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Habas E, Akbar RA, Alfitori G, Farfar KL, Habas E, Errayes N, Habas A, Al Adab A, Rayani A, Geryo N, Elzouki ANY. Effects of Nondipping Blood Pressure Changes: A Nephrologist Prospect. Cureus 2023; 15:e42681. [PMID: 37649932 PMCID: PMC10464654 DOI: 10.7759/cureus.42681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/01/2023] Open
Abstract
Blood pressure (BP) variations depend on various internal, environmental, and behavioral factors. BP fluctuations occur both in normotensive and hypertensive people. Although it fluctuates over the 24-hr day and night, the morning BP increases after waking up and declines throughout sleep. It is typical for BP to decrease by 10% to 20%, while sleeping, known as dipping BP. However, if there is no decrease in nighttime mean systolic BP or a drop of less than 10 mmHg, it is called nondipping BP. Conversely, reverse dipping BP means an increase in mean systolic BP instead of a drop during the night. Reverse dipping is observed in hypertension (HTN), diabetes mellitus (DM), chronic kidney disease (CKD), and obstructive sleep apnea (OSA) syndrome. The introduction of ambulatory BP monitoring (ABPM) led to the emergence of identifying normal and elevated BP patterns. Non-dipping BP increases the risk of cardiovascular system (CVS) complications such as left ventricular hypertrophy, proteinuria, glomerular filtration rate (GFR) reduction, and CKD progression. A loss or blunting of the normal BP profile is recognized as a deleterious variant, and restoring abnormal BP patterns has been reported to significantly impact end-organ damage, morbidity, and mortality. In this non-systematic clinically-oriented, comprehensive review, we aim to update the BP variables and the pathophysiology of nondipping BP and point out the areas which need more investigation from a nephrology perspective because the nondipping BP increases the risk of proteinuria, GFR reduction, and CKD progression. A literature search of PubMed, Google, EMBASE, and Google Scholar was conducted. Checks of selected papers and relevant reviews complemented the electronic search. With improved BP measurement methods, the physiology of BP profile variations is readily detectable during the day and night. A nondipping BP profile is a distinct BP pattern that may have significant end-organ damage effects and therapeutic importance for nephrologists. The pathophysiology of the nondipping BP variant must be clarified to prevent complications, and further investigations are required. Furthermore, there is debate about the best BP index to utilize: systolic BP, diastolic BP, mean arterial pressure, or a mixture of all. All these areas are important and need new research projects.
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Affiliation(s)
| | - Raza A Akbar
- Internal Medicine, Hamad General Hospital, Doha, QAT
| | | | | | - Eshrak Habas
- Internal Medicine, Tripoli University, Tripoli, LBY
| | - Nada Errayes
- Medical Education, University of Lincoln, Lincoln, GBR
| | - Aml Habas
- Renal and Dialysis, Tripoli Pediatric Hospital, Tripoli, LBY
| | - Aisha Al Adab
- Pulmonary Medicine, Hamad General Hospital, Doha, QAT
| | - Amnna Rayani
- Hemato-Oncology, Tripoli Pediatric Hospital, Tripoli University, Tripoli, LBY
| | - Nagat Geryo
- Internal Medicine, Hamad General Hospital, Doha, QAT
| | - Abdel-Naser Y Elzouki
- Medicine, Hamad General Hospital, Doha, QAT
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
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Kartaler F, Şahin M, Turan OE, Kutlu M. The Relationship Between the Dipping Pattern and Coronary Artery Disease Severity Assessed by the SYNTAX Score in Patients With Hypertension. Cureus 2023; 15:e36057. [PMID: 37065383 PMCID: PMC10096864 DOI: 10.7759/cureus.36057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 03/14/2023] Open
Abstract
Background The morbidity and mortality rates related to hypertension (HT) are still high despite the developments in this area. Nondipper hypertension (NDHT) is related to worse clinical outcomes. But the dipping pattern of HT is not still used for treatment targets. In this study, we investigated the effect of dipping patterns on coronary artery disease (CAD) complexity evaluated by the SYNTAX score (SS). Methodology Patients with stable CAD and HT were included in the study. All patients were monitored with 24-hour ambulatory monitoring, and dipping patterns were evaluated. Coronary artery complexity was determined by SS for all patients and compared along with different dipping patterns. Results A total of 331 patients with HT and stable CAD were evaluated in the study. The mean age of the patients was 62.6 ± 9.9 years, and 172 (52%) were male. The number and percentage of patients with dipper HT (DHT), NDHT, over-dipper HT (ODHT), and reverse-dipper HT (RDHT) were 89 (26%), 143 (43%), 11 (3%), and 88 (26%), respectively. When the groups were compared according to SS, the SS of the patients with RDHT were significantly higher (the SS were 6.33, 4.99, 3.09, and 2.7 for RDHT, ODHT, NDHT, and DHT, respectively, P = 0.003). The mean SS between the DHT group and the NDHT group (P = 0.03) and between the DHT group and the RDHT group (P = 0.01) was significantly different. The less decrease or increase in mean blood pressure (MnBP) values was significantly correlated with high SS. Conclusions NDHT, especially the reverse dipping pattern, is closely related to complex CAD. Meticulous consideration of dipping patterns can identify high-risk patients and improve clinical outcomes.
