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Vogl B, Sularz A, Ahn S, Gadhave R, Lilly S, Thourani V, Lindman B, Alkhouli M, Hatoum H. Analysis of Energy and Pressure in the Sinus with Different Blood Pressures after Bioprosthetic Aortic Valve Replacement. Ann Biomed Eng 2024:10.1007/s10439-024-03587-w. [PMID: 39103737 DOI: 10.1007/s10439-024-03587-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 07/11/2024] [Indexed: 08/07/2024]
Abstract
PURPOSE To investigate the effect of changing systolic and diastolic blood pressures (SBP and DBP, respectively) on sinus flow and valvular and epicardial coronary flow dynamics after TAVR and SAVR. METHODS SAPIEN 3 and Magna valves were deployed in an idealized aortic root model as part of a pulse duplicating left heart flow loop simulator. Different combinations of SBP and DBP were applied to the test setup and the resulting change in total coronary flow from baseline (120/60 mmHg), effective orifice area (EOA), and left ventricular (LV) workload, with each combination, was assessed. In addition, particle image velocimetry was used to assess the Laplacian of pressure (∇ 2 P ) in the sinus, coronary and main flow velocities, the energy dissipation rate (EDR) in the sinus and the LV workload. RESULTS This study shows that under an elevated SBP, there is an increase in the total coronary flow, EOA, LV workload, peak velocities downstream of the valve,∇ 2 P , and EDR. With an elevated DBP, there was an increase in the total coronary flow and∇ 2 P . However, EOA and LV workload decreased with an increase in DBP, and EDR increased with a decrease in DBP. CONCLUSIONS Blood pressure alters the hemodynamics in the sinus and downstream flow following aortic valve replacement, potentially influencing outcomes in some patients.
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Affiliation(s)
- Brennan Vogl
- Department of Biomedical Engineering, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA
| | - Agata Sularz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sunyoung Ahn
- Department of Biomedical Engineering, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA
| | - Rajat Gadhave
- Department of Biomedical Engineering, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA
| | - Scott Lilly
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Vinod Thourani
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Marcus Valve Center, Atlanta, GA, USA
| | - Brian Lindman
- Division of Cardiovascular Medicine, Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA.
- Health Research Institute, Center of Biocomputing and Digital Health and Institute of Computing and Cybersystems, Michigan Technological University, Houghton, MI, USA.
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Rabkin SW. Searching for the Best Machine Learning Algorithm for the Detection of Left Ventricular Hypertrophy from the ECG: A Review. Bioengineering (Basel) 2024; 11:489. [PMID: 38790356 PMCID: PMC11117908 DOI: 10.3390/bioengineering11050489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Left ventricular hypertrophy (LVH) is a powerful predictor of future cardiovascular events. Objectives: The objectives of this study were to conduct a systematic review of machine learning (ML) algorithms for the identification of LVH and compare them with respect to the classical features of test sensitivity, specificity, accuracy, ROC and the traditional ECG criteria for LVH. Methods: A search string was constructed with the operators "left ventricular hypertrophy, electrocardiogram" AND machine learning; then, Medline and PubMed were systematically searched. Results: There were 14 studies that examined the detection of LVH utilizing the ECG and utilized at least one ML approach. ML approaches encompassed support vector machines, logistic regression, Random Forest, GLMNet, Gradient Boosting Machine, XGBoost, AdaBoost, ensemble neural networks, convolutional neural networks, deep neural networks and a back-propagation neural network. Sensitivity ranged from 0.29 to 0.966 and specificity ranged from 0.53 to 0.99. A comparison with the classical ECG criteria for LVH was performed in nine studies. ML algorithms were universally more sensitive than the Cornell voltage, Cornell product, Sokolow-Lyons or Romhilt-Estes criteria. However, none of the ML algorithms had meaningfully better specificity, and four were worse. Many of the ML algorithms included a large number of clinical (age, sex, height, weight), laboratory and detailed ECG waveform data (P, QRS and T wave), making them difficult to utilize in a clinical screening situation. Conclusions: There are over a dozen different ML algorithms for the detection of LVH on a 12-lead ECG that use various ECG signal analyses and/or the inclusion of clinical and laboratory variables. Most improved in terms of sensitivity, but most also failed to outperform specificity compared to the classic ECG criteria. ML algorithms should be compared or tested on the same (standard) database.
