hypertensive patients?

The aim of this study was to examine the diagnostic usefulness of carbohydrate-deficient transferrin (CDT) in serum in a cross-sectional study of 439 treated hypertensive men. We related the results to alcohol intake by questionnaire and to biochemical and hemodynamic measurements known to reflect excessive alcohol consumption. The diagnostic sensitivity and the specificity for high alcohol intake (&gt; or = 24 g/day of ethanol) were 44% and 87%, respectively. The group with reported high alcohol intake (n = 32) was characterized by hemodynamic and biochemical changes typical of alcohol abuse. The corresponding profile for the patients with increased serum CDT concentrations (n = 70) was different in several respects, indicating a considerable number of false-positive tests. We conclude that serum CDT determination had low sensitivity and specificity for excessive alcohol consumption in this group of hypertensive patients. The results illustrate the importance of evaluating new laboratory methods in unselected patient populations before drawing any conclusions about their clinical value.

Is carbohydrate-deficient transferrin in serum useful for detecting excessive alcohol consumption in hypertensive patients?

The aim of this study was to examine the diagnostic usefulness of carbohydrate-deficient transferrin (CDT) in serum in a cross-sectional study of 439 treated hypertensive men. We related the results to alcohol intake by questionnaire and to biochemical and hemodynamic measurements known to reflect excessive alcohol consumption. The diagnostic sensitivity and the specificity for high alcohol intake (> or = 24 g/day of ethanol) were 44% and 87%, respectively. The group with reported high alcohol intake (n = 32) was characterized by hemodynamic and biochemical changes typical of alcohol abuse. The corresponding profile for the patients with increased serum CDT concentrations (n = 70) was different in several respects, indicating a considerable number of false-positive tests. We conclude that serum CDT determination had low sensitivity and specificity for excessive alcohol consumption in this group of hypertensive patients. The results illustrate the importance of evaluating new laboratory methods in unselected patient populations before drawing any conclusions about their clinical value.

Carbohydrate-deficient transferrin is associated with insulin sensitivity in hypertensive men

An elevated concentration of carbohydrate-deficient transferrin in serum (CDT) has been reported to indicate excessive ethanol consumption. However, in hypertensive men, we found low values for diagnostic sensitivity and specificity. Furthermore, in the individuals with high CDT values, the concentrations of serum triglycerides and blood glucose were low rather than high, indicating that factors related to insulin/glucose metabolism may be operative. The current study addresses this issue by examining 48 patients with treated hypertension and at least 1 of following: hypercholesterolemia, history of smoking, and diabetes mellitus. We determined serum CDT, fasting plasma insulin, and glucose disposal rate during hyperinsulinemic euglycemic clamp. Seven patients had elevated CDT concentrations. This group of patients had higher glucose disposal rates than the others (mean difference, 19 mumol/min.kg lean body mass; 95% confidence interval, 5-33 mumol/min.kg lean body mass; P = 0.0096), but did not differ in body mass index or alcohol intake. Serum CDT correlated positively with glucose disposal rate (r = 0.55; P = 0.0004) and negatively with fasting plasma insulin (r = -0.43; P = 0.0039). These relationships remained after exclusion of 8 patients with diabetes mellitus and adjustment for potentially confounding factors. We conclude that the serum CDT concentrations in our patients were associated with insulin sensitivity.

Ultrasound evaluation of atherosclerotic manifestations in the carotid artery in high-risk hypertensive patients. Risk Intervention Study (RIS) Group

The aim of this study was to evaluate whether high-risk hypertensive patients (n = 137) had larger far-wall common carotid artery intima-media thickness than a control group (n = 37) and to study whether intima-media thickness was related to other signs of atherosclerotic disease. The results showed that intima-media thickness was significantly larger in the hypertension group than in the control group. Lumen diameter and mean cross-sectional area of the intima-media complex were larger both for hypertensive patients with a positive history of manifest clinical cardiovascular disease and for hypertensive patients with no such history than in the control group. There was a significant relationship between far-wall common carotid artery intima-media thickness and plaque status (visual scoring, no, small, moderate/large) in the carotid artery region. In univariate analyses, low diastolic blood pressure and high pulse pressure were both significantly related to plaque status. In multivariate analyses, pulse pressure was significantly and independently related both to common carotid artery intima-media thickness and to plaque status in the carotid artery region. In multivariate analyses, there was also an independent relationship between age and common carotid artery intima-media thickness, between smoking status and plaque status, and between a positive history of manifest clinical cardiovascular disease and plaque status. In conclusion, common carotid artery intima-media thickness and lumen diameter were increased in elderly high-risk hypertensive patients, in whom more than one third of the patients also had a moderate to large plaque in the carotid artery region.(ABSTRACT TRUNCATED AT 250 WORDS)