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Affiliation(s)
| | - Mürsel Şahin
- Cardiology, Medical School, Karadeniz Technical University, Trabzon, TUR
| | - Oğuzhan E Turan
- Cardiology, Medical School, Dokuz Eylül University, İzmir, TUR
| | - Merih Kutlu
- Cardiology, Medical School, Karadeniz Technical University, Trabzon, TUR
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Huang PH, Huang CC, Lin SJ, Chen JW. Prediction of atrial fibrillation in patients with hypertension: A comprehensive comparison of office and ambulatory blood pressure measurements. J Clin Hypertens (Greenwich) 2022; 24:838-847. [PMID: 35695288 PMCID: PMC9278568 DOI: 10.1111/jch.14524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/21/2022] [Accepted: 05/01/2022] [Indexed: 11/29/2022]
Abstract
Hypertension is associated with the development of atrial fibrillation (AF). Evidence has shown that reverse dipping pattern, an abnormal increase of night-time blood pressure (BP) comparing to daytime BP, is associated with cardiovascular events. However, the relationship between diurnal changes in BP and AF has not been sufficiently explored. This paper aims to cross-sectionally explore the relationship between AF and ambulatory BP parameters, especially reverse dippers to the others, and further longitudinally analyze how BP patterns are associated to the risk of developing new-onset AF. Between February 2012 and March 2021, five out of 412 patients were identified of AF at baseline; four were reverse dippers (3.7%) and one was from the others (.3%). Cross-sectionally, the multivariate logistic regression analysis showed that reverse dippers were significantly more likely to have AF (odds ratio: 12.39, p = .030). After excluding patients with baseline AF, during the mean follow-up of 4.6 ± 3.0 years, seven patients developed AF. Longitudinally, the multivariate Cox regression analysis revealed that 24-h systolic BP (hazard ratio per 10 mmHg: 2.12, p = .015), night-time systolic BP (hazard ratio per 10 mmHg: 2.27, p = .002), and presentation of reverse dipping (hazard ratio: 5.25, p = .042) were independently associated with new-onset AF. None of the office BP measurements were associated with new-onset AF. While ambulatory BP measurements were better predictors for the incidence of AF, careful management is necessary for reverse dippers as they are at high risk of developing AF.
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Affiliation(s)
- Pin-Hsiang Huang
- Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Office of Medical Education, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Chin-Chou Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Pharmacology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shing-Jong Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Jaw-Wen Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Pharmacology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
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4
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Sun Q, Pan Y, Zhao Y, Liu Y, Jiang Y. Association of Nighttime Systolic Blood Pressure With Left Atrial-Left Ventricular–Arterial Coupling in Hypertension. Front Cardiovasc Med 2022; 9:814756. [PMID: 35282370 PMCID: PMC8907528 DOI: 10.3389/fcvm.2022.814756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Hypertension (HT) induces left atrial (LA) and left ventricular (LV) dysfunction, and an increase in arterial stiffness. In this study, we investigated the association between LA-LV–arterial coupling and nighttime systolic blood pressure (BP) as well as BP circadian rhythm in essential hypertension. Methods We enrolled 290 HT patients. All subjects were evaluated by 2- dimensional speckle tracking echocardiography (2DSTE), ambulatory 24 h BP monitoring (ABPM), and brachial–ankle pulse wave velocity (PWV). According to BP patterns, these patients were divided into two groups, which included dippers (n = 111), patients with a >10% reduction in BP at nighttime; non-dippers (n = 179), patients with a <10% reduction in BP at nighttime. 2D-STE based LA and LV strains were studied and the following parameters were measured, LV global longitudinal strain (GLS), LA reservoir strain (LAS−S), LA conduit strain (LAS−E), and LA booster pump strain (LAS−A). LA stiffness index (LASI) defined as the ratio of E/e′ to LAS−S, and PWV-to-GLS ratio (PWV/GLS) were calculated to reflect LA-LV–arterial coupling. Furthermore, we also explored the correlation between LASI (or PWV/GLS) and ambulatory blood pressure indexes. Results Left atrial stiffness index was significantly higher in non-dippers [0.29 (0.21, 0.41)] than in dippers [0.26 (0.21, 0.33)] (P < 0.05). PWV/GLS was significantly higher in non-dippers [−80.9 (−69.3, −101.5)] than in dippers [−74.2 (−60.2, −90.6)] (P < 0.05). LAS−S, LAS−E, LAS−A,and LV GLS were significantly lower in non-dippers than in dippers (P < 0.05). Multivariate linear regression analysis revealed that nighttime systolic BP was independently correlated with LASI and PWV/GLS, even adjusted for multiple clinical risk factors, LVMI, and LVEF. Conclusions The dipping pattern of BP was related to the abnormalities of myocardial mechanics and LA-LV–arterial coupling. However, absolute nocturnal systolic BP value maybe more important than BP circadian profile in the progression of abnormal LA-LV–arterial coupling.