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Affiliation(s)
- Simon W Rabkin
- Department of Medicine, Division of Cardiology, University of British Columbia, 9th Floor 2775 Laurel St., Vancouver, BC V5Z 1M9, Canada
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Vogl B, Sularz A, Lilly S, Thourani VH, Lindman BR, Alkhouli M, Hatoum H. Effect of Blood Pressure Levels on Sinus Hemodynamics in Relation to Calcification After Bioprosthetic Aortic Valve Replacement. Ann Biomed Eng 2024; 52:888-897. [PMID: 38157105 DOI: 10.1007/s10439-023-03426-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
Coexisting hypertension and aortic stenosis are common. Some studies showed that elevated blood pressures may be associated with progression of calcific aortic valve disease (CAVD) while others showed no correlation. Flow dynamics in the sinuses of Valsalva are considered key factors in the progression of CAVD. While the relationship between hemodynamics and CAVD is not yet fully understood, it has been demonstrated that they are tightly correlated. This study aims to investigate the effect of changing systolic and diastolic blood pressures (SBP and DBP, respectively) on sinus hemodynamics in relation to potential initiation or progression of CAVD after aortic valve replacement (AVR). Evolut R, SAPIEN 3 and Magna valves were deployed in an aortic root under pulsatile conditions. Using particle image velocimetry, the hemodynamics in the sinus were assessed. The velocity, vorticity, circulation ( Γ ) and shear stress were calculated. This study shows that under elevated SBP and DBP, velocity, vorticity, and shear stress nearby the leaflets increased. Additionally, larger fluctuations of Γ and area under the curve throughout the cardiac cycle were observed. Elevated blood pressures are associated with higher velocity, vorticity, and shear stress near the leaflets which may initiate or accelerate pro-calcific changes in the prosthetic leaflets leading to bioprosthetic valve degeneration.
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Affiliation(s)
- Brennan Vogl
- Biomedical Engineering Department, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA
| | - Agata Sularz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Scott Lilly
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Brian R Lindman
- Division of Cardiovascular Medicine, Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hoda Hatoum
- Biomedical Engineering Department, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA.
- Health Research Institute, Center of Biocomputing and Digital Health and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, MI, USA.
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Rabkin SW, Zhou JCJ. Estimating Left Ventricular Mass from the Electrocardiogram across the Spectrum of LV Mass from Normal to Increased LV Mass in an Older Age Group. Cardiol Res Pract 2024; 2024:6634222. [PMID: 38500683 PMCID: PMC10948226 DOI: 10.1155/2024/6634222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 03/20/2024] Open
Abstract
Objectives To examine the relationship of QRS voltages and left ventricular (LV) mass across the spectrum of individuals with different LV mass. Methods Twenty QRS voltage measurements or combinations were determined in a consecutive series of 159 adults with an ECG and echocardiogram without previous myocardial infarction, left or right bundle branch block, pre-excitation, or electronic pacemaker. Results The four strongest and significant correlations between QRS and LV mass were S in V4, deepest S wave in any precordial lead plus S in V4, S in V3, and S in V3 plus R in AVL times QRS duration. For men, the strength of the relationships were S in V3 (F = 33.8), deepest S wave in any precordial lead plus S V4 (F = 33.7), S in V3 plus R aVL (F = 29.9), S in V4 (F = 29.79), and deepest S in precordial leads (F = 17.9). The R wave in AVL alone did not correlate with LV mass. Criteria using the R wave in lateral precordial leads did not correlate as strongly with LV mass. For women, only S in V4 significantly correlated with LV mass. Overall, the R wave voltage in limb leads (AVL I or II) did not correlate with precordial S wave amplitudes. Univariate and multivariate analysis showed that some but not all QRS voltages correlated with each other. In multivariate analysis, using only single variables and not combination of QRS variables, the only significant relationship between QRS voltage and left ventricular mass was for men the S in V3 (p = 0.04) and for women S in V4 (p = 0.016) and R in V6 (p = 0.04). Conclusion The S wave in V3 and V4 correlate most strongly with LV mass while the R wave in limb leads, including AVL, do not correlate.
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Affiliation(s)
- Simon W. Rabkin
- University of British Columbia, Vancouver, B.C., Canada
- Division of Cardiology, Vancouver, B.C., Canada
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Ruddy TD, Tavoosi A, Taqueti VR. Role of nuclear cardiology in diagnosis and risk stratification of coronary microvascular disease. J Nucl Cardiol 2023; 30:1327-1340. [PMID: 35851643 DOI: 10.1007/s12350-022-03051-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/22/2022] [Indexed: 10/17/2022]
Abstract
Coronary flow reserve (CFR) with positron emission tomography/computed tomography (PET/CT) has an important role in the diagnosis of coronary microvascular disease (CMD), aids risk stratification and may be useful in monitoring therapy. CMD contributes to symptoms and a worse prognosis in patients with coronary artery disease (CAD), nonischemic cardiomyopathies, and heart failure. CFR measurements may improve our understanding of the role of CMD in symptoms and prognosis in CAD and other cardiovascular diseases. The clinical presentation of CAD has changed. The prevalence of nonobstructive CAD has increased to about 50% of patients with angina undergoing angiography. Ischemia with nonobstructive arteries (INOCA) is recognized as an important cause of symptoms and has an adverse prognosis. Patients with INOCA may have ischemia due to CMD, epicardial vasospasm or diffuse nonobstructive CAD. Reduced CFR in patients with INOCA identifies a high-risk group that may benefit from management strategies specific for CMD. Although measurement of CFR by PET/CT has excellent accuracy and repeatability, use is limited by cost and availability. CFR measurement with single-photon emission tomography (SPECT) is feasible, validated, and would increase availability and use of CFR. Patients with CMD can be identified by reduced CFR and selected for specific therapies.
