Practical Suitability of a Stand-Alone Oscillometric Central Blood Pressure Monitor: A Review of the Microlife WatchBP Office Central

Accumulating evidence indicates that central blood pressure (CBP) is a better cardiovascular risk predictor than brachial blood pressure (BP). Although more additional benefits of CBP-based treatment above usual hypertension treatment are to be demonstrated, the demand for implementing CBP assessment in general clinical practice is increasing. For this, the measurement procedure must be noninvasive, easy to perform, and cost- and time-efficient. Therefore, oscillometric devices with the possibility to assess CBP seem the best option. Recently, such an oscillometric BP monitor, the Microlife WatchBP Office Central, was developed, which demonstrated its high accuracy in a validation study against invasive BP measurement. Calibration errors of this device are limited because the procedure is automated, standardized, and performed at the same place of and within 30 s from pulse wave assessment. The transformation from the peripheral pulse wave to CBP is done by means of an individual-based pulse wave analysis according to a theory of arterial compliance and wave reflections. In addition, the device has demonstrated to enable a more reliable diagnosis of hypertension by CBP than by peripheral BP, with a lower frequency of over- and underdiagnosis. Altogether, the available clinical evidence suggests that the Microlife WatchBP Office Central fulfills the criteria for general clinical use.

Graphene oxide/graphene vertical heterostructure electrodes for highly efficient and flexible organic light emitting diodes

The relatively high sheet resistance, low work function and poor compatibility with hole injection layers (HILs) seriously limit the applications of graphene as transparent conductive electrodes (TCEs) for organic light emitting diodes (OLEDs). Here, a graphene oxide/graphene (GO/G) vertical heterostructure is developed as TCEs for high-performance OLEDs, by directly oxidizing the top layer of three-layer graphene films with ozone treatment. Such GO/G heterostructure electrodes show greatly improved optical transmittance, a large work function, high stability, and good compatibility with HIL materials (MoO3 in this work). Moreover, the conductivity of the heterostructure is not sacrificed compared to the pristine three-layer graphene electrodes, but is significantly higher than that of pristine two-layer graphene films. In addition to high flexibility, OLEDs with different emission colors based on the GO/G heterostructure TCEs show much better performance than those based on indium tin oxide (ITO) anodes. Green OLEDs with GO/G heterostructure electrodes have the maximum current efficiency and power efficiency, as high as 82.0 cd A(-1) and 98.2 lm W(-1), respectively, which are 36.7% (14.8%) and 59.2% (15.0%) higher than those with pristine graphene (ITO) anodes. These findings open up the possibility of using graphene for next generation high-performance flexible and wearable optoelectronics with high stability.

Comparative Effectiveness of Blood Pressure-lowering Drugs in Patients who have Already Suffered From Stroke: Traditional and Bayesian Network Meta-analysis of Randomized Trials

Hypertension is the most important risk factor for stroke and stroke recurrence. However, the preferred blood pressure (BP)-lowering drug class for patients who have suffered from a stroke has yet to be determined. To investigate the relative effects of BP-lowering therapies [angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blockers (ARB), β blockers, calcium channel blockers (CCBs), diuretics, and combinations of these drugs] in patients with a prior stroke history, we performed a systematic review and meta-analysis using both traditional frequentist and Bayesian random-effects models and meta-regression of randomized controlled trials (RCTs) on the outcomes of recurrent stroke, coronary heart disease (CHD), and any major adverse cardiac and cerebrovascular events (MACCE). Trials were identified from searches of published hypertension guidelines, electronic databases, and previous systematic reviews. Fifteen RCTs composed of 39,329 participants with previous stroke were identified. Compared with the placebo, only ACEI along with diuretics significantly reduced recurrent stroke events [odds ratio (OR) = 0.54, 95% credibility interval (95% CI) 0.33-0.90]. On the basis of the distribution of posterior probabilities, the treatment ranking consistently identified ACEI along with diuretics as the preferred BP-lowering strategy for the reduction of recurrent stroke and CHD (31% and 35%, respectively). For preventing MACCE, diuretics appeared to be the preferred agent for stroke survivors (34%). Moreover, the meta-regression analysis failed to demonstrate a statistical significance between BP reduction and all outcomes (P = 0.1618 for total stroke, 0.4933 for CHD, and 0.2411 for MACCE). Evidence from RCTs supports the use of diuretics-based treatment, especially when combined with ACEI, for the secondary prevention of recurrent stroke and any vascular events in patients who have suffered from stroke.