Thyroid hormones, procollagen III peptide, body composition and basal metabolic rate in euthyroid individuals

We examined 103 euthyroid men and women within a wide range of body weights and ages. Fat free mass (FFM) and body fat (BF) were determined with the total body potassium technique, basal metabolic rate (BMR) by indirect calorimetry and serum concentrations of thyroid hormones (free and total T3 and T4) and the aminoterminal propeptide of collagen III (pIIIp) by immunoassays. BMR was positively related to FFM, BF, total T3, the free T3/free T4 ratio and pIIIp, and negatively to free T4 (men) and to the ratios free T4/total T4 and free T3/total T3. pIIIp was as strongly related to BMR as to total T3. It is suggested that pIIIp may serve as an indicator of peripheral energy expenditure. The negative relationship between BMR and free T4 was unexpected and different to the situation in hypo- and hyperthyreosis where BMR and thyroid hormone are positively related. Our hypothesis is that euthyroid subjects with low serum free thyroid hormone concentrations and comparatively high BMR may have high intracellular thyroid hormone concentrations.

Effects of alcohol intake and obesity on serum liver enzyme activity in obese men with mild hypertension

OBJECTIVES

To examine the relationships between alcohol intake, obesity, plasma insulin concentration and serum activities of three liver enzymes in obese men with mild hypertension.

DESIGN

A 6-week run-in period followed by randomization to either diet treatment or antihypertensive drug treatment, lasting for 1 year. Alcohol intake was estimated using questionnaires. Plasma insulin concentration, serum activities of gamma-glutamyl transferase, and aspartate and alanine aminotransferase, respectively, were measured at entry and after 1 year.

SETTING

Out-patient clinic, city hospital.

PATIENTS

Sixty-four men aged 40-69 years with a body mass index > or = 26 kg m-1 and with mild untreated hypertension. Exclusion criteria were alcoholism and diabetes mellitus. Sixty-one patients completed the study.

INTERVENTIONS

Dietary treatment was based upon weight reduction and recommendations about a low alcohol intake. Drug treatment used a stepped-care approach with atenolol as the first-choice drug.

MAIN OUTCOME MEASURES

Serum activities of the liver enzymes, body weight, body mass index, alcohol intake, plasma insulin concentration.

RESULTS

Body weight decreased by 7.8 kg in the diet group and increased by 1.0 kg in the drug-treated group. Alcohol intake did not differ between the groups before or after 1 year. Serum gamma-glutamyl transferase activity correlated with alcohol consumption; it showed no significant change after weight loss. At entry, serum activities of aspartate and alanine aminotransferases correlated to plasma insulin concentration independent of body mass index. Weight reduction significantly lowered serum activities of these liver enzymes as well as plasma insulin concentrations and normalized elevated serum activity of alanine aminotransferase in a majority of the cases.

CONCLUSION

Alcohol intake was an important determinant for elevated serum gamma-glutamyl transferase activity. The degree of obesity was a contributing factor for elevations of serum alanine aminotransferase activity. We speculate that insulin may play a role in this relationship.

Microalbuminuria in treated hypertensive men at high risk of coronary disease. The Risk Factor Intervention Study Group

OBJECTIVE

To examine whether microalbuminuria is a marker of cardiovascular disease in treated hypertensive men without diabetes mellitus at high coronary risk and to examine the associations between microalbuminuria and recognized cardiovascular risk factors.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinic in city hospital.

PATIENTS

Three hundred and thirty-three treated hypertensive men, aged 50-72 years, either with a serum cholesterol of > or = 6.5 mmol/l or smokers, or both. The patients were recruited mainly from a population-based sample of hypertensive men. Patients with diabetes mellitus or overnight urinary albumin excretion of > 100 mg/12 h were excluded from the analyses.

MAIN OUTCOME MEASURES

Overnight urinary albumin excretion, prevalence of microalbuminuria (defined as 17-100 mg/12 h) and organ damage (cardiovascular events or major electrocardiogram changes, or both), various well-established risk factor levels, blood glucose and plasma insulin responses to an oral glucose tolerance test.