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Affiliation(s)
- Qiaobing Sun
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yu Pan
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yixiao Zhao
- Department of Geriatric Cerebrovasology, Baoji Central Hospital, Baoji, China
| | - Yan Liu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- *Correspondence: Yan Liu
| | - Yinong Jiang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Yinong Jiang
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5
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Abstract
OBJECTIVE We examined the associations among the circadian rhythms of blood pressure (BP), heart rate (HR) and left atrial function in essential hypertensive patients. METHODS The study included 237 essential hypertensive patients who completed 24-h ambulatory BP, HR monitoring and two-dimensional speckle tracking echocardiography (2DSTE). The strain and strain rate images were studied, and the following parameters were measured: left atrial reservoir strain and strain rate (LAS-S and LASR-S), left atrial conduit strain and strain rate (LAS-E and LASR-E), and left atrial booster strain and strain rate (LAS-A and LASR-A). The left atrial stiffness index (LASI) was identified as the ratio of E/e' to LAS-S. All participants were divided into three groups according to the percentage of nocturnal BP dipping (dippers, nondippers and reverse dippers). RESULTS The LASI was significantly higher in BP reverse dippers than in dippers and nondippers. LAS-S, LAS-E and LASR-E were significantly lower in BP reverse dippers than dippers and nondippers. Multivariate logistic regression analysis demonstrated that age, night-time mean SBP and the percentage of nocturnal HR decline were independently related to an increased LASI. CONCLUSION Impairment of the left atrial reservoir and conduit functions was correlated with abnormal BP and HR circadian rhythms in hypertension. Increased left atrial stiffness was associated with night-time SBP and the percentage of nocturnal HR decline.
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Chen R, Yang J, Liu C, Ke J, Gao X, Yang Y, Shen Y, Yuan F, He C, Cheng R, Lv H, Zhang C, Gu W, Tan H, Zhang J, Huang L. Blood pressure and left ventricular function changes in different ambulatory blood pressure patterns at high altitude. J Clin Hypertens (Greenwich) 2021; 23:1133-1143. [PMID: 33677845 PMCID: PMC8678730 DOI: 10.1111/jch.14235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/18/2021] [Accepted: 02/25/2021] [Indexed: 11/29/2022]
Abstract
Acute high‐altitude (HA) exposure induces physiological responses of the heart and blood pressure (BP). However, few studies have investigated the responses associated with dipper and non‐dipper BP patterns. In this prospective study, 72 patients underwent echocardiography and 24‐h ambulatory BP testing at sea level and HA. Patients were divided into dipper and non‐dipper groups according to BP at sea level. Acute HA exposure elevated 24‐h systolic and diastolic BP and increased BP variability, particularly in the morning. Moreover, acute exposure increased left ventricular torsion, end‐systolic elastance, effective arterial elastance, and untwisting rate, but reduced peak early diastolic velocity/late diastolic velocity and peak early diastolic velocity/early diastolic velocity, implying enhanced left ventricular systolic function but impaired filling. Dippers showed pronounced increases in night‐time BP, while non‐dippers showed significant elevation in day‐time BP, which blunted differences in nocturnal BP fall, and lowest night‐time and evening BP. Dippers had higher global longitudinal strain, torsion, and untwisting rates after acute HA exposure. Variations in night‐time systolic BP correlated with variations in torsion and global longitudinal strain. Our study firstly demonstrates BP and cardiac function variations during acute HA exposure in different BP patterns and BP increases in dippers at night, while non‐dippers showed day‐time increases. Furthermore, enhanced left ventricular torsion and global longitudinal strain are associated with BP changes. Non‐dippers showed poor cardiac compensatory and maladaptive to acute HA exposure. However, the exact mechanisms involved need further illumination.