Hyponatremia and Worsening Sodium Levels Are Associated With Long-Term Outcome in Patients Hospitalized for Acute Heart Failure

Background

Hyponatremia predicts poor prognosis in patients with acute heart failure (AHF). However, the association of the severity of hyponatremia and changes of serum sodium levels with long‐term outcome has not been delineated.

Methods and Results

The study population was drawn from the HARVEST registry (Heart Failure Registry of Taipei Veterans General Hospital), so that patients hospitalized for acute heart failure (AHF) composed this study. The National Death Registry was linked to identify the clinical outcomes of all‐cause mortality and cardiovascular death, with a follow‐up duration of up to 4 years. Among a total of 2556 patients (76.4 years of age, 67% men), 360 had on‐admission hyponatremia, defined as a serum sodium level of <135 mEq/L on the first day of hospitalization. On‐admission hyponatremia was a predictor for all‐cause mortality (hazard ratio and 95% CI: 1.43, 1.11–1.83) and cardiovascular mortality (1.50, 1.04–2.17), independent of age, sex, hematocrit, estimated glomerular filtration rate, left ventricular ejection fraction, and prescribed medications. Subjects with severe hyponatremia (<125 mEq/L) would even have worse clinical outcomes. During hospitalization, a drop of sodium levels of >3 mEq/L was associated with a marked increase of mortality than those with minimal or no drop of sodium levels. In addition, subjects with on‐admission hyponatremia and drops of serum sodium levels during hospitalization had an incremental risk of death (2.26, 1.36–3.74), relative to those with normonatremia at admission and no treatment‐related drop of serum sodium level in the fully adjusted model.

Conclusions

On‐admission hyponatremia is an independent predictor for long‐term outcomes in patients hospitalized for AHF. Combined the on‐admission hyponatremia with drops of serum sodium levels during hospitalization may make a better risk assessment in AHF patients.

Heart Rate Variability Is Associated with Exercise Capacity in Patients with Cardiac Syndrome X

Heart rate variability (HRV) reflects the healthiness of autonomic nervous system, which is associated with exercise capacity. We therefore investigated whether HRV could predict the exercise capacity in the adults with cardiac syndrome X (CSX). A total of 238 subjects (57±12 years, 67.8% men), who were diagnosed as CSX by the positive exercise stress test and nearly normal coronary angiogram were enrolled. Power spectrum from the 24-hour recording of heart rate was analyzed in frequency domain using total power (TP) and spectral components of the very low frequency (VLF), low frequency (LF) and high frequency (HF) ranges. Among the study population, 129 subjects with impaired exercise capacity during the treadmill test had significantly lower HRV indices than those with preserved exercise capacity (≥90% of the age predicted maximal heart rate). After accounting for age, sex, and baseline SBP and heart rate, VLF (odds ratio per 1SD and 95% CI: 2.02, 1.19–3.42), LF (1.67, 1.10–2.55), and TP (1.82, 1.17–2.83) remained significantly associated with preserved exercise capacity. In addition, increased HRV indices were also associated with increased exercise duration, rate-pressure product, and heart rate recovery, independent of age, body mass index, and baseline SBP and heart rate. In subgroup analysis, HRV indices demonstrated similar predictive values related to exercise capacity across various subpopulations, especially in the young. In patients with CSX, HRV was independently associated with exercise capacity, especially in young subjects. The healthiness of autonomic nervous system may have a role in modulating the exercise capacity in patients with CSX.

Additive Value of Heart Rate Variability in Predicting Obstructive Coronary Artery Disease Beyond Framingham Risk

BACKGROUND

Heart rate variability (HRV) is usually reduced in patients with CAD. We therefore investigated whether reduced HRV is predictive of angiographic CAD beyond Framingham risk in patients with stable angina.