RESULTS

Microalbuminuria was found in 25% of the cohort. Among microalbuminuric patients, organ damage was significantly more common (47.6%) than in the normoalbuminuric group (30.9%). However, the sensitivity and specificity of microalbuminuria as a marker of organ damage were only 34 and 80%, respectively. Microalbuminuria was significantly related to body mass index and waist:hip ratio, age and plasma insulin during oral glucose tolerance testing. These relationships also persisted after adjustment for treatment with thiazides or beta-blockers.

CONCLUSIONS

In treated hypertensive men without diabetes mellitus, microalbuminuria was associated with factors known to be related to insulin resistance. It had a low sensitivity as a marker of concomitant cardiovascular disease.

A health-economic comparison of diet and drug treatment in obese men with mild hypertension

OBJECTIVE

To compare dietary and antihypertensive drug treatment in obese men with mild hypertension in economic terms.

DESIGN

A 6-week run-in period followed by randomization to either diet or drug treatment, lasting for 1 year. Blood pressure was measured blindly and serum lipid concentrations assessed at run-in and after 1 year. A computer-based model was used in five cost-effectiveness simulations with different assumptions as to the effect upon coronary heart disease risk from the changes in diastolic blood pressure and cholesterol, both total and high-density lipoprotein. A cost-benefit analysis was also performed, calculated as willingness to pay for treatment, as assessed by questionnaire, minus total cost.

SETTING

Outpatient clinic in city hospital.

PATIENTS

Sixty-four men aged 40-69 years with body mass index > or = 26 kg/m2 and a diastolic blood pressure 90-104 mmHg when untreated were recruited (screening after advertisement in newspaper). Exclusion criteria were diabetes mellitus, organ damage secondary to hypertension, and diseases that might have interfered with compliance and the interpretation of results. Sixty-one patients completed the study.

INTERVENTIONS

Dietary treatment was based upon weight reduction and sodium restriction. Drug treatment used a stepped-care approach, with atenolol as the drug of first choice.

MAIN OUTCOME MEASURES

Life years gained and willingness to pay.

RESULTS

Drug treatment was the preferred option in three of the five cost-effectiveness simulations. The cost-benefit analysis did not show any difference between the two groups.

CONCLUSIONS

Non-pharmacological treatment seemed to be less cost-effective than drug treatment. However, more studies and further methodological development are needed to verify this finding.

Weight reduction versus antihypertensive drug therapy in obese men with high blood pressure: effects upon plasma insulin levels and association with changes in blood pressure and serum lipids

OBJECTIVES

First, to compare dietary and antihypertensive drug treatment in obese men with mild hypertension with respect to effects upon insulin, glucose, lipid metabolism and blood pressure. Second, to test the hypothesis that in the diet group changes in blood pressure and serum lipid concentration were associated with changes in plasma insulin concentration.

DESIGN

A 6-week run-in period followed by random assignment to either diet or drug treatment, lasting for 1 year. Blood pressure measurements were performed blind after 5 and 45 min rest, and during isometric exercise. Plasma insulin and blood glucose concentrations were measured before and after an oral glucose load.

SETTING

Outpatient clinic in a city hospital.

PATIENTS

Sixty-four men aged 40-69 years with a body mass index > or = 26 kg/m2 and with a diastolic blood pressure of 90-104 mmHg when untreated were recruited (screening after an advertisement in a newspaper). Exclusion criteria were diabetes mellitus, organ damage secondary to hypertension and diseases that may have interfered with compliance and the interpretation of results. Sixty-one patients completed the study.

INTERVENTIONS

Dietary treatment was based upon weight reduction and sodium restriction. Drug treatment used a stepped-care approach with atenolol as first choice drug.

MAIN OUTCOME MEASURES

Absolute reductions in blood pressure, plasma insulin, blood glucose, serum lipid concentration and the waist:hip circumference ratio.

RESULTS

Mean body weight decreased in the diet group and increased in the drug-treatment group. Plasma insulin concentrations, the waist:hip circumference ratio and serum lipid profile improved in the diet group compared with the drug group. Blood pressure control was significantly better in the drug group. In the diet group the changes in mean arterial pressure after 5 min rest and serum triglyceride levels correlated with changes in plasma insulin concentrations independent of changes in body mass index or body weight.