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Affiliation(s)
- Renzheng Chen
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jie Yang
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Chuan Liu
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jingbin Ke
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xubin Gao
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yuanqi Yang
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yang Shen
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Fangzhengyuan Yuan
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Chunyan He
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ran Cheng
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hailin Lv
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Chen Zhang
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Wenzhu Gu
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hu Tan
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jihang Zhang
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Lan Huang
- Institute of Cardiovascular Diseases of PLA, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, the Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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Ould Setti M, Voutilainen A, Tuomainen TP. Renal hyperfiltration, fatty liver index, and the hazards of all-cause and cardiovascular mortality in Finnish men. Epidemiol Health 2020; 43:e2021001. [PMID: 33445827 PMCID: PMC7952838 DOI: 10.4178/epih.e2021001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Renal hyperfiltration (RHF) and fatty liver are separately associated with adverse health outcomes. In this study, we investigated the mortality hazard of coexisting RHF and fatty liver. METHODS Middle-aged men from the Kuopio Ischaemic Disease Risk Factor Study (n=1,552) were followed up for a median of 29 years. Associations among RHF, fatty liver index (FLI) score, age, body mass index, smoking status, alcohol consumption, and hypertension status were assessed using logistic regression. Cox proportional hazards models were used to determine the hazard ratios (HRs) for all-cause and cardiovascular disease (CVD) mortality with respect to RHF and fatty liver. RESULTS Of the men, 5% had RHF (n=73), whereas a majority had fatty liver (n=848). RHF was associated specifically with smoking, and fatty liver was associated specifically with overweight. The all-cause mortality hazard was highest (HR, 1.96; 95% confidence interval [CI], 1.27 to 3.01) among men with RHF and fatty liver (n=33). Among men with RHF but normal FLI (n=40), the HR of all-cause mortality was 1.67 (95% CI, 1.15 to 2.42). Among men with fatty liver but a normal estimated glomerular filtration rate (n=527), the HR of all-cause mortality was 1.35 (95% CI, 1.09 to 1.66). CVD mortality hazard was associated with RHF, but not fatty liver. We detected no interaction effect between RHF and fatty liver for all-cause (synergy index, 0.74; 95% CI, 0.21 to 2.67) or CVD (synergy index, 0.94; 95% CI, 0.34 to 2.60) mortality. CONCLUSIONS RHF and fatty liver are independently associated with all-cause and CVD mortality
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Affiliation(s)
- Mounir Ould Setti
- Department of Public Health, University of Eastern Finland, Kuopio, Finland
| | - Ari Voutilainen
- Department of Public Health, University of Eastern Finland, Kuopio, Finland
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8
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Overwyk KJ, Quader ZS, Maalouf J, Bates M, Webster J, George MG, Merritt RK, Cogswell ME. Dietary Sodium Intake and Health Indicators: A Systematic Review of Published Literature between January 2015 and December 2019. Adv Nutr 2020; 11:1174-1200. [PMID: 32449929 PMCID: PMC7490163 DOI: 10.1093/advances/nmaa049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 12/29/2022] Open
Abstract
As the science surrounding population sodium reduction evolves, monitoring and evaluating new studies on intake and health can help increase our understanding of the associated benefits and risks. Here we describe a systematic review of recent studies on sodium intake and health, examine the risk of bias (ROB) of selected studies, and provide direction for future research. Seven online databases were searched monthly from January 2015 to December 2019. We selected human studies that met specified population, intervention, comparison, outcome, time, setting/study design (PICOTS) criteria and abstracted attributes related to the study population, design, intervention, exposure, and outcomes, and evaluated ROB for the subset of studies on sodium intake and cardiovascular disease risks or indicators. Of 41,601 abstracts reviewed, 231 studies were identified that met the PICOTS criteria and ROB was assessed for 54 studies. One hundred and fifty-seven (68%) studies were observational and 161 (70%) focused on the general population. Five types of sodium interventions and a variety of urinary and dietary measurement methods were used to establish and quantify sodium intake. Five observational studies used multiple 24-h urine collections to assess sodium intake. Evidence mainly focused on cardiovascular-related indicators (48%) but encompassed an assortment of outcomes. Studies varied in ROB domains and 87% of studies evaluated were missing information on ≥1 domains. Two or more studies on each of 12 outcomes (e.g., cognition) not previously included in systematic reviews and 9 new studies at low ROB suggest the need for ongoing or updated systematic reviews of evidence on sodium intake and health. Summarizing evidence from assessments on sodium and health outcomes was limited by the various methods used to measure sodium intake and outcomes, as well as lack of details related to study design and conduct. In line with research recommendations identified by the National Academies of Science, future research is needed to identify and standardize methods for measuring sodium intake.