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Affiliation(s)
- Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
| | - Anahita Tavoosi
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Viviany R Taqueti
- Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Rabkin SW. Assessing Myocardial Strain and Myocardial Work as a Marker for Hypertensive Heart Disease: A Meta-Analysis. Rev Cardiovasc Med 2023; 24:217. [PMID: 39076705 PMCID: PMC11266759 DOI: 10.31083/j.rcm2408217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 01/29/2023] [Accepted: 02/22/2023] [Indexed: 07/31/2024] Open
Abstract
Background The main objective of this study was to determine whether myocardial strain and myocardial work are altered in hypertension and whether the strain is independent of hypertension-induced left ventricular hypertrophy. Methods Two systematic literature searches were conducted using Medline and EMBASE through to June 30, 2022. In the first, search terms left ventricular strain or speckle tracking AND hypertension and left ventricular hypertrophy were used in conjunction with Boolean operators to identify articles reporting left ventricular strain in patients with hypertension. In the second, the terms Global cardiac or myocardial work AND hypertension were used to identify articles. Publication bias was assessed by examination of funnel plots and calculation of the Failsafe N and Duval and Tweedie's Trim and fill. The results were presented as Forrest plots. Results Global longitudinal strain (GLS) was significantly lower in patients with hypertension compared to those without hypertension with a mean difference of 2.0 ± 0.1 (standard error of mean(SEM)) in the fixed effect model. Global circumferential strain (GCS) was significantly lower in hypertension. The mean difference between the hypertensive and non-hypertensive groups was 1.37 ± 0.17. Global radial strain (GRS) was significantly (p < 0.05) greater in hypertension. However, this difference was significant in only 3 and of borderline significance in 3 of 14 studies where GRS was measured. The mean difference between the hypertensive and non-hypertensive groups was 1.5 ± 0.5 using the fixed effects model. There was a significant relationship between GLS and GCS as well as between GCS and GRS but no significant relationship between GLS and GRS. There was no significant difference in left ventricular ejection fraction (LVEF) between the hypertension and no hypertension groups. There was no significant relationship between LVEF and either GLS or GCS but a significant negative correlation was found between LVEF and GRS. GLS was further reduced in persons with hypertension and left ventricular hypertrophy (LVH) compared to hypertension without LVH. In contrast, there were no or minimal differences in GCS and GRS for individuals with hypertension and LVH compared to those without LVH. Global myocardial work index (GWI) and Global constructive work (GCW) were significantly greater in patients with hypertension compared to controls. Global wasted work (GWW) indicated significantly less wasted work in controls compared to hypertension. In contrast, Global work efficiency (GWE) was significantly lower in hypertension compared to the control. Conclusions There was a significant reduction in GLS and GCS in hypertension while GRS was increased. The reduction in GLS in hypertension was not dependent on the presence of LVH. GLS was further reduced in persons with hypertension when LVH was present. In contrast, there were no or minimal differences in GCS and GRS for individuals with LVH compared to those without LVH. GLS was independent of left ventricle (LV) ejection fraction. GWI, GCW and GWW were greater in hypertension while GWE was lower in hypertension compared to controls. These data support the contention that GLS and indices of global work are early markers of hypertensive heart disease.
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Affiliation(s)
- Simon W. Rabkin
- Department of Medicine, Division of Cardiology, University of British
Columbia, Vancouver, BC V5Z 1M9, Canada
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7
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Brown JM, Zhou W, Weber B, Divakaran S, Barrett L, Bibbo CF, Hainer J, Taqueti VR, Dorbala S, Blankstein R, Di Carli MF. Low coronary flow relative to myocardial mass predicts heart failure in symptomatic hypertensive patients with no obstructive coronary artery disease. Eur Heart J 2022; 43:3323-3331. [PMID: 34491335 PMCID: PMC9470377 DOI: 10.1093/eurheartj/ehab610] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/04/2021] [Accepted: 08/20/2021] [Indexed: 01/14/2023] Open
Abstract
AIMS The transition from hypertension to heart failure (HF) remains poorly understood. We hypothesized that insufficient perfusion to match global metabolic demand, reflected by a low ratio of myocardial blood flow to global myocardial mass, may be a HF risk marker. METHODS AND RESULTS A retrospective cohort (n = 346) of patients with hypertension who underwent clinical positron emission tomography (PET) myocardial perfusion imaging for chest pain and/or dyspnoea at Brigham and Women's Hospital (Boston, MA, USA) were studied. Patients without obstructive coronary artery disease by history or PET perfusion (summed stress score <3), HF, cardiomyopathy, or ejection fraction (EF) <40% were followed for HF hospitalization (primary outcome), all-cause death, and their composite. Myocardial blood flow, left ventricular (LV) mass, volumes, and EF were obtained from PET, and a 'flow/mass ratio' was determined as hyperaemic myocardial blood flow over LV mass indexed to body surface area. A lower flow/mass ratio was independently associated with larger end-diastolic (β = -0.44, P < 0.001) and end-systolic volume (β = -0.48, P < 0.001) and lower EF (β = 0.33, P < 0.001). A flow/mass ratio below the median was associated with an adjusted hazard ratio of 2.47 [95% confidence interval (CI) 1.24-4.93; P = 0.01] for HF hospitalization, 1.95 (95% CI 1.12-3.41; P = 0.02) for death, and 2.20 (95% CI 1.39-3.49; P < 0.001) for the composite. CONCLUSION An integrated physiological measure of insufficient myocardial perfusion to match global metabolic demand identifies subclinical hypertensive heart disease and elevated risk of HF and death in symptomatic patients with hypertension but without flow-limiting coronary artery disease.