CONCLUSIONS

Diet treatment was inferior to drug treatment in controlling hypertension, but superior in lowering plasma insulin concentrations and improving the serum lipid profile. The hypothesis of a relation between changes in blood pressure, serum triglycerides and plasma insulin was supported.

Withdrawal of antihypertensive drug treatment: time-course for redevelopment of hypertension and effects upon left ventricular mass

OBJECTIVES

To examine: (1) in how many treated hypertensive patients it was possible to discontinue drug treatment; (2) the time-course for redevelopment of hypertension after discontinuation of therapy; and (3) whether drug withdrawal was associated with an increase in left ventricular mass (LVM).

DESIGN

Fifty-four men with primary hypertension treated for a mean period of 6 years (primarily beta 1-selective beta-blockade) were evaluated for withdrawal of treatment. Exclusion criteria were signs of organ damage, severe hypertension, other serious disease and unwillingness. Treatment was reinstituted if blood pressure increased above a safety level or if symptoms occurred. Echocardiographic estimations of LVM were obtained before withdrawal and 1, 4 and 8 weeks after withdrawal or before return to treatment.

SETTING

Outpatient clinic in a city hospital.

PATIENTS

A random sample of 56-year-old hypertensive men.

INTERVENTION

Gradual discontinuation of treatment with close follow-up of blood pressure.

MAIN OUTCOME MEASURES

Number of patients who could withdraw from treatment and who had to return to pharmacological therapy; time-courses for development of hypertension; absolute changes in LVM.

RESULTS

Thirty-two patients withdrew from treatment for 1-1000 days. Therapy was reinstituted in all owing to hypertension or symptoms. Serial echocardiograms were obtained in 22 patients. During the drug-free period, relative wall thickness increased, but LVM did not. Patients with rapid redevelopment of hypertension had larger prewithdrawal LVM than patients whose blood pressure increased more slowly.

CONCLUSION

It was possible to withdraw treatment and obtain readable echocardiograms in a minority of the patients. After drug-withdrawal, relative wall thickness increased, but not LVM. We suggest that previously treated patients should be avoided in studies examining reversal of left ventricular hypertrophy.

Secondary polycythaemia associated with nocturnal apnoea--a relationship not mediated by erythropoietin?

A polysomnographic study was undertaken in nine patients with unexplained polycythaemia and nine age- and sex-matched controls. Circulating plasma levels of immunoreactive erythropoietin (IrEPO) were analysed before and after sleep. Seven out of nine polycythaemia patients were found to have sleep-disordered breathing and fulfilled the criteria for the sleep apnoea syndrome. Erythrocyte volume fraction was by definition higher among polycythaemia patients, and showed a weak positive correlation with minimum oxygen saturation during sleep (P less than 0.05). However, plasma IrEPO did not differ between the two groups or between morning and evening samples within the respective groups. In a separate study, IrEPO was repeatedly analysed during sleep in a group of six patients with severe obstructive sleep apnoea and six matched controls. No correlation with severity of sleep-disordered breathing was found. None of these patients had polycythaemia, and there was no obvious diurnal variation in IrEPO levels. A nocturnal sleep study may be warranted in patients with unexplained polycythaemia. Obstructive sleep apnoea does not appear to be related to increased IrEPO levels, although polycythaemia has been reported as a relatively common finding in this disease.

Cardiovascular effects of weight reduction versus antihypertensive drug treatment: a comparative, randomized, 1-year study of obese men with mild hypertension

The aim of the study was to compare cardiovascular effects of weight reduction and sodium restriction with antihypertensive drug treatment in obese middle-aged men with mild hypertension in an open randomized trial lasting for 1 year, preceded by a 6-week run-in period. In the diet group (n = 31), weight decreased by 7.8 kg and salt intake by 2 g/day. In the other group (n = 30), treatment was structured with atenolol as the first line drug. The differences in antihypertensive response were highly significant when measured as casual blood pressure, with drug treatment being favoured. Echocardiographic estimations of left ventricular morphology and function showed no difference in effects between the two treatment modalities. Further analyses showed that the presence of previous antihypertensive treatment was modulating the effect of intervention on left ventricular mass. The response to treatment in plethysmographic estimations of resistance at maximal dilatation in the forearm did not differ between the groups. We conclude that drug treatment was superior to the diet regimen in controlling hypertension, that no differences were observed in effects on cardiovascular structure and that previous antihypertensive treatments seems to be a potent confounding factor that should be taken into consideration in future studies.