METHODS AND RESULTS

A total of 514 patients (age, 66.1 ± 14.3 years, 358 men) were enrolled. Holter ECG was performed before catheterization, and 24-h HRV was analyzed in both the frequency domain (VLF, LF, HF and total power) and the time domain (SDNN, SDANN, RMSSD and pNN20). Angiographic CAD was defined as ≥ 50% diameter reduction of 1 or more coronary arteries. On coronary angiography 203 patients (39.6%) had angiographic CAD. Patients with CAD had significantly higher Framingham risk and lower HRV according to both frequency and time domain parameters. After controlling for age, gender, heart rate, SBP, renal function, lipids and Framingham risk, reduced HRV indices remained predictors of CAD (OR, 95% CI for LF, HF, SDNN, RMSSD and pNN20: 0.81, 0.66-0.99; 0.77, 0.63-0.94; 0.75, 0.59-0.96; 0.72, 0.58-0.88; and 0.76, 0.62-0.94, respectively). On subgroup analysis, HRV parameters appeared to be predictive of CAD only in subjects with high Framingham risk or diabetes.

CONCLUSIONS

Reduced HRV is predictive of CAD in patients with stable angina, independent of traditional risk factors and Framingham risk. The predictive value of HRV may be relevant only in subjects with high Framingham risk or diabetes.

Determinants and Prognostic Impact of Hyperuricemia in Hospitalization for Acute Heart Failure

BACKGROUND

Hyperuricemia is a prognostic factor in patients with chronic heart failure, but whether uric acid level can predict clinical outcome of acute heart failure (AHF) remains to be elucidated. We therefore investigated the association of uric acid with mortality in patients hospitalized for AHF.

METHODS AND RESULTS

Data for patients hospitalized for AHF were drawn from an intramural registry. Biochemistry data, echocardiographic characteristics, and uric acid level were collected. National Death Registry was linked for the identification of mortality data. Among a total of 1,835 participants (age, 75 ± 13 years, 68% men), 794 patients died during follow-up. Patients who died were older, had lower hemoglobin and estimated glomerular filtration rate, and higher pulmonary artery systolic pressure, NT-proBNP, and uric acid. Uric acid was a significant predictor of mortality on univariate analysis (HR per 1 SD, 1.18; 95% CI: 1.11-1.26) and in multivariate Cox models (HR, 1.15; 95% CI: 1.02-1.29). Survival analysis showed an increasing risk of death along the quartile distribution of uric acid level. Given renal function, cardiac performance, and kidney perfusion as major determinants of hyperuricemia, the prognostic impact of uric acid level was diminished as renal function deteriorated.

CONCLUSIONS

Uric acid level was an independent predictor of mortality in patients hospitalized for AHF, but the prognostic impact of hyperuricemia was attenuated by worsening renal function.

Systematic review of optical coherence tomography usage in the diagnosis and management of basal cell carcinoma

Optical coherence tomography (OCT) is a noninvasive imaging tool used in vivo in real time for diagnosis, treatment delineation and monitoring of basal cell carcinoma (BCC). Features of BCC on OCT have been widely described and reviewed. However, the diagnostic accuracy of OCT in these various applications is unclear. We systematically reviewed the literature to assess the accuracy of OCT in diagnosis and management of BCC using the Embase and Medline databases. In total 179 unique references were identified in the initial search, of which 22 studies with 556 histologically proven BCCs were eligible. Assessment of the quality of eligible studies was undertaken using the STROBE criteria. Data extraction and quality assessment were performed independently by the two authors. This systematic review provides an overview of the clinical applications of OCT in the diagnosis and management of BCC. OCT has been suggested to be useful in the diagnosis, treatment planning and treatment monitoring of BCC. As the technology improves and its utility increases, further studies with good methodological quality will be needed to implement OCT into daily practice.

Patient-Specific Oscillometric Blood Pressure Measurement

OBJECTIVE

Most automatic cuff blood pressure (BP) measurement devices are based on oscillometry. These devices estimate BP from the envelopes of the cuff pressure oscillations using fixed ratios. The values of the fixed ratios represent population averages, so the devices may only be accurate in subjects with normal BP levels. The objective was to develop and demonstrate the validity of a patient-specific oscillometric BP measurement method.

METHODS

The idea of the developed method was to represent the cuff pressure oscillation envelopes with a physiologic model, and then estimate the patient-specific parameters of the model, which includes BP levels, by optimally fitting it to the envelopes. The method was investigated against gold standard reference BP measurements from 57 patients with widely varying pulse pressures. A portion of the data was used to optimize the patient-specific method and a fixed-ratio method, while the remaining data were used to test these methods and a current office device.