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Affiliation(s)
- Jenifer M Brown
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Wunan Zhou
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
- Cardiology Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
| | - Brittany Weber
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Sanjay Divakaran
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Leanne Barrett
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Sharmila Dorbala
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Ron Blankstein
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Marcelo F Di Carli
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
- Cardiovascular Imaging Program, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Semerdzhieva NE, Denchev SV, Gospodinova MV. Left Ventricular Diastolic Function: Comparison of Slow Coronary Flow Phenomenon and Left Ventricular Hypertrophy in the Absence of Obstructive Coronary Disease. Cureus 2022; 14:e24789. [PMID: 35673304 PMCID: PMC9165915 DOI: 10.7759/cureus.24789] [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] [Accepted: 05/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background An interplay of myocardial structural abnormalities and coronary arterial dysfunction underlies the worsening left ventricular compliance. The conventionally used angina drugs have demonstrated a beneficial effect on both angina and coronary flow in cases with microvascular dysfunction and non-obstructive coronary disease. Despite that, vasoactive therapy only partially affects diastolic function in this patient population. Purpose This retrospective study was planned to evaluate the association of myocardial mass, delayed epicardial coronary flow, and vasoactive drugs with parameters of diastolic function in two cohorts with preserved left ventricular function and non-obstructive coronary disease in patients with slow coronary flow phenomenon (SCFP) and patients with the hypertensive disease and left ventricular hypertrophy. Material and methods The epicardial coronary flow was evaluated in 48 patients with unstable angina in the absence of coronary stenosis >50%, by applying the methods of corrected thrombolysis in myocardial infraction frame count (cTFC). The abnormalities in the left ventricular function were assessed by echocardiography using PW-Doppler of the diastolic mitral inflow and tissue Doppler imaging. Twenty-one (43.8%) patients were diagnosed with SCFP, and twelve patients (25%) had slow epicardial coronary flow, hypertensive disease, and ventricular hypertrophy (SFLVH). The remaining 15 (31.3%) were patients with ventricular hypertrophy, hypertension, and non-delayed epicardial coronary flow (NFLVH). Results The patients with SFLVH showed reduced peak early diastolic lateral mitral annular velocity (e'L) when compared to SCFP (7.1±1.9cm/s vs 8.6±2.1 cm/s, p=0.045) and NFLVH (7.1±1.9 cm/s vs 8.7±1.8 cm/s, p=0.018). A borderline significant difference was observed for the peak early diastolic septal mitral annular velocity (e'S) between the patients with SFLVH and SCFP ( 7.0±1.3 cm/s vs 8.3±2.1 cm/s, p=0.057). The ratio of mitral diastolic inflow velocity to early diastolic velocity of the mitral annulus (E/e') in the SFLVH group was a tendency higher than E/e' of the patients with SCFP (9.8±3.1 vs. 8.2±2.1, p=0.084) and NFLVH (9.8±3.1 vs. 7.8±1.5, p=0.051) .In the group with left ventricular hypertrophy, E/e' >10 was more frequently observed in patients with a marked delay in the epicardial flow (33.1 ± 13.1 frames vs. 25.4 ± 11.8 frames, p=0.011) and higher left ventricular mass (146.9 ± 17.7 g/m2 vs. 126.1 ± 121.5 g/m2, p=0.027). Conclusions Patients with microvascular angina represent a diverse population. The echocardiographic parameters of left ventricular relaxation (e') and end-diastolic pressure (E/e') are abnormally altered in the population with left ventricular hypertrophy compared to SCFP. The delayed epicardial flow further impairs diastolic function in hypertensive patients with hypertrophy and non-obstructive coronary disease.