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Affiliation(s)
- Katherine J Overwyk
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, GA, USA
- IHRC, Inc. Atlanta, GA, USA
| | - Zerleen S Quader
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, GA, USA
- IHRC, Inc. Atlanta, GA, USA
| | - Joyce Maalouf
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, GA, USA
| | - Marlana Bates
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, GA, USA
| | - Robert K Merritt
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, GA, USA
| | - Mary E Cogswell
- Division for Heart Disease and Stroke Prevention, CDC, Atlanta, GA, USA
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9
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Urinary Sodium-to-Potassium Ratio and Blood Pressure in CKD. Kidney Int Rep 2020; 5:1240-1250. [PMID: 32775823 PMCID: PMC7403539 DOI: 10.1016/j.ekir.2020.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction In the general population, urinary sodium-to-potassium (uNa/K) ratio associates more strongly with high blood pressure (BP) than either urinary sodium or potassium alone. Whether this is also the case among patients with chronic kidney disease (CKD) is unknown. Methods We studied the associations of spot urine sodium-to-creatinine (uNa/Cr), potassium-to-creatinine (uK/Cr), and uNa/K ratios with a single office BP reading in 1660 patients with moderate to severe CKD at inclusion in the CKD-REIN cohort. Results Patients' median age was 68 (interquartile range [IQR], 59-76) years; most were men (65%), had moderate CKD (57%), and albuminuria (72%). Mean systolic and diastolic BP was 142/78 mm Hg. Spot uNa/Cr and uNa/K ratios were positively associated with systolic, mean arterial, and pulse pressures. The mean adjusted difference in systolic BP between the highest and the lowest quartile (Q4 vs. Q1) was 4.24 (95% confidence interval [CI], 1.53-6.96) mm Hg for uNa/Cr and 4.79 (95% CI, 2.18-7.39) mm Hg for uNa/K. Quartiles of spot uK/Cr were not associated with any BP index. The higher the quartile of uNa/K, the higher the prevalence ratio of uncontrolled (Q4 vs. Q1, 1.43; 95% CI, 1.19-1.72) or apparently treatment-resistant hypertension (Q4 vs. Q1, 1.35; 95% CI, 1.14-1.60). Findings were consistent in a subset of 803 individuals with 2 BP readings. Conclusion In patients with CKD, higher urinary sodium excretion is associated with higher BP, but unlike in general population, lower potassium excretion is not. Urinary Na/K does not add significant value in assessing high BP risk, except perhaps for hypertension control assessment.
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10
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Zhang J, Rao J, Liu M, Zhou W, Li Y, Wu J, Peng H, Lou T. Abnormal circadian rhythm of urinary sodium excretion correlates closely with hypertension and target organ damage in Chinese patients with CKD. Int J Med Sci 2020; 17:702-711. [PMID: 32218691 PMCID: PMC7085274 DOI: 10.7150/ijms.42875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/03/2020] [Indexed: 12/18/2022] Open
Abstract
Whether the abnormal circadian rhythm of urinary sodium excretion is associated with hypertension in chronic kidney disease (CKD) is poorly understood. In this study, we assessed the relationship between the circadian rhythm of urinary sodium excretion and hypertension. Urinary samples were collected during both the day (07:00 to 22:00) and night (22:00 to 07:00) to estimate night/day urinary sodium excretion ratios. Blood pressure (BP) and clinical data were also measured. A total of 1,099 Chinese CKD patients were recruited, 308 patients were excluded, and 791 patients were final enrolled in this study. Among them, 291 patients were normotensive and 500 were hypertensive CKD patients. A 1:1 propensity score matching (PSM) analysis was performed with age and estimated glomerular filtration rate (eGFR) matched between 190 normotensive and hypertensive patients. In the full cohort and PSM cohort, multivariate regression analysis showed that the night/day urinary sodium excretion ratio was an independent risk factor for clinical hypertension, whereas 24 h urinary sodium excretion, diurnal and nocturnal urinary sodium excretion were not. When the night/day urinary sodium excretion ratios were further divided into tertiles (tertile 1 < 0.47, tertile 2, 0.47-0.84 and tertile 3 > 0.84), multivariate analysis showed that tertile 3 was independently associated with hypertension in the full and PSM cohorts. In addition, tertile 3 was also independently associated with eGFR ≤ 60 mL/min/1.73 m2 and left ventricular hypertrophy. These data suggested that an abnormal circadian rhythm of urinary sodium excretion was independently associated with hypertension and target-organ damage. Individualized salt intake and therapeutic strategies should be used to normalize the natriuretic dipping profile in CKD patients.