RESULTS

The patient-specific method yielded BP root-mean-square-errors ranging from 6.0 to 9.3 mmHg. On an average, these errors were nearly 40% lower than the errors of each existing method.

CONCLUSION

The patient-specific method may improve automatic cuff BP measurement accuracy.

SIGNIFICANCE

A patient-specific oscillometric BP measurement method was proposed and shown to be more accurate than the conventional method and a current device.

Night-time electromechanical activation time, pulsatile hemodynamics, and discharge outcomes in patients with acute heart failure

Aims

Both electromechanical activation time (EMAT) and pulsatile hemodynamics measured during the hospitalization course are useful in the prediction of cardiovascular outcomes in patients with acute heart failure syndrome (AHFS). We investigated whether night‐time monitoring of EMAT with the ambulatory acoustic cardiography is superior to the measures of pulsatile hemodynamics for prediction of AHFS post‐discharge outcomes.

Methods and results

A total of 97 patients (71.1 ± 15.4 years old, 81% male, and 73.8% systolic heart failure) hospitalized for AHFS were included. Before discharge, 24 h ambulatory acoustic cardiography and a comprehensive echocardiographic and pulsatile hemodynamic study were performed to assess the mean 24 h, daytime, and night‐time EMAT, carotid systolic blood pressure (SBP) and pulse pressure (PP), amplitude of the reflected pressure wave from a decomposed carotid pressure wave (Pb), and carotid–femoral pulse wave velocity (cfPWV), in addition to measurement of N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) levels. During a mean follow‐up of 389 ± 281 days, 49 patients (50.5%) experienced events including re‐hospitalization for heart failure, myocardial infarction, stroke, or death. Pulsatile hemodynamics, including carotid SBP and PP and Pb, but not cfPWV, and night‐time EMAT, but not daytime EMAT, significantly predicted post‐discharge events when age and NT‐proBNP were accounted for (all P < 0.05). In a final model with adjustment for age and NT‐proBNP, night‐time EMAT, but not Pb, significantly predicted post‐discharge events [hazard ratio per 1 SD and 95% confidence intervals: 1.33 (1.05–1.69), P < 0.05].

Conclusion

Pre‐discharge night‐time EMAT may be a better predictor for post‐discharge adverse events than the measures of the pulsatile hemodynamics in patients with AHFS.

Prognostic Significance of Premature Atrial Complexes Burden in Prediction of Long-Term Outcome

Background

The prognostic significance of premature atrial complex (PAC) burden is not fully elucidated. We aimed to investigate the relationship between the burden of PACs and long-term outcome.

Methods and Results

We investigated the clinical characteristics of 5371 consecutive patients without atrial fibrillation (AF) or a permanent pacemaker (PPM) at baseline who underwent 24-hour electrocardiography monitoring between January 1, 2002, and December 31, 2004. Clinical event data were retrieved from the Bureau of National Health Insurance of Taiwan. During a mean follow-up duration of 10±1 years, there were 1209 deaths, 1166 cardiovascular-related hospitalizations, 3104 hospitalizations for any reason, 418 cases of new-onset AF, and 132 PPM implantations. The optimal cut-off of PAC burden for predicting mortality was 76 beats per day, with a sensitivity of 63.1% and a specificity of 63.5%. In multivariate analysis, a PAC burden >76 beats per day was an independent predictor of mortality (hazard ratio: 1.384, 95% CI: 1.230 to 1.558), cardiovascular hospitalization (hazard ratio: 1.284, 95% CI: 1.137 to 1.451), new-onset AF (hazard ratio: 1.757, 95% CI: 1.427 to 2.163), and PPM implantation (hazard ratio: 2.821, 95% CI: 1.898 to 4.192). Patients with frequent PAC had increased risk of mortality attributable to myocardial infarction, heart failure, and sudden cardiac death. Frequent PACs increased risk of PPM implantation owing to sick sinus syndrome, high-degree atrioventricular block, and/or AF.

Conclusions

The burden of PACs is independently associated with mortality, cardiovascular hospitalization, new-onset AF, and PPM implantation in the long term.