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9
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Liu X, Xu C, Rao S, Zhang Y, Ghista D, Gao Z, Yang G. Physiologically personalized coronary blood flow model to improve the estimation of noninvasive fractional flow reserve. Med Phys 2022; 49:583-597. [PMID: 34792807 DOI: 10.1002/mp.15363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Coronary outlet resistance is influenced by the quantification and distribution of resting coronary blood flow. It is crucial for a more physiologically accurate estimation of fractional flow reserve (FFR) derived from computed tomography angiography (CTA), referred to as FFRCT. This study presents a physiologically personalized (PP)-based coronary blood flow model involving the outlet boundary condition (BC) and a standardized outlet truncation strategy to estimate the outlet resistance and FFRCT. METHODS In this study, a total of 274 vessels were retrospectively collected from 221 patients who underwent coronary CTA and invasive FFR within 14 days. For FFRCT determination, we have employed a PP-based outlet BC model involving personalized physiological parameters and left ventricular mass (LVM) to quantify resting coronary blood flow. We evaluated the improvement achieved in the diagnostic performance of FFRCT by using the PP-based outlet BC model relative to the LVM-based model, with respect to the invasive FFR. Additionally, in order to evaluate the impact of the outlet truncation strategy on FFRCT, 68 vessels were randomly selected and analyzed independently by two operators, by using two different outlet truncation strategies at 1-month intervals. RESULTS The per-vessel diagnostic performance of the PP-based outlet BC model was improved, based on invasive FFR as reference, compared to the LVM-based model: (i) accuracy/sensitivity/specificity: 91.2%/90.4%/91.8% versus 86.5%/84.6%/87.6%, for the entire dataset of 274 vessels, (ii) accuracy/sensitivity/specificity: 88.7%/82.4%/90.4% versus 82.4%/ 76.5%/84.0%, for moderately stenosis lesions. The standardized outlet truncation strategy showed good repeatability with the Kappa coefficient of 0.908. CONCLUSIONS It has been shown that our PP-based outlet BC model and standardized outlet truncation strategy can improve the diagnostic performance and repeatability of FFRCT.
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Affiliation(s)
- Xiujian Liu
- School of Biomedical Engineering, Sun Yat-sen University, Shenzhen, China
| | - Chuangye Xu
- School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Simin Rao
- Beijing GuanShengYun Medical Technology Co.,Ltd, Beijing, China
| | - Ye Zhang
- Beijing GuanShengYun Medical Technology Co.,Ltd, Beijing, China
| | - Dhanjoo Ghista
- University 2020 Foundation, Northborough, Massachusetts, USA
| | - Zhifan Gao
- School of Biomedical Engineering, Sun Yat-sen University, Shenzhen, China
| | - Guang Yang
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiovascular Research Centre, Royal Brompton Hospital, London, UK
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Beneficial Effects of Receiving Johrei on General Health or Hypothermia Tendency. Explore (NY) 2021; 18:446-456. [PMID: 34969609 DOI: 10.1016/j.explore.2021.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 11/05/2021] [Accepted: 12/04/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Johrei is a type of biofield therapy that is said to bring physical and mental well-being to the recipient. This study sought to measure changes in body temperature and circulation resulting from Johrei treatment, for generally healthy subjects and for individuals with a tendency toward hypothermia. PARTICIPANTS A total of 199 qualified Johrei practitioners and 144 non-qualified operators provided Johrei and placebo treatments, respectively. Volunteer subjects -186 in general health and 39 with a hypothermia tendency - participated in this study to receive either or both of these treatments. METHODS Each subject was given a 10 min treatment daily by either a qualified practitioner or a non-qualified operator. The effects on subjects of receiving each treatment were compared by observing quantitative changes in blood flow and surface body temperature after a course of treatment. RESULTS A total of 107 healthy subjects were randomly assigned to the qualified-practitioner group or the non-qualified operator group. Treatment by qualified practitioners significantly enhanced blood flow and surface body temperature in the subjects' designated neck area compared to that in treatment by non-qualified operators. This finding was further corroborated by a comparative experiment in which each healthy subject was treated by both a qualified practitioner and a non-qualified operator. These results indicate that only the qualified-practitioner treatment increased the subject's-blood flow and surface body temperature. Similarly, in a comparative study of qualified-practitioner treatment against non-qualified-operator treatment, subjects tending toward hypothermia showed increased blood flow and elevated body temperature with only the authentic Johrei treatment.
