The Duke treadmill score with bicycle ergometer: Exercise capacity is the most important predictor of cardiovascular mortality

Background

The Duke treadmill score, a widely used treadmill testing tool, is a weighted index combining exercise time or capacity, maximum ST-segment deviation and exercise-induced angina. No previous studies have investigated whether the Duke treadmill score and its individual components based on bicycle exercise testing predict cardiovascular death.

Design

Two populations with a standard bicycle testing were used: 3936 patients referred for exercise testing (2371 men, age 56 ± 13 years) from the Finnish Cardiovascular Study (FINCAVAS) and a population-based sample of 2683 men (age 53 ± 5.1 years) from the Kuopio Ischaemic Heart Disease study (KIHD).

Methods

Cox regression was applied for risk prediction with cardiovascular mortality as the primary endpoint.

Results

In FINCAVAS, during a median 6.3-year (interquartile range (IQR) 4.5–8.2) follow-up period, 180 patients (4.6%) experienced cardiovascular mortality. In KIHD, 562 patients (21.0%) died from cardiovascular causes during the median follow-up of 24.1 (IQR 18.0–26.2) years. The Duke treadmill score was associated with cardiovascular mortality in both populations (FINCAVAS, adjusted hazard ratio (HR) 3.15 for highest vs. lowest Duke treadmill score tertile, 95% confidence interval (CI) 1.83–5.42, P < 0.001; KIHD, adjusted HR 1.71, 95% CI 1.34–2.18, P < 0.001). However, after progressive adjustment for the Duke treadmill score components, the score was not associated with cardiovascular mortality in either study population, as exercise capacity in metabolic equivalents of task was the dominant harbinger of poor prognosis.

Conclusions

The Duke treadmill score is associated with cardiovascular mortality among patients who have undergone bicycle exercise testing, but metabolic equivalents of task, a component of the Duke treadmill score, proved to be a superior predictor.

Increased Cardiac Workload in the Upright Posture in Men: Noninvasive Hemodynamics in Men Versus Women

Background

Men and women differ in the risk of cardiovascular disease, but the underlying mechanisms are not completely understood. We examined possible sex‐related differences in supine and upright cardiovascular regulation.

Methods and Results

Hemodynamics were recorded from 167 men and 167 women of matching age (≈45 years) and body mass index (≈26.5) during passive head‐up tilt. None had diabetes mellitus or cardiovascular disease other than hypertension or used antihypertensive medication. Whole‐body impedance cardiography, tonometric radial blood pressure, and heart rate variability were analyzed. Results were adjusted for height, smoking, alcohol intake, mean arterial pressure, plasma lipids, and glucose. Supine hemodynamic differences were minor: Men had lower heart rate (−4%) and higher stroke index (+7.5%) than women (P<0.05 for both). Upright systemic vascular resistance was lower (−10%), but stroke index (+15%), cardiac index (+16%), and left cardiac work were clearly higher (+20%) in men than in women (P<0.001 for all). Corresponding results were observed in a subgroup of men and postmenopausal women (n=76, aged >55 years). Heart rate variability analyses showed higher low:high frequency ratios in supine (P<0.001) and upright (P=0.003) positions in men.

Conclusions

The foremost difference in cardiovascular regulation between sexes was higher upright hemodynamic workload for the heart in men, a finding not explained by known cardiovascular risk factors or hormonal differences before menopause. Heart rate variability analyses indicated higher sympathovagal balance in men regardless of body position. The deviations in upright hemodynamics could play a role in the differences in cardiovascular risk between men and women.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01742702.

Central wave reflection is associated with peripheral arterial resistance in addition to arterial stiffness in subjects without antihypertensive medication

Background

Augmentation index, a marker of central wave reflection, is influenced by age, sex, height, blood pressure, heart rate, and arterial stiffness. However, the detailed haemodynamic determinants of augmentation index, and their relations, remain uncertain. We examined the association of augmentation index with vascular resistance and other haemodynamic and non-haemodynamic factors.

Methods

Background information, laboratory values, and haemodynamics of 488 subjects (239 men, 249 women) without antihypertensive medication were obtained. Indices of central wave reflection, systemic vascular resistance, cardiac function, and pulse wave velocity were measured using continuous radial pulse wave analysis and whole-body impedance cardiography.

Results

In a regression model including only haemodynamic variables, augmentation index in males and female subjects, respectively, was associated with systemic vascular resistance (β = 0.425, β = 0.336), pulse wave velocity (β = 0.409, β = 0.400) (P < 0.001 for all), stroke volume (β = 0.256, β = 0.278) (P = 0.001 for both) and heart rate (β = −0.150, β = −0.156) (P = 0.049 and P = 0.036). When age, height, weight, smoking habits, and laboratory values were included in the regression model, the most significant explanatory variables for augmentation index in males and females, respectively, were age (β = 0.577, β = 0.557) and systemic vascular resistance (β = 0.437, β = 0.295) (P < 0.001 for all). In the final regression model, pulse wave velocity was not a significant explanatory variable for augmentation index, probably due to the high correlation of this variable with age (Spearman’s correlation ≥0.617).

Conclusion

Augmentation index is strongly associated with systemic vascular resistance in addition to arterial stiffness.

Trial registration

ClinicalTrials.gov, NCT01742702.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0303-6) contains supplementary material, which is available to authorized users.

The type of the functional cardiovascular response to upright posture is associated with arterial stiffness: a cross-sectional study in 470 volunteers

BACKGROUND

In a cross-sectional study we examined whether the haemodynamic response to upright posture could be divided into different functional phenotypes, and whether the observed phenotypes were associated with known determinants of cardiovascular risk.