Cost-effectiveness of noninvasive central blood pressure monitoring in the diagnosis of hypertension

BACKGROUND

Central blood pressure (CBP) betters conventional clinical BP (cuff BP) in predicting cardiovascular outcomes. Noninvasive CBP monitoring has emerged as a new technology for management of hypertension. This study aimed to analyze the cost-effectiveness of noninvasive CBP compared to cuff BP monitoring for confirming a diagnosis of hypertension.

METHODS

Lifetime costs and quality-adjusted life years (QALYs) were estimated for CBP and cuff BP monitoring using a cohort Markov model. We applied model calibration and probabilistic sensitivity analysis on populations representative of the general population, in 10-year age brackets, from age 35 years to over 75 years of age.

RESULTS

The CBP strategy was more cost-effective than cuff BP for men and women across all age subgroups, with mean incremental cost-effectiveness ratios ranging from £226 to £2,750 per QALY gained. The cost-effectiveness was mainly driven by improved patient outcomes, represented by the QALY gains (0.09-0.88), at an acceptable incremental cost (£116-£371). Deterministic and probabilistic sensitivity analyses demonstrated the consistency and robustness of the cost-effectiveness of the CBP strategy.

CONCLUSIONS

Early evidence on the diagnostic accuracy of noninvasive CBP monitoring suggests significant improvements in the confirmation of suspected hypertension, compared to cuff BP. This paper suggests that the long-term benefits of improved diagnostic performance justify the supplementary purchase costs of new, noninvasive CBP monitors. The results highlight the potential value of CBP, and hence the value of further research to confirm the diagnostic and prognostic role of CBP for the management of hypertension.

The Novelty of the 2015 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension

The prevalence rate of hypertension in Asian countries grows faster than in other parts of the world, where stroke exceeds coronary heart disease in causing morbidities and mortalities. The optimal management of hypertension is therefore an especially important task in Asia. In a transparent and rigorous guideline development process, the most updated information available on the management of hypertension was summarized in the 2015 Taiwan Society of Cardiology (TSOC)/Taiwan Hypertension Society (TSH) hypertension guideline. In contradiction with the ESH/ESH joint hypertension guidelines and the 2014 Joint National Committee (JNC) report, this updated guideline suggests some different blood pressure (BP) targets. In brief, the BP target is 150/90 mm Hg for very elderly patients (≥ 80 years), 130/80 mm Hg for patients with diabetes, coronary heart disease, proteinuric chronic kidney disease or those receiving antithrombotics for stroke prevention, and 140/90 mm Hg for all the other hypertension patients with or without the aforementioned comorbidities. To facilitate the adherence to the guideline, the following was proposed: mnemonics for lifestyle modifications: S-ABCDE (Sodium restriction, Alcohol limitation, Body weight reduction, Cigarette smoking cessation, Diet adaptation, and Exercise adoption), treatment algorithm: PROCEED (Previous experience, Risk factors, Organ damage, Contraindications or unfavorable conditions, Expert's or doctor's judgment, Expenses or cost, and Delivery and compliance issue), and medication adjustment algorithm: AT GOALs (Adherence, Timing of administration, Greater doses, Other classes of drugs, Alternative combination or single-pill combination, and Lifestyle modification + Laboratory tests). In particular, the effort of translating the concept of central BP into clinical practice may stand out from all other hypertension guidelines. In summary, our guidelines may deliver useful information and guidance to clinicians in managing hypertensive patients, including the approach to a more accurate diagnosis, treatment and adjustment algorithm, and evidence-based recommendations.

