Microalbuminuria, pulse pressure, left ventricular hypertrophy, and myocardial ultrasonic tissue characterization in essential hypertension

Topical use of antithrombotics: review of literature

While antithrombotics are usually administered intravenously, subcutaneously or orally, there are a number of publications reporting topical application of anticoagulation therapy. This paper aims to review the available literature regarding clinical conditions, the details of the topical antithrombotic treatment, as well as positive or adverse effects in an attempt to ascertain the safety and efficacy of this form of treatment. Published literature was searched to identify publications reporting the use of antithrombotic treatments administered via topical application between 1st January 1990 and 1st January 2013. There were 43 studies reported in 10 different clinical conditions. Majority of the studies were randomized controlled trials (51.2%), prospective studies (18.6%) or case reports (11.6%). The clinical conditions in which topical antithrombotics were administered included: microangiopathy, acute haemorrhoids, periodontitis, dermatitis, burns, ocular conditions and surgery, blunt force impact, scars, as well as clinical conditions associated with superficial venous thrombosis (SVT). The most commonly used topical antithrombotic was heparin (79.1% of studies). The respective dosage of different antithrombotics varied depending on specific clinical conditions. While most studies reported mean improvements or resolution of symptoms/condition in patients, the patient outcomes were variable. This review demonstrates that topical antithrombotic treatment is used according to a wide variety of protocols, with a subsequent variability in patient outcomes. Specific guidelines for the use of topical antithrombotics should be developed to standardize this form of treatment and ensure the best possible outcomes for patients.

Efficacy and tolerability of DHEP-heparin plaster in reducing pain in mild-to-moderate muscle contusions: a double-blind, randomized trial

OBJECTIVES

To investigate if the 180-mg diclofenac epolamine and heparin sodium 5600 IU medicated plaster (DHEP-heparin) is more effective for pain reduction in mild-to-moderate contusions than the reference diclofenac epolamine 180 mg plaster (DHEP).

RESEARCH DESIGN AND METHODS

This multicenter, multinational, prospective, double-blind versus reference comparator and versus placebo, controlled trial had balanced random assignment in three parallel treatment groups. The DHEP-heparin medicated plaster was compared to the DHEP medicated plaster and a placebo medicated plaster. A total of 331 outpatients, aged ≥18 and ≤65 years, with unilateral mild-to-moderate muscle contusion, pain on standardized movement of ≥50 mm, and superficial hematoma of ≤10 × 14 cm(2) completed the study. Plasters were applied each morning, for ≥20 hours daily for 14 consecutive days. Outcomes were assessed in three visits, over 14 days, plus patients' daily self-assessment.

CLINICAL TRIAL REGISTRATION

05DCz/FHp11 - Eudra CT n: 2005-003829-31

MAIN OUTCOME MEASURES

Primary efficacy endpoint was mean change from baseline in pain on movement after 3 days of treatment, compared between groups. Secondary efficacy endpoints included mean daily change from baseline in pain on movement during treatment, pain level as assessed at control visits after 7 and 14 days, time (days) to hematoma disappearance based on patients' daily evaluations, rescue medication use, and overall treatment efficacy as judged by both patients and investigators.

RESULTS

Pain progressively declined in all groups, more rapidly in DHEP-heparin recipients, compared to DHEP, and in both active treatment groups compared to placebo. Adverse events were recorded in 24 of the 355 (6.7%) exposed patients, and generally resolved without need to interrupt treatment.

CONCLUSION

The DHEP-heparin plaster is superior to the reference DHEP plaster in reducing pain associated with mild-to-moderate muscle contusion. Both active treatments were significantly more effective than placebo, and each showed a comparably favorable, placebo-like safety profile.

Effect of a plaster containing DHEP and heparin in acute ankle sprains with oedema: a randomized, double-blind, placebo-controlled, clinical study

OBJECTIVE

Ankle sprains are the most frequent injuries in sport and daily life, and are usually treated with anti-inflammatory drugs or compounds that have an effect on microcirculation. The efficacy and tolerability of a novel plaster containing both diclofenac epolamine (DHEP) and heparin in the treatment of acute painful ankle sprains with oedema was investigated in a randomized, double-blind, placebo-controlled study.

RESEARCH DESIGN AND METHODS

This study, carried out in 32 French medical centres, enrolled 233 patients (148 male and 86 female, aged 18-65 years) with an ankle sprain that had occurred within the previous 48 hours. Patients were treated once daily with DHEP heparin or placebo plaster for 7 days.