Thyrotoxic atrial fibrillation: an underdiagnosed or overdiagnosed condition?

Hyperthyroidism has been considered to be underdiagnosed as a pathogenetic factor for atrial fibrillation, according to results of thyroliberin stimulation tests. We assessed, clinically and biochemically, thyroid function in 110 ambulatory patients with atrial fibrillation [mean age 64 (SD 11) years] from a group of consecutive cases referred to a specialist cardiology unit during one year. Patients finally categorized as euthyroid (n = 100) commonly presented with one or more symptoms or signs considered to be typical for thyrotoxic patients. Three patients (2.7%; 95% confidence interval, 0-7.5%) fulfilled criteria for hyperthyroidism, but only one was identified from clinical examination. The thyroliberin stimulation test (performed in all patients) identified another seven patients who might have been classified as hyperthyroid according to commonly used criteria for an abnormal thyrotropin response. However, none of these seven patients was judged as hyperthyroid after follow-up. Their thyrotropin concentrations were all above the detection limit for the immunoenzymometric assay. With few exceptions, they had thyroid hormone concentrations within reference limits calculated from the results for the 100 euthyroid subjects, and their concentration ratio for free 3,5,3'-triiodothyronine to free thyroxin, 0.31 (SD 0.05), was lower than that found in the euthyroid group [0.38 (SD 0.08), P less than 0.05]. We conclude that (a) criteria for evaluating results of the thyroliberin stimulation test should be revised, (b) this test is still useful in evaluating suspected cases of hyperthyroidism, for which results of current, improved methods for thyrotropin determination are equivocal, and (c) improved diagnostic methods should be used to characterize the relative importance of hyperthyroidism as a causal factor for atrial fibrillation.

Thyrotoxic atrial fibrillation: an underdiagnosed or overdiagnosed condition?

Hyperthyroidism has been considered to be underdiagnosed as a pathogenetic factor for atrial fibrillation, according to results of thyroliberin stimulation tests. We assessed, clinically and biochemically, thyroid function in 110 ambulatory patients with atrial fibrillation [mean age 64 (SD 11) years] from a group of consecutive cases referred to a specialist cardiology unit during one year. Patients finally categorized as euthyroid (n = 100) commonly presented with one or more symptoms or signs considered to be typical for thyrotoxic patients. Three patients (2.7%; 95% confidence interval, 0-7.5%) fulfilled criteria for hyperthyroidism, but only one was identified from clinical examination. The thyroliberin stimulation test (performed in all patients) identified another seven patients who might have been classified as hyperthyroid according to commonly used criteria for an abnormal thyrotropin response. However, none of these seven patients was judged as hyperthyroid after follow-up. Their thyrotropin concentrations were all above the detection limit for the immunoenzymometric assay. With few exceptions, they had thyroid hormone concentrations within reference limits calculated from the results for the 100 euthyroid subjects, and their concentration ratio for free 3,5,3'-triiodothyronine to free thyroxin, 0.31 (SD 0.05), was lower than that found in the euthyroid group [0.38 (SD 0.08), P less than 0.05]. We conclude that (a) criteria for evaluating results of the thyroliberin stimulation test should be revised, (b) this test is still useful in evaluating suspected cases of hyperthyroidism, for which results of current, improved methods for thyrotropin determination are equivocal, and (c) improved diagnostic methods should be used to characterize the relative importance of hyperthyroidism as a causal factor for atrial fibrillation.

Metabolic effects of controlled-release metoprolol in hypertensive men with impaired or diabetic glucose tolerance: a comparison with atenolol

In a double-blind, randomized, cross-over study with a single-blind placebo run-in period a new controlled-release (CR) formulation of metoprolol 200 mg once daily was compared with atenolol tablets 100 mg once daily in 22 patients (age 60.9 +/- 0.93 (SE) years) with primary hypertension and impaired or diabetic glucose tolerance. Each period lasted for three weeks. The two agents produced similar blood pressure 3 h as well as 24 h after drug intake. Three hours after drug intake, heart rate was lower on atenolol than metoprolol CR treatment, indicating a higher degree of beta-receptor blockade for atenolol at this point in time, when the plasma concentration of atenolol was most likely to be close to its peak. Concentrations of blood glucose, serum insulin, and serum C-peptide in the fasting state or after an oral glucose load did not differ between the active agents. HbA1c was marginally, but significantly, lower on atenolol than metoprolol CR treatment. No differences were found in serum levels of total, low density lipoprotein (LDL), and high density lipoprotein (HDL) cholesterol or apoA-I, and apoB lipoproteins or triglycerides. In comparison to the placebo run-in period, both agents showed an unexpected improvement in glucose tolerance, a decrease in HDL cholesterol and for metoprolol CR a small, but significant decrease in LDL cholesterol. Thus, treatment with metoprolol CR tablets producing even plasma levels without high peak concentrations and conventional atenolol treatment had similar effects on metabolic control in hypertensive men and abnormal glucose tolerance.