2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension

It has been almost 5 years since the publication of the 2010 hypertension guidelines of the Taiwan Society of Cardiology (TSOC). There is new evidence regarding the management of hypertension, including randomized controlled trials, non-randomized trials, post-hoc analyses, subgroup analyses, retrospective studies, cohort studies, and registries. More recently, the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) published joint hypertension guidelines in 2013. The panel members who were appointed to the Eighth Joint National Committee (JNC) also published the 2014 JNC report. Blood pressure (BP) targets have been changed; in particular, such targets have been loosened in high risk patients. The Executive Board members of TSOC and the Taiwan Hypertension Society (THS) aimed to review updated information about the management of hypertension to publish an updated hypertension guideline in Taiwan. We recognized that hypertension is the most important risk factor for global disease burden. Management of hypertension is especially important in Asia where the prevalence rate grows faster than other parts of the world. In most countries in East Asia, stroke surpassed coronary heart disease (CHD) in causing premature death. A diagnostic algorithm was proposed, emphasizing the importance of home BP monitoring and ambulatory BP monitoring for better detection of night time hypertension, early morning hypertension, white-coat hypertension, and masked hypertension. We disagreed with the ESH/ESH joint hypertension guidelines suggestion to loosen BP targets to <140/90 mmHg for all patients. We strongly disagree with the suggestion by the 2014 JNC report to raise the BP target to <150/90 mmHg for patients between 60-80 years of age. For patients with diabetes, CHD, chronic kidney disease who have proteinuria, and those who are receiving antithrombotic therapy for stroke prevention, we propose BP targets of <130/80 mmHg in our guidelines. BP targets are <140/90 mmHg for all other patient groups, except for patients ≥80 years of age in whom a BP target of <150/90 mmHg would be optimal. For the management of hypertension, we proposed a treatment algorithm, starting with life style modification (LSM) including S-ABCDE (Sodium restriction, Alcohol limitation, Body weight reduction, Cigarette smoke cessation, Diet adaptation, and Exercise adoption). We emphasized a low-salt strategy instead of a no-salt strategy, and that excessively aggressive sodium restriction to <2.0 gram/day may be harmful. When drug therapy is considered, a strategy called "PROCEED" was suggested (Previous experience, Risk factors, Organ damage, Contraindications or unfavorable conditions, Expert's or doctor's judgment, Expenses or cost, and Delivery and compliance issue). To predict drug effects in lowering BP, we proposed the "Rule of 10" and "Rule of 5". With a standard dose of any one of the 5 major classes of anti-hypertensive agents, one can anticipate approximately a 10-mmHg decrease in systolic BP (SBP) (Rule of 10) and a 5-mmHg decrease in diastolic BP (DBP) (Rule of 5). When doses of the same drug are doubled, there is only a 2-mmHg incremental decrease in SBP and a 1-mmHg incremental decrease in DBP. Preferably, when 2 drugs with different mechanisms are to be taken together, the decrease in BP is the sum of the decrease of the individual agents (approximately 20 mmHg in SBP and 10 mmHg in DBP). Early combination therapy, especially single-pill combination (SPC), is recommended. When patient's initial treatment cannot get BP to targeted goals, we have proposed an adjustment algorithm, "AT GOALs" (Adherence, Timing of administration, Greater doses, Other classes of drugs, Alternative combination or SPC, and LSM + Laboratory tests). Treatment of hypertension in special conditions, including treatment of resistant hypertension, hypertension in women, and perioperative management of hypertension, were also mentioned. The TSOC/THS hypertension guidelines provide the most updated information available in the management of hypertension. The guidelines are not mandatory, and members of the task force fully realize that treatment of hypertension should be individualized to address each patient's circumstances. Ultimately, the decision of the physician decision remains of the utmost importance in hypertension management.

Wave reflections, arterial stiffness, and orthostatic hypotension

BACKGROUND

The effect of wave reflections on blood pressure change associated with posture remains unclear. We therefore applied a wave separation technique to investigate the relations of the backward pressure wave amplitude with orthostatic pressure changes and orthostatic hypotension (OH).

METHODS

We analyzed data from 613 subjects who had participated in our hemodynamic studies. Measurements of brachial systolic (SBP) and diastolic blood pressures (DBP), carotid-femoral pulse wave velocity (cf-PWV), and backward pressure wave amplitude from a decomposed carotid pressure wave (Pb) were obtained at supine position. SBP and DBP were measured again 3 minutes after standing. OH was defined as a fall of ≥20 mm Hg in SBP and/or ≥10 mm Hg in DBP.

RESULTS

Subjects with OH (n = 100) were characterized with significantly higher supine SBP and DBP and significantly lower standing SBP and DBP when compared with subjects without OH. Subjects with OH were also characterized with significantly higher cf-PWV and Pb. cf-PWV and Pb separately were significantly associated with the orthostatic SBP change in univariable and multivariable analyses. Also, cf-PWV and Pb separately were significant predictors of OH in univariable and multivariable analyses. cf-PWV predicted OH in the younger but less so in the older subgroup, whereas Pb demonstrated similar prediction in both subgroups. In a final multivariable model, both cf-PWV and Pb were significant independent predictors of OH.