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Souza DS, Barreto TDO, Menezes-Filho JERD, Heimfarth L, Rhana P, Rabelo TK, Santana MNS, Durço AO, Conceição MRDL, Quintans-Júnior LJ, Guimarães AG, Cruz JS, Vasconcelos CMLD. Myocardial hypertrophy is prevented by farnesol through oxidative stress and ERK1/2 signaling pathways. Eur J Pharmacol 2020; 887:173583. [DOI: 10.1016/j.ejphar.2020.173583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/23/2022]
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12
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Suppogu N, Wei J, Nelson MD, Cook-Wiens G, Cheng S, Shufelt CL, Thomson LEJ, Tamarappoo B, Berman DS, Samuels B, Azarbal B, Anderson RD, Petersen JW, Handberg EM, Pepine CJ, Merz CNB. Resting coronary velocity and myocardial performance in women with impaired coronary flow reserve: Results from the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD) study. Int J Cardiol 2020; 309:19-22. [PMID: 32037132 PMCID: PMC7195998 DOI: 10.1016/j.ijcard.2020.01.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/07/2020] [Accepted: 01/22/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Women with evidence of ischemia and no obstructive coronary arteries (INOCA) often have coronary microvascular dysfunction (CMD) indicated by impaired coronary flow reserve (CFR) to adenosine. Low CFR is associated with an adverse prognosis, including incident heart failure. Because the CFR calculation relies on the baseline intrinsic coronary vasomotor flow velocity, a major determinate of CFR and the degree of variation in baseline flow alone may be an important contributor to risk of adverse outcomes in women with CMD. A better understanding of baseline blood flow in the setting of low CFR and its association with myocardial performance would be helpful. METHODS We evaluated 74 women who underwent invasive coronary reactivity testing in the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD) study and had impaired CFR (<2.32). We assessed the relationship between coronary artery baseline average peak velocity (bAPV) at rest and cardiac magnetic resonance imaging measures of left ventricular (LV) structure and function. RESULTS When stratified as low (<22 cm/s) versus high (≥22 cm/s) bAPV, there were no differences in cardiovascular risk factors, coronary plaque burden, or LV structure. However, low bAPV was associated with higher LV end-diastolic filling pressure (P = 0.04), lower LV ejection fraction (P = 0.001), and differences in late systolic and diastolic strain rates (P = 0.01 to 0.05). CONCLUSIONS In women with impaired CFR, low resting coronary flow velocity is associated with more adverse myocardial performance, which may contribute to risk for adverse outcomes and particularly heart failure in women with CMD.
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Affiliation(s)
- Nissi Suppogu
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael D Nelson
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; University of Texas at Arlington, USA
| | - Galen Cook-Wiens
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susan Cheng
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Chrisandra L Shufelt
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Balaji Tamarappoo
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bruce Samuels
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Babak Azarbal
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - R David Anderson
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - John W Petersen
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| | | | - Carl J Pepine
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Lin SR, Lin SY, Chen CC, Fu YS, Weng CF. Exploring a New Natural Treating Agent for Primary Hypertension: Recent Findings and Forthcoming Perspectives. J Clin Med 2019; 8:E2003. [PMID: 31744165 PMCID: PMC6912567 DOI: 10.3390/jcm8112003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/14/2019] [Accepted: 11/14/2019] [Indexed: 12/13/2022] Open
Abstract
Primary hypertension describes abnormally-high systolic/diastolic blood pressure in a resting condition caused by various genetic or environmental risk factors. Remarkably, severe complications, such as ischemic cardiovascular disease, stroke, and chronic renal disease have led to primary hypertension becoming a huge burden for almost one-third of the total population. Medication is the major regimen for treating primary hypertension; however, recent medications may have adverse effects that attenuate energy levels. Hence, the search for new hypotensive agents from folk or traditional medicine may be fruitful in the discovery and development of new drugs. This review assembles recent findings for natural antihypertensive agents, extracts, or decoctions published in PubMed, and provides insights into the search for new hypotensive compounds based on blood-pressure regulating mechanisms, including the renin-angiotensin-aldosterone system and the sympathetic/adrenergic receptor/calcium channel system.
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Affiliation(s)
- Shian-Ren Lin
- Department of Life Science and Institute of Biotechnology, National Dong Hwa University, Hualien 97401, Taiwan; (S.-R.L.); (C.-C.C.)
- Graduate Institute of Cancer Biology and Drug Discovery, Taipei Medical University, Taipei 110, Taiwan
| | - Shiuan-Yea Lin
- Department of Anatomy, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Ching-Cheng Chen
- Department of Life Science and Institute of Biotechnology, National Dong Hwa University, Hualien 97401, Taiwan; (S.-R.L.); (C.-C.C.)