Antihypertensive effect of diet compared with drug treatment in obese men with mild hypertension

OBJECTIVE

To determine whether dietary treatment has a similar antihypertensive effect to conventional drug treatment while being superior to drugs in improving serum lipid concentrations in obese men with mild hypertension.

DESIGN

Six week run in period followed by randomisation to either diet or drug treatment groups for one year.

SETTING

Outpatient clinic in city hospital.

PATIENTS

61 Men aged 40-69 years, body mass index greater than or equal to 26, diastolic blood pressure 90-104 mm Hg when untreated. Exclusion criteria were signs of organ damage secondary to hypertension and diseases that might have interfered with compliance or with interpretation of results.

INTERVENTIONS

Dietary treatment was based on weight reduction, restriction of sodium, and decrease of excess alcohol intake (defined as greater than or equal to 250 g alcohol per week). Drug treatment used a stepped care approach with atenolol as drug of first choice.

MAIN OUTCOME MEASURES

Diastolic blood pressure less than 90 mm Hg; absolute reductions in blood pressure and serum lipid concentrations.

RESULTS

Mean body weight decreased 7.6 kg in the diet group and increased 0.9 kg in the drug treatment group (p less than 0.0001), and mean sodium excretion decreased 42 and 10 mmol/24 h respectively (p = 0.019). There was no difference in reported alcohol intake. Mean systolic blood pressure decreased 4 mm Hg in the diet group and 16 mm Hg in the drug group (p = 0.003) and diastolic blood pressure 3 and 11 mm Hg respectively (p = 0.002). Diastolic blood pressure of 90 mm Hg was attained by 29% of the diet group (nine men) and 73% (22) of those receiving drug treatment (mean difference 44%, 95% confidence interval 21 to 67%, p = 0.001). Dietary treatment produced decreases in mean serum concentrations of total and low density lipoprotein cholesterol as well as triglycerides and an increase in high density lipoprotein cholesterol concentration. In the drug treatment group the changes were in the opposite direction, and the groups differed significantly in all but total cholesterol.

CONCLUSIONS

Dietary treatment was inferior to conventional drug treatment in controlling mild hypertension but superior in lowering serum concentrations of lipids.

Central haemodynamics, baroreceptor sensitivity and alpha 1-adrenoceptor-mediated vascular reactivity during weight-stable sodium restriction in obese men with hypertension

Ten obese men (20-40% overweight) with previously untreated arterial hypertension (WHO stages I and II) were examined before and during sodium-restricted isocaloric diets. The mean (+/- s.d.) daily sodium excretion was reduced from 199 +/- 65 to +/- 25 mmol/24 h. Intra-arterial blood pressure (BP), cardiac output (CO), plasma volume, circulating and urinary noradrenaline (NA), plasma renin activity (PRA) and urinary aldosterone were measured. Vascular reactivity was assessed with intravenous bolus injections of 50, 100 and 200 micrograms phenylephrine, and baroreflex sensitivity was assessed with the R-R interval response to pressure elevations on electrocardiogram. Significant reductions in systolic BP from 163 +/- 18 to 147 +/- 17 mmHg and in diastolic BP from 97 +/- 7 to 88 +/- 9 mmHg occurred during salt restriction. Blood pressure reductions were correlated with changes of urinary sodium excretion (r = 0.71; P less than 0.05). No significant changes in CO, heart rate (HR) or stroke volume (SV) were observed; therefore, BP reduction was secondary to the fall in total peripheral resistance (TPR) from 21.8 +/- 4.1 to 19.0 +/- 4.1 units (P = 0.05). Plasma volume, as well as total blood volume, was not affected by the moderate sodium restriction, but PRA rose from 0.71 +/- 0.1 to 0.87 +/- 0.1 micrograms angiotensin 1/ml per h (P less than 0.05). Urinary aldosterone was increased from 32 +/- 12 to 54 +/- 9 nmol/24 h. No change in venous or arterial concentrations of NA or of urinary NA was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Toxic epidermal necrolysis with extensive mucosal erosions of the gastrointestinal and respiratory tracts