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Affiliation(s)
- Jun Zhang
- Division of Nephrology, Department of medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Jialing Rao
- Division of Nephrology, Department of medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Man Liu
- Division of Gastroenterology and Hepatology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wenying Zhou
- Department of Laboratory medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Yuanqing Li
- Division of Nephrology, Department of medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Jianhao Wu
- Division of Nephrology, Department of medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Hui Peng
- Division of Nephrology, Department of medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Tanqi Lou
- Division of Nephrology, Department of medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
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11
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Kanbay M, Ertuglu LA, Afsar B, Ozdogan E, Kucuksumer ZS, Ortiz A, Covic A, Kuwabara M, Cherney DZI, van Raalte DH, de Zeeuw D. Renal hyperfiltration defined by high estimated glomerular filtration rate: A risk factor for cardiovascular disease and mortality. Diabetes Obes Metab 2019; 21:2368-2383. [PMID: 31297976 DOI: 10.1111/dom.13831] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/30/2019] [Accepted: 07/08/2019] [Indexed: 12/22/2022]
Abstract
Renal hyperfiltration, defined as an increased glomerular filtration rate above normal values, is associated with early phases of kidney disease in the setting of various conditions such as obesity and diabetes. Although it is recognized that glomerular hyperfiltration, that is, increased filtration per nephron unit (usually studied at low glomerular filtration levels and often referred to as single nephron hyperfiltration), is a risk factor for the progression of chronic kidney disease, the implications of having renal hyperfiltration for cardiovascular disease and mortality risk are incompletely understood. Recent evidence from diverse populations, including healthy individuals and patients with diabetes or established cardiovascular disease, suggests that renal hyperfiltration is associated with a higher risk of cardiovascular disease and all-cause mortality. In this review, we critically summarize the existing studies, discuss possible mechanisms, and describe the remaining gaps in our knowledge regarding the association of renal hyperfiltration with cardiovascular disease and mortality risk.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koç University School of Medicine, Istanbul, Turkey
| | - Lale A Ertuglu
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Elif Ozdogan
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Zeynep S Kucuksumer
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Alberto Ortiz
- Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | | | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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12
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Abstract
BACKGROUND White-coat hypertension (WCH) is a debatable risk factor of cardio-cerebrovascular diseases and the current study results on the association between WCH and arterial stiffness are inconsistent. The aim was to investigate the effect of WCH on arterial stiffness using meta-analysis. METHODS Based on prespecified search strategies and inclusion criteria, Medline, Embase, Web Of Science, Cochrane Library, and BioSciences Information Service Preview databases were reviewed. A total of 20 studies involving 1538 WCH patients and 3582 normotensives (NT) were included. Literatures were screened for data extraction and quality assessment. Overall analysis and subgroup analysis were conducted in RevMan version 5.3 and Stata version 14.0 software. RESULTS Overall analysis showed that carotid-femoral pulse wave velocity (cf-PWV) was significantly higher in WCH group than in the NT group (P < .00001, 95% CI: 0.79-3.26). Subgroup analysis showed that in adults, cf-PWV was significantly higher in the WCH patients than in the NT subjects (P<.001, 95% CI: 0.46-0.87), while in juveniles, cf-PWV was comparable between the WCH group and the NT group (P = .25, 95% CI: -0.39 to 0.61). CONCLUSION This meta-analysis showed that WCH may increase arterial stiffness in adult population.