CONCLUSIONS

Wave reflections are an independent determinant of orthostatic SBP change and OH in both younger and older subjects.

Synergistic effect of gestational hypertension and postpartum incident hypertension on cardiovascular health: a nationwide population study

BACKGROUND

Gestational hypertension (GH) is a common complication of pregnancy and is associated with increased risk of incident hypertension in later life (IH) and cardiovascular events. However, the interactive effect of GH and IH on postpartum cardiovascular health remains unclear.

METHODS AND RESULTS

A nationwide population-based study was conducted using 1 million individuals from the Taiwan National Health Insurance database. Records from 1998 to 2009 were used to identify 1260 pregnant women with GH and without previous cardiovascular disease. The control group comprised 5040 pregnant women without GH, matched for age and date of delivery. During the follow-up period (median duration, 5.8 years), 182 cardiovascular events developed. Women with GH had significantly higher risk of cardiovascular events (hazard ratio [95% CI], 2.44 [1.80 to 3.31]) and IH (8.29 [6.30 to 10.91]) than controls. Compared with women without GH and IH, there was a significantly higher risk of cardiovascular events for women without GH but with IH (relative risk [95% CI], 2.89 [1.27-6.58]), women with GH but without IH (1.66 [1.16-2.39]), and women with GH and IH (8.11 [5.36-12.30]). The synergy index was 2.91 (95% CI 1.11 to 7.59), suggesting a positive interaction between GH and IH.

CONCLUSIONS

GH increased the risk of subsequent IH. Women with both GH and IH were at a substantially higher cardiovascular risk than were women with either GH or IH. The synergistic adverse effect of GH and IH on postpartum cardiovascular health indicates that more attention should be paid to this special population.

Grommets for otitis media with effusion in children with cleft palate: a systematic review

BACKGROUND AND OBJECTIVE

No consensus has yet been reached with regard to the link between otitis media with effusion (OME), hearing loss, and language development in children with cleft palate. The objective of this study was to address the effectiveness of ventilation tube insertion (VTI) for OME in children with cleft palate.

METHODS

A dual review process was used to assess eligible studies drawn from PubMed, Medline via Ovid, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, and reference lists between 1948 and November 2013. Potentially relevant papers were selected according to the full text of the articles. Relevant data were extracted onto a data extraction sheet.

RESULTS

Nine high- or moderate-quality cohort studies were included in this study. VTI was administered in 38% to 53% of the OME cases, and more severe cases appeared more likely to undergo VTI. Compared with conservative forms of management (eg, watchful waiting), VTI has been shown to be beneficial to the recovery of hearing in children with cleft palate and OME. A growing body of evidence demonstrates the benefits of VTI in the development of speech and language in children with cleft palate and OME. These children face a higher risk of complications than those undergoing conservative treatments, the most common of which are eardrum retraction and tympanosclerosis, with an incidence of ∼ 11% to 37%.

CONCLUSIONS

This review provides evidence-based information related to the selection of treatment for OME in children with cleft palate. Additional randomized controlled trials are required to obtain bias-resistant evidence capable of reliably guiding treatment decisions. The conclusions in this review are based on underpowered cohort studies and very-low-strength evidence.

Common Carotid Artery Stiffness Is Associated with Left Ventricular Structure and Function and Predicts First Hospitalization for Acute Heart Failure

AIMS

Proximal aortic stiffness may be more important than carotid-femoral pulse wave velocity (cf-PWV) in the pathogenesis of heart failure. The present study investigated the associations of common carotid artery (CCA) stiffness, which might be a surrogate for proximal aortic stiffness, with left ventricular (LV) structure and function, and the development of acute heart failure (AHF).