- Camillian Saint Mary’s Hospital Luodong,160 Zhongzheng S. Rd. Luodong, Yilan 26546, Taiwan
| | - Yaw-Syan Fu
- Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Center for Infectious Disease and Cancer Research, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Ching-Feng Weng
- Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Basic Medical Science, Center for Transitional Medicine, Xiamen Medical College, Xiamen 361023, China
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14
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Yim J, Rabkin SW. A patient-specific approach to assessing blood pressure management in patients with hypertension and coronary artery disease. J Clin Hypertens (Greenwich) 2018; 20:233-239. [PMID: 29370480 DOI: 10.1111/jch.13191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/02/2017] [Accepted: 11/07/2017] [Indexed: 11/30/2022]
Abstract
The objective was to improve the management of patients with hypertension (HTN) and coronary artery disease (CAD), utilizing a model which integrates 3 determinants of coronary blood flow (CBF)-CAD severity, diastolic blood pressure (DBP), and left ventricular (LV) mass. We validated non-parametric equations for CBF estimation in a consecutive patient sample (N = 81) with HTN and CAD. There was a highly significant correlation (r = .565; P < .01) between clinical DBP and estimated CBF. Greater LV mass and more severe CAD shifted the relationship towards less CBF at the same DBP. LV mass was more critical when DBP >70 mm Hg. Estimated changes in CBF at different DBP considering the severity of CAD and LV mass can be calculated. In summary, the severity of CAD from coronary CT or coronary angiography combined with LV mass from echocardiography permits clinicians to guide the extent of, or target for, DBP to avoid seriously compromising CBF.
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Affiliation(s)
- Jeffrey Yim
- Department of Medicine (Cardiology), University of British Columbia, Vancouver, BC, Canada
| | - Simon W Rabkin
- Department of Medicine (Cardiology), University of British Columbia, Vancouver, BC, Canada
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15
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Lamb SA, Al Hamarneh YN, Houle SKD, Leung AA, Tsuyuki RT. Hypertension Canada's 2017 guidelines for diagnosis, risk assessment, prevention and treatment of hypertension in adults for pharmacists: An update. Can Pharm J (Ott) 2018; 151:33-42. [PMID: 29317935 PMCID: PMC5755821 DOI: 10.1177/1715163517743525] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sarah A. Lamb
- the Faculty of Pharmacy and Pharmaceutical Sciences (Lamb), Department of Medicine (Al Hamarneh, Tsuyuki), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
- the School of Pharmacy (Houle), University of Waterloo, Ontario
- the Department of Medicine (Leung), University of Calgary, Alberta
| | - Yazid N. Al Hamarneh
- the Faculty of Pharmacy and Pharmaceutical Sciences (Lamb), Department of Medicine (Al Hamarneh, Tsuyuki), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
- the School of Pharmacy (Houle), University of Waterloo, Ontario
- the Department of Medicine (Leung), University of Calgary, Alberta
| | - Sherilyn K. D. Houle
- the Faculty of Pharmacy and Pharmaceutical Sciences (Lamb), Department of Medicine (Al Hamarneh, Tsuyuki), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
- the School of Pharmacy (Houle), University of Waterloo, Ontario
- the Department of Medicine (Leung), University of Calgary, Alberta
| | - Alexander A. Leung
- the Faculty of Pharmacy and Pharmaceutical Sciences (Lamb), Department of Medicine (Al Hamarneh, Tsuyuki), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
- the School of Pharmacy (Houle), University of Waterloo, Ontario
- the Department of Medicine (Leung), University of Calgary, Alberta
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16
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Leung AA, Daskalopoulou SS, Dasgupta K, McBrien K, Butalia S, Zarnke KB, Nerenberg K, Harris KC, Nakhla M, Cloutier L, Gelfer M, Lamarre-Cliche M, Milot A, Bolli P, Tremblay G, McLean D, Tran KC, Tobe SW, Ruzicka M, Burns KD, Vallée M, Prasad GVR, Gryn SE, Feldman RD, Selby P, Pipe A, Schiffrin EL, McFarlane PA, Oh P, Hegele RA, Khara M, Wilson TW, Penner SB, Burgess E, Sivapalan P, Herman RJ, Bacon SL, Rabkin SW, Gilbert RE, Campbell TS, Grover S, Honos G, Lindsay P, Hill MD, Coutts SB, Gubitz G, Campbell NRC, Moe GW, Howlett JG, Boulanger JM, Prebtani A, Kline G, Leiter LA, Jones C, Côté AM, Woo V, Kaczorowski J, Trudeau L, Tsuyuki RT, Hiremath S, Drouin D, Lavoie KL, Hamet P, Grégoire JC, Lewanczuk R, Dresser GK, Sharma M, Reid D, Lear SA, Moullec G, Gupta M, Magee LA, Logan AG, Dionne J, Fournier A, Benoit G, Feber J, Poirier L, Padwal RS, Rabi DM. Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults. Can J Cardiol 2017; 33:557-576. [PMID: 28449828 DOI: 10.1016/j.cjca.2017.03.005] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 03/04/2017] [Accepted: 03/05/2017] [Indexed: 01/29/2023] Open
Abstract
Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.