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Affiliation(s)
- Peng Cai
- Department of Cardiology, Institute of Field Surgery, Daping Hospital, Third Military Medical University, Chongqing
| | - Yan Peng
- Department of Cardiology, Institute of Field Surgery, Daping Hospital, Third Military Medical University, Chongqing
| | - Yan Wang
- Key Laboratory of Basic Pharmacology of Ministry of Education Joint International Research Laboratory of Ministry Education, Zunyi Medical University, Zunyi, China
| | - Xukai Wang
- Department of Cardiology, Institute of Field Surgery, Daping Hospital, Third Military Medical University, Chongqing
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13
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The time has come to change ambulatory blood pressure monitoring from 24-hour to 48-hour for the diagnosis of hypertension and cardiovascular risk assessment. Rev Port Cardiol 2018; 37:329-331. [PMID: 29685848 DOI: 10.1016/j.repc.2018.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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14
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Machado AP. The time has come to change ambulatory blood pressure monitoring from 24-hour to 48-hour for the diagnosis of hypertension and cardiovascular risk assessment. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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15
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Afsar B, Sag AA, Kanbay M. Should we take renal denervation with a grain of salt? J Clin Hypertens (Greenwich) 2017; 19:1134-1136. [PMID: 28942601 DOI: 10.1111/jch.13069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Baris Afsar
- Division of Nephrology, Department of Medicine, Suleyman Demirel University School of Medicine, Faculty of Medicine, Isparta, Turkey
| | - Alan A Sag
- Division of Interventional Radiology, Department of Radiology, Koc University School of Medicine, Istanbul, Turkey
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
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16
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Cuspidi C, Sala C, Tadic M, Gherbesi E, De Giorgi A, Grassi G, Mancia G. Clinical and prognostic significance of a reverse dipping pattern on ambulatory monitoring: An updated review. J Clin Hypertens (Greenwich) 2017; 19:713-721. [PMID: 28692165 PMCID: PMC8031119 DOI: 10.1111/jch.13023] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/15/2017] [Accepted: 03/26/2017] [Indexed: 11/28/2022]
Abstract
Reverse or inverted dipping (ie, the phenomenon characterized by higher nighttime compared with daytime blood pressure values) is an alteration of circadian blood pressure rhythm frequently documented in hypertension, type 2 diabetes mellitus, chronic kidney disease, and sleep apnea syndrome, and generally regarded as a harmful condition. Available literature on the clinical and prognostic implications of reverse dipping is scanty. The present article will review a number of relevant issues concerning reverse dipping, in particular: (1) its possible mechanisms; (2) prevalence and clinical correlates, (3) concomitant cardiac and extracardiac subclinical organ damage; (4) association with acute and chronic cardiovascular diseases; (5) prognostic value in predicting cardiovascular events and mortality; and (6) therapeutic interventions aimed at reverting this abnormal circadian blood pressure rhythm.
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Affiliation(s)
- Cesare Cuspidi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
- Istituto Auxologico ItalianoMilanoItaly
| | - Carla Sala
- Department of Clinical Sciences and Community HealthUniversity of Milano and Fondazione IRCCS Policlinico di MilanoMilanoItaly
| | - Marijana Tadic
- University Clinical Hospital Centre “Dragisa Misovic”BelgradeSerbia
| | - Elisa Gherbesi
- Department of Clinical Sciences and Community HealthUniversity of Milano and Fondazione IRCCS Policlinico di MilanoMilanoItaly
| | | | - Guido Grassi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
- Istituto di Ricerche a Carattere Scientifico MultimedicaSesto San GiovanniMilanItaly
| | - Giuseppe Mancia
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
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17
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Chang H, Gu HX, Gong M, Han JJ, Wang Y, Xia ZL, Zhao XM. Characteristic enhancement of blood pressure V-shaped waves in sinoaortic-denervated rats in a conscious and quiet state. Physiol Res 2016; 65:571-580. [PMID: 26988153 DOI: 10.33549/physiolres.933062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A hemodynamic feature of chronic sinoaortic-denervated (SAD) rats is the increase in blood pressure variability (BPV) without significant changes in the average level of blood pressure (BP). The current study was designed to investigate the changes in BP V-shaped waves (V waves) in SAD rats. Sprague-Dawley (SD) rats were divided into 2 groups: SAD rats and sham-operated rats (n=13). Hemodynamics measurements were obtained in conscious, freely moving rats, four weeks after sinoaortic denervation or sham operation. V wave indices were evaluated in rats in both conscious and quiet states. Additionally, normal and high BPV was simulated by the production of V waves with different amplitudes. The results showed that the V wave amplitude was dramatically increased, with a significantly prolonged duration and reduced frequency in SAD rats. V wave BPV in SAD rats was significantly increased, though BP remained unchanged. The twenty-four hour BPV in all rats was positively correlated with amplitude, duration time and V wave BPV and negatively correlated with frequency. The systolic BP spectral powers in the low frequency range (0.38-0.45 Hz) were significantly reduced in the V waves of SAD rats. Moreover, there was a remarkable increase in mean BPV and a normal mean BP after simulating high BPV in SAD rats. These results suggest that enhancement of V waves might be a waveform character of BP in SAD rats in both the conscious and quiet states. These types of V waves appear to be related to a depression of sympathetic regulation of BP induced by sinoaortic denervation.
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Affiliation(s)
- Huan Chang
- Key Laboratory of Atherosclerosis in Universities of Shandong (Taishan Medical University), Taian, China.