METHODS AND RESULTS

Outpatients without a history of heart failure (114 subjects aged 63.5 ± 17.5 years) were enrolled for comprehensive noninvasive cardiovascular examinations. The LV mass index, the LV ejection fraction (EF), and the ratio of the early diastolic transmitral flow velocity to the early septal mitral annular diastolic velocity (E/E') were measured by echocardiography. CCA mechanical properties, including the incremental elastic modulus (Einc), β stiffness index, CCA distensibility (CD) and circumferential strain (CS), were assessed by carotid artery ultrasonography. cf-PWV was measured by arterial tonometry. CD was significantly associated with the LV mass index, and all CCA stiffness indices were significantly associated with EF and E/E' independently of age, mean blood pressure, and cf-PWV. During a mean follow-up of 265 ± 106 days, 9 patients presented with AHF. Einc (hazard ratio 6.56, 95% confidence interval 1.64-26.26, by quartile analysis), CS (6.82, 1.70-27.35), and β stiffness index (3.91, 1.05-14.57) but not cf-PWV (1.62, 0.41-6.51) significantly predicted the events.

CONCLUSIONS

In patients at risk for heart failure, CCA stiffness was significantly associated with LV structure and function independently of cf-PWV. In addition, CCA stiffness but not cf-PWV predicted first AHF.

Application of the N-Point Moving Average Method for Brachial Pressure Waveform–Derived Estimation of Central Aortic Systolic Pressure

The N-point moving average (NPMA) is a mathematical low-pass filter that can smooth peaked noninvasively acquired radial pressure waveforms to estimate central aortic systolic pressure using a common denominator of N/4 (where N=the acquisition sampling frequency). The present study investigated whether the NPMA method can be applied to brachial pressure waveforms. In the derivation group, simultaneously recorded invasive high-fidelity brachial and central aortic pressure waveforms from 40 subjects were analyzed to identify the best common denominator. In the validation group, the NPMA method with the obtained common denominator was applied on noninvasive brachial pressure waveforms of 100 subjects. Validity was tested by comparing the noninvasive with the simultaneously recorded invasive central aortic systolic pressure. Noninvasive brachial pressure waveforms were calibrated to the cuff systolic and diastolic blood pressures. In the derivation study, an optimal denominator of N/6 was identified for NPMA to derive central aortic systolic pressure. The mean difference between the invasively/noninvasively estimated (N/6) and invasively measured central aortic systolic pressure was 0.1±3.5 and −0.6±7.6 mm Hg in the derivation and validation study, respectively. It satisfied the Association for the Advancement of Medical Instrumentation standard of 5±8 mm Hg. In conclusion, this method for estimating central aortic systolic pressure using either invasive or noninvasive brachial pressure waves requires a common denominator of N/6. By integrating the NPMA method into the ordinary oscillometric blood pressure determining process, convenient noninvasive central aortic systolic pressure values could be obtained with acceptable accuracy.

Diagnostic performance of a stand-alone central blood pressure monitor: application of central blood pressure in the diagnosis of high blood pressure

BACKGROUND

Oscillometric central blood pressure (CBP) monitors have emerged as a new technology for blood pressure (BP) measurements. With a newly proposed diagnostic threshold for CBP, we investigated the diagnostic performance of a novel CBP monitor.

METHODS

We recruited a consecutive series of 138 subjects (aged 30-93 years) without previous use of antihypertensive agents for simultaneous invasive and noninvasive measurements of BP in a catheterization laboratory. With the cutoff (CBP ≥130/90 mm Hg) for high blood pressure (HBP), the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the novel CBP monitor were calculated with reference to the measured CBP. In comparison, the diagnostic performance of the conventional cuff BP was also evaluated.

RESULTS

The noninvasive CBP for detecting HBP in a sample with a prevalence of 52% showed a sensitivity of 93% (95% confidence interval (CI) = 91-95), specificity of 95% (95% CI = 94-97), PPV of 96% (95% CI = 94-97), and NPV of 93% (95% CI = 90-95). In contrast, with cuff BP and the traditional HBP criterion (cuff BP ≥140/90 mm Hg), the sensitivity, specificity, PPV, and NPV were 49% (95% CI = 44-53), 94% (95% CI = 92-96), 90% (95% CI = 86-93), and 63% (95% CI 59-66), respectively.

CONCLUSIONS

A stand-alone oscillometric CBP monitor may provide CBP values with acceptable diagnostic accuracy. However, with reference to invasively measured CBP, cuff BP had low sensitivity and NPV, which could render possible management inaccessible to a considerable proportion of HBP patients, who may be identifiable through noninvasive CBP measurements from the CBP monitor.