Toxic epidermal necrolysis with epidermal shedding over almost the entire body occurred in a patient with classical rheumatoid arthritis treated with sulindac, penicillamine and a combination analgesic containing paracetamol and chlormezanone. Erosions in the lower respiratory tract and the intestine contributed to a lethal outcome of the disease and showed a microscopical picture similar to that of the skin involved. The histopathological picture of these extracutaneous lesions have been only briefly reported previously.

Fluid homeostasis and haemodynamics during sodium restriction in hypertensive men

To investigate the antihypertensive effect of moderate sodium restriction, the sodium intake of 11 male outpatients was reduced by 120 mmol/day for 4-6 weeks. These patients and an untreated control group were slightly obese and had mild untreated hypertension (WHO 1-2). All subjects were examined before and at the end of the experiment. Diastolic blood pressure fell significantly in the diet group in comparison with the control group. Invasive haemodynamic examinations in the diet group showed an unchanged mean cardiac output and a reduction of mean total peripheral resistance. Plasma volume (Evan's Blue) did not change, neither did extracellular volume as calculated from determinations of tritiated water, total body potassium and body mass. During sodium restriction, plasma renin activity and urinary aldosterone excretion significantly increased. Noradrenaline and dopamine excretion in urine showed no significant changes during sodium restriction, neither did the plasma concentrations of atrial natriuretic peptides. The reduction in mean arterial blood pressure was correlated significantly with a decrease in 24-h sodium excretion and an increase in urinary aldosterone excretion. In conclusion, moderate dietary sodium restriction seems to lower blood pressure by diminishing the total peripheral resistance while cardiac output, extracellular and intravascular volumes are maintained.

Reactivity to norepinephrine and effect of sodium on blood pressure during weight loss

Eighteen moderately obese middle-aged men with untreated mild hypertension were randomized to two groups and placed on a low energy diet regimen for 9 to 11 weeks. In Group I (n = 10) the amount of sodium chloride in the diet maintained the urinary sodium excretion at the predieting level. Mean body mass was reduced by 9.1 +/- 0.7 (SEM) kg. Mean intra-arterial pressure showed no significant change. There were significant decreases in heart rate (p less than 0.05) and urinary norepinephrine excretion (p less than 0.05) but not in plasma concentration of norepinephrine. In Group II (n = 8) energy as well as sodium intake was restricted, with a 95 +/- 22 mmol/24 hour reduction of urinary sodium excretion. Body mass decreased by 9.3 +/- 1.1 kg, and mean arterial pressure decreased by -18.9 to -4.3 mm Hg (95% confidence interval). There were also significant reductions in heart rate (p less than 0.001) and plasma norepinephrine concentrations (p less than 0.01) but not in urinary norepinephrine excretion. The pressor response (mean arterial pressure) to norepinephrine infusion at different dose rates was significantly elevated (p less than 0.05) in Group I during dieting in comparison with baseline. The blood pressure response to norepinephrine during dieting in patients in Group II was not changed from baseline.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased erythrocyte sodium efflux during overfeeding without evidence of mediation by circulating catecholamines or thyroid hormone

Ten slightly obese middle-aged men were instructed to increase their energy intake 25% during a period of 1 week, which was preceded by a control period of seven days. Body weight increased by 0.67 kg (SD 0.60) indicating good compliance with the regimen. Transmembrane sodium fluxes were determined with the use of 22Na. The pre-diet erythrocyte sodium content was 9.7 mmol/L (SD 0.8) decreasing to 8.9 mmol/L (SD 1.1) (P less than 0.05) during overfeeding. The Na-efflux rate constant increased from 0.40 h-1 to 0.54 h-1 (P less than 0.05). Urinary excretion of catecholamines and concentrations of catecholamines and insulin in plasma and of thyroxine, triiodothyronine, and reverse T3 in serum did not change. Thus, overfeeding seems to enhance the total Na efflux in erythrocytes from slightly obese men. There were no measurable changes in thyroid hormone or catecholamine levels leaving the regulatory mechanisms unexplained.