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18
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Afsar B, Vaziri ND, Aslan G, Tarim K, Kanbay M. Gut hormones and gut microbiota: implications for kidney function and hypertension. ACTA ACUST UNITED AC 2016; 10:954-961. [PMID: 27865823 DOI: 10.1016/j.jash.2016.10.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 10/25/2016] [Indexed: 02/07/2023]
Abstract
Increased blood pressure (BP) and chronic kidney disease are two leading risk factors for cardiovascular disease. Increased sodium intake is one of the most important risk factors for development of hypertension. Recent data have shown that gut influences kidney function and BP by variety of mechanisms. Various hormones and peptides secreted from gut such as gastrin, glucocorticoids, Glucagon-like peptide-1 impact on kidney function and BP especially influencing sodium absorption from gut. These findings stimulate scientist to find new therapeutic options such as tenapanor for treatment of hypertension by blocking sodium absorption from gut. The gastrointestinal tract is also occupied by a huge community of microbes (microbiome) that under normal condition has a symbiotic relationship with the host. Alterations in the structure and function of the gut microbiota have been shown to play a key role in the pathogenesis and complications of numerous diseases including hypertension. Based on these data, in this review, we provide a summary of the available data on the role of gut and gut microbiota in regulation of BP and kidney function.
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Affiliation(s)
- Baris Afsar
- Division of Nephrology, Department of Medicine, Konya Numune State Hospital, Konya, Turkey
| | - Nosratola D Vaziri
- Division of Nephrology and Hypertension, Department of Medicine, Schools of Medicine and Biological Science, University of California, Irvine, CA, USA
| | - Gamze Aslan
- Department of Cardiology, Koc University School of Medicine, Istanbul, Turkey
| | - Kayhan Tarim
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey.
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19
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Kario K. Perfect 24-h management of hypertension: clinical relevance and perspectives. J Hum Hypertens 2016; 31:231-243. [PMID: 27604658 DOI: 10.1038/jhh.2016.65] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/27/2016] [Accepted: 08/05/2016] [Indexed: 12/31/2022]
Abstract
Out-of-office blood pressure (BP) measured by home BP monitoring, or ambulatory BP monitoring, was demonstrated to be superior to office BP for the prediction of cardiovascular events. The J-HOP study of a nationwide Japanese cohort demonstrated that morning home BP is the best stroke predictor. In the prospective HONEST study of >21 000 hypertensives, on-treatment morning home BP was shown to be a strong predictor both of future coronary artery disease and stroke events. In subjects whose office BP was maintained at ⩾150 mm Hg, there was no increase in cardiovascular events when their morning systolic BP was well-controlled at <125 mm Hg. Since Asians show greater morning BP surges, it is particularly important for Asians to achieve 'perfect 24-hr BP control,' that is, the 24-h BP level, nocturnal BP dipping and BP variability including morning surge. The morning BP surge and the extremes of disrupted circadian rhythm (riser and extreme dipper patterns) are independent risks for stroke in hypertensives. A morning BP-guided approach is thus the first step toward perfect 24-h BP control, followed by the control of nocturnal hypertension. In the resonance hypothesis, the synergistic resonance of BP variability phenotypes would produce an extraordinary large 'dynamic BP surge' that can trigger a cardiovascular event, especially in high-risk patients with systemic hemodynamic atherothrombotic syndrome, a vicious cycle of exaggerated BP variability and vascular disease. In the future, information and communications technology and artificial intelligence technology with the innovation of wearable continuous surge BP monitoring will contribute to 'anticipation medicine' with the goal of zero cardiovascular events.
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Affiliation(s)
- K Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi.,Jichi Medical University Center of Excellence, Cardiovascular Research and Development (JCARD), Shimotsuke, Tochigi.,Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network, Tokyo
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20
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Afsar B, Kanbay M. Reply to: Hemodynamic and Arterial Stiffness Parameters in Ambulatory Blood Pressure Phenotypes and the Clinical Scenario of Polypharmacy and Comorbidities. J Clin Hypertens (Greenwich) 2015; 17:656. [DOI: 10.1111/jch.12543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Baris Afsar
- Department of Nephrology; Konya Numune State Hospital; Konya Turkey
| | - Mehmet Kanbay
- Division of Nephrology; Department of Medicine; Koc University School of Medicine; Istanbul Turkey
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21
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Anyfanti P, Triantafyllou A, Douma S. Hemodynamic and Arterial Stiffness Parameters in Ambulatory Blood Pressure Phenotypes and the Clinical Scenario of Polypharmacy and Comorbidities. J Clin Hypertens (Greenwich) 2015; 17:655. [PMID: 25823434 DOI: 10.1111/jch.12544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Panagiota Anyfanti
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Areti Triantafyllou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stella Douma
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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