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Affiliation(s)
- Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Stella S Daskalopoulou
- Divisions of General Internal Medicine, Clinical Epidemiology and Endocrinology, Department of Medicine, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kaberi Dasgupta
- Divisions of General Internal Medicine, Clinical Epidemiology and Endocrinology, Department of Medicine, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kerry McBrien
- Departments of Family Medicine and Community Health Sciences, Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sonia Butalia
- Departments of Medicine and Community Health Sciences, Libin Cardiovascular Institute of Alberta, O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Kelly B Zarnke
- Division of General Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kara Nerenberg
- Department of Medicine and Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Kevin C Harris
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Meranda Nakhla
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Lyne Cloutier
- Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Mark Gelfer
- Department of Family Medicine, University of British Columbia, Copeman Healthcare Centre, Vancouver, British Columbia, Canada
| | - Maxime Lamarre-Cliche
- Institut de Recherches Cliniques de Montréal, Université de Montréal, Montréal, Quebec, Canada
| | - Alain Milot
- Department of Medicine, Université Laval, Québec, Quebec, Canada
| | - Peter Bolli
- McMaster University, Hamilton, Ontario, Canada
| | - Guy Tremblay
- CHU-Québec-Hopital St Sacrement, Québec, Quebec, Canada
| | - Donna McLean
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Marcel Ruzicka
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kevin D Burns
- Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel Vallée
- Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Quebec, Canada
| | | | - Steven E Gryn
- Department of Medicine, Division of Clinical Pharmacology, Western University, London, Ontario, Canada
| | - Ross D Feldman
- Discipline of Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador
| | - Peter Selby
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Pipe
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ernesto L Schiffrin
- Department of Medicine and Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Philip A McFarlane
- Division of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Oh
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert A Hegele
- Departments of Medicine (Division of Endocrinology) and Biochemistry, Western University, London, Ontario, Canada
| | - Milan Khara
- Vancouver Coastal Health Addiction Services, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas W Wilson
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - S Brian Penner
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ellen Burgess
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Praveena Sivapalan
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Robert J Herman
- Division of General Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simon L Bacon
- Department of Exercise Science, Concordia University, and Montreal Behavioural Medicine Centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM), Hôpital du Sacré-Coeur de Montréal, Montréal, Quebec, Canada
| | - Simon W Rabkin
- Vancouver Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard E Gilbert
- University of Toronto, Division of Endocrinology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tavis S Campbell
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Steven Grover
- Division of Clinical Epidemiology, Montreal General Hospital, Montreal, Quebec, Canada
| | - George Honos
- University of Montreal, Montreal, Quebec, Canada
| | - Patrice Lindsay
- Stroke, Heart and Stroke Foundation of Canada, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Shelagh B Coutts
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gord Gubitz
- Division of Neurology, Halifax Infirmary, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Norman R C Campbell
- Medicine, Community Health Sciences, Physiology and Pharmacology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Gordon W Moe
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan G Howlett
- Departments of Medicine and Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jean-Martin Boulanger
- Charles LeMoyne Hospital Research Centre, Sherbrooke University, Sherbrooke, Quebec, Canada
| | | | - Gregory Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lawrence A Leiter
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Charlotte Jones
- University of British Columbia, Southern Medical Program, Kelowna, British Columbia, Canada
| | | | - Vincent Woo
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Janusz Kaczorowski
- Université de Montréal and Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Quebec, Canada
| | - Luc Trudeau
- Division of Internal Medicine, McGill University, Montréal, Quebec, Canada
| | - Ross T Tsuyuki
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Swapnil Hiremath
- Faculty of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Denis Drouin
- Faculty of Medicine, Université Laval, Québec, Quebec, Canada
| | - Kim L Lavoie
- Department of Psychology, University of Quebec at Montreal, Montréal, Quebec, Canada
| | - Pavel Hamet
- Faculté de Médicine, Université de Montréal, Montréal, Quebec, Canada
| | - Jean C Grégoire
- Université de Montréal, Institut de cardiologie de Montréal, Montréal, Quebec, Canada
| | | | - George K Dresser
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Mukul Sharma
- McMaster University, Hamilton Health Sciences Population Health Research Institute, Hamilton, Ontario, Canada
| | - Debra Reid
- Centre intégré de santé et de services sociaux (CISSS) de l'Outaouais, Groupes de médecine de famille (GMF) de Wakefield, Wakefield, Quebec, Canada
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Gregory Moullec
- Research Center, Hôpital du Sacré-Coeur de Montréal, Public Health School, University of Montréal, Montréal, Quebec, Canada
| | - Milan Gupta
- McMaster University, Hamilton, Ontario, and Canadian Collaborative Research Network, Brampton, Ontario, Canada
| | - Laura A Magee
- St George's, University of London and the St George's Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | | | - Janis Dionne
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anne Fournier
- Service de cardiologie, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Geneviève Benoit
- Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Janusz Feber
- Division of Neurology, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Luc Poirier
- Centre Hospitalier Universitaire de Québec et Faculté de Pharmacie, Université Laval, Québec, Quebec, Canada
| | - Raj S Padwal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Doreen M Rabi
- Departments of Medicine, Community Health and Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
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