MAIN OUTCOME MEASURES

Reduction in ankle joint swelling measured by submalleolar circumference was the primary efficacy endpoint; secondary endpoints were pain (at rest, in active mobilization, by passive stretch and by pressure), functional disability and global judgement of efficacy and tolerability.

RESULTS

DHEP heparin-treated patients experienced a significantly greater reduction in joint swelling compared with placebo (p = 0.005). The reduction in pain was also in favour of DHEP heparin patients, with significantly lower pain in DHEP heparin-treated than placebo-treated patients within 3 hours of the first application (p < 0.05). Only two patients in the DHEP heparin plaster group and six in the placebo group experienced minor adverse events, all of which resolved spontaneously. By design, the study was limited to a placebo-controlled comparison, and there was no test for possible selection bias (subsequently ruled out by choice of efficacy parameters and measures) that may have resulted in a baseline imbalance between patient groups.

CONCLUSIONS

Results confirm the efficacy of DHEP heparin plaster compared with placebo for the treatment of painful ankle sprain with oedema. Prompt control of pain and oedema may shorten the time to initiation of a rehabilitation programme, thus reducing the risk of ankle disability recurrence and the development of chronic injury.

Abdominal aortic wall motion of healthy and hypertensive subjects: evaluation of tissue Doppler velocity imaging

PURPOSE

To investigate the potential clinical application of tissue Doppler imaging (TDI) for motion measurement of the aortic wall in healthy and hypertensive adults.

METHOD

We used TDI to examine 53 hypertensive and 29 sex-matched healthy adults. Maximum velocity of the first and second systolic wall expansion peaks (S1, S2), maximum velocity of early (D) and end (E) diastolic retraction velocity peaks, pulse wave transmit time (PWTT), and stiffness index (beta) of the abdominal aorta were measured and compared as for factors influencing vascular compliance, including age, sex, and blood pressure.

RESULTS

Compared with the healthy subjects, the wall motion waveform of hypertensive patients showed absent E, mixed S1 and S2 peaks, and blunted S1. S1 and D were lower in hypertensive than in healthy subjects. Shortened PWTT and increased indicated increased aortic stiffness in both male and female hypertensive subects when compared with controls. Age, diastolic blood pressure (DBP) and sex were the significant independent factors modulating S1, while DBP and age were the significant independent factors modulating D. PWTT was independently influenced by age and systolic blood pressure.

CONCLUSION

This study provides evidence that abdominal aortic wall motion measurement with TDI could demonstrate qualitative and quantitative wall motion features differentiating hypertensive from healthy adults. Wall motion velocity and PWTT could reflect abdominal aortic compliance changes related to age, sex, and blood pressure.

The controversial role of serum uric acid in essential hypertension: relationships with indices of target organ damage

The role of serum uric acid (SUA) in the context of adverse cardiovascular events in hypertensive subjects is controversial. Additionally, the relationship between SUA and indices of target organ damage is not well defined in this setting. Towards this end, we studied 842 consecutive nondiabetic patients with stage I-II essential hypertension (office blood pressure=148/95 mmHg, aged 53.4 years), referred to our outpatient hypertensive unit within a period of 4 years. According to the urinary albumin excretion (UAE), the study population was classified into those with microalbuminuria [MA(+), UAE=20-200 mg/24 h, n=222] and those without MA [MA (-), UAE< 20 mg/24 h, n=620]. Moreover, according to the presence of left ventricular hypertrophy (LVH) the participants were subdivided into two additional groups: [LVH (+), n=305 and LVH (-), n=537]. SUA levels were higher by 0.4 mg/dl, (P=0.04) in group MA (+) compared with the group MA (-), while no difference was observed between groups LVH (+) and LVH (-) (P=NS). In the entire population, SUA was correlated with body mass index (BMI) (r=0.17, P<0.001), waist/hip ratio (r=0.3, P<0.001), office systolic blood pressure (SBP) (r=0.14, P<0.05), triglycerides levels (r=0.25, P<0.001), UAE (r=0.35, P<0.001) and HDL (r=-0.26, P<0.001). Multiple regression analysis demonstrated that SUA was significantly related with BMI, office SBP and UAE (P<0.05). In conclusion, increased SUA levels are associated with MA but not with LVH in essential hypertensive subjects. Whether these inter-relationships may elucidate the clinical positioning of augmented SUA in this setting remains to be clarified in future studies.

Microalbuminuria Is Associated with Reduced Cardiac Cyclic Variation of Integrated Backscatter Signal in Severe Hypertension

OBJECTIVE

Microalbuminuria (MA) as a marker of systemic vascular disease and left ventricular (LV) hypertrophy is associated with increased cardiovascular mortality and morbidity in patients with essential hypertension. The aim of this study was to investigate changes in cardiac cycle-dependent variation of integrated backscatter signals (CVIBS) in hypertensive patients with MA.

METHODS

Randomly selected 60 hypertensive patients (mean age 51 +/- 8) with uncontrolled blood pressure (BP) (>/=130 mmHg systolic and/or 85 mmHg diastolic) were included. All patients underwent urinary albumin excretion (UAE) measurements, 24-hour ambulatory BP monitoring, and LV echocardiographic examination. UAE was measured in two separate 24-hour urine collection and mean of two values was taken into consideration. Normotensive 20 healthy subjects served as controls. CVIBS values were obtained from mid-anteroseptal, mid-posterolateral, and mid-inferior areas at the papillary muscle level in the parasternal short-axis view. CVIBS was defined as the difference in integrated backscatter values between systole and diastole. CVIBS values in MA positive patients were compared with the values in MA negative patients and control subjects.

RESULTS

Twelve patients had MA (UAE 30 to 300 mg/day) while 48 patients had normal UAE (<30 mg/day). The wall thickness (at septum and posterior) and left ventricular mass index (LVMI) values were all significantly higher in hypertensive patients with MA (P < 0.01). The CVIBS values in MA positive group were significantly lower than the CVIBS values both in MA negative hypertensive patients and control subjects (P < 0.01).

CONCLUSION

This study demonstrates that in hypertensive patients a high LVMI is associated with reduced CVIBS values and MA appears to be a marker of hypertrophy.

Ultrasonic backscatter and diastolic function in hypertensive patients

This study was designed to assess whether ultrasonic reflectivity, evaluated by a real-time integrated backscatter analysis, was related to the severity of diastolic dysfunction, as studied by Doppler echocardiography in patients with essential hypertension. One hundred nine subjects were included in the study. Diastolic function was assessed by mitral-inflow Doppler ultrasound recordings. Backscatter cyclic variation and maximal intensity were measured in 6 regions throughout the left ventricle. The subjects were classified in 5 groups according to blood pressure and diastolic function: 29 normotensives with normal diastolic function (group 1), 18 hypertensives with normal diastolic function (group 2), 47 hypertensives with a delayed relaxation pattern (group 3), 11 hypertensives with a pseudonormal filling pattern (group 4), and 4 hypertensives with a restrictive filling pattern (group 5). The highest cyclic variation was found in groups 1 and 2, the lowest in groups 4 and 5 (5.7+/-0.2 dB in group 1 and 5.7+/-0.2 dB in group 2 versus 2.9+/-0.3 dB in group 4 and 2.1+/-0.4 dB in group 5; P<0.001), with intermediate values in group 3 (5.2+/-0.2 dB). Cyclic variation was inversely correlated with left ventricular chamber stiffness (P<0.05) and directly correlated with midwall fractional shortening (P<0.02) in all hypertensives. No differences in maximal intensity were found among the 5 groups of subjects. These results show an association between diminished cyclic variation of backscatter and deterioration of diastolic function in hypertensive patients. Thus, alterations in this parameter may be useful for the assessment of diastolic dysfunction in hypertension.

Clinical aspects of hypertensive myocardial fibrosis

Myocardial fibrosis is one of the histologic constituents of myocardial remodeling present in hypertensive patients with hypertensive heart disease. In fact, an exaggerated interstitial and perivascular accumulation of fibrillar collagens type I and type III has been found in the myocardium of patients with arterial hypertension and left ventricular hypertrophy. Hypertensive myocardial fibrosis has been shown to facilitate abnormalities of cardiac function, coronary reserve, and electrical activity that adversely affect the clinical outcome of hypertensive patients. Therefore, development of noninvasive tools for the monitoring of myocardial fibrosis and pharmacological strategies aimed to promote the regression of fibrosis could be of particular relevance in the clinical treatment of patients with hypertensive heart disease.