METHODS

Volunteers (n = 470) without medication with cardiovascular effects were examined using radial pulse wave analysis, whole-body impedance cardiography, and heart rate variability analysis. Based on the passive head-up tilt induced changes in systemic vascular resistance and cardiac output, the principal determinants of blood pressure, a cluster analysis was performed.

RESULTS

The haemodynamic response could be clustered into 3 categories: upright increase in vascular resistance and decrease in cardiac output were greatest in the first (+45 % and -27 %, respectively), smallest in the second (+2 % and -2 %, respectively), and intermediate (+22 % and -13 %, respectively) in the third group. These groups were named as 'constrictor' (n = 109), 'sustainer' (n = 222), and 'intermediate' (n = 139) phenotypes, respectively. The sustainers were characterized by male predominance, higher body mass index, blood pressure, and also by higher pulse wave velocity, an index of large arterial stiffness, than the other groups (p < 0.01 for all). Heart rate variability analysis showed higher supine and upright low frequency/high frequency (LF/HF) ratio in the sustainers than constrictors, indicating increased sympathovagal balance. Upright LF/HF ratio was also higher in the sustainer than intermediate group. In multivariate analysis, independent explanatory factors for higher pulse wave velocity were the sustainer (p < 0.022) and intermediate phenotypes (p < 0.046), age (p < 0.001), body mass index (p < 0.001), and hypertension (p < 0.001).

CONCLUSIONS

The response to upright posture could be clustered to 3 functional phenotypes. The sustainer phenotype, with smallest upright decrease in cardiac output and highest sympathovagal balance, was independently associated with increased large arterial stiffness. These results indicate an association of the functional haemodynamic phenotype with an acknowledged marker of cardiovascular risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01742702.

Lower glomerular filtration rate is associated with higher systemic vascular resistance in patients without prevalent kidney disease

The authors examined the association between estimated glomerular filtration rate (eGFR), calculated using the Chronic Kidney Disease Epidemiology Collaboration creatinine-cystatin C equation, and hemodynamics in 556 normotensive or never-treated hypertensive patients without kidney disease (mean age, 46 years). Hemodynamic variables were recorded using pulse wave analysis and whole-body impedance cardiography. The mean eGFR was 98 mL/min/1.73 m(2) (range, 64-145 mL/min/1.73 m(2) and one third of the patients had values below 92, while none had proteinuria. In linear regression analyses adjusted for differences in age, weight:height ratio, low-density lipoprotein cholesterol, and sex, significant associations were found between lower eGFR and higher systolic (P=.001) and diastolic blood pressure (P<.001) and higher systemic vascular resistance (P=.001). There was no association between eGFR and cardiac output or extracellular volume. In the absence of clinical kidney disease, lower eGFR was associated with higher blood pressure and systemic vascular resistance. Therefore, early impairment in kidney function may be involved in the pathogenesis of essential hypertension.

Daily liquorice consumption for two weeks increases augmentation index and central systolic and diastolic blood pressure

BACKGROUND

Liquorice ingestion often elevates blood pressure, but the detailed haemodynamic alterations are unknown. We studied haemodynamic changes induced by liquorice consumption in 20 subjects versus 30 controls with average blood pressures of 120/68 and 116/64 mmHg, respectively.

METHODS

Haemodynamic variables were measured in supine position before and after two weeks of liquorice consumption (daily glycyrrhizin dose 290-370 mg) with tonometric recording of radial blood pressure, pulse wave analysis, and whole-body impedance cardiography. Thirty age-matched healthy subjects maintaining their normal diet were studied as controls.

RESULTS

Two weeks of liquorice ingestion elevated peripheral and central systolic and diastolic blood pressure (by 7/4 and 8/4 mmHg, 95% confidence intervals [CI] 2-11/1-8 and 3-13/1-8, respectively, P<0.05), and increased extracellular volume by 0.5 litres (P<0.05 versus controls). Also augmentation index adjusted to heart rate 75/min (from 7% to 11%, 95% CI for change 0.3-7.5, P<0.05) and aortic pulse pressure (by 4 mmHg, 95% CI 1-7, P<0.05) were elevated indicating increased wave reflection from the periphery. In contrast, peripheral (-3/-0.3 mmHg) and central blood pressure (-2/-0.5 mmHg), aortic pulse pressure (-1 mmHg), and augmentation index adjusted to heart rate 75/min (from 9% to 7%) decreased numerically but not statistically significantly without changes in extracellular volume in the control group. Heart rate, systemic vascular resistance, cardiac output, and pulse wave velocity did not differ between the groups.

CONCLUSIONS

Two weeks of daily liquorice consumption increased extracellular volume, amplified pressure wave reflection from the periphery, and elevated central systolic and diastolic blood pressure.

TRIAL REGISTRATION

EU Clinical Trials Register EudraCT 2006-002065-39 ClinicalTrials.gov NCT01742702.

Association of resting heart rate with cardiovascular function: a cross-sectional study in 522 Finnish subjects

Background

High resting heart rate (HR) is associated with increased cardiovascular risk in general populations, possibly due to elevated blood pressure (BP) or sympathetic over-activity. We studied the association of resting HR with cardiovascular function, and examined whether the hemodynamics remained similar during passive head-up tilt.

Methods

Hemodynamics were recorded using whole-body impedance cardiography and continuous radial pulse wave analysis in 522 subjects (age 20–72 years, 261 males) without medication influencing HR or BP, or diagnosed diabetes, coronary artery, renal, peripheral arterial, or cerebrovascular disease. Correlations were calculated, and results analysed according to resting HR tertiles.

Results

Higher resting HR was associated with elevated systolic and diastolic BP, lower stroke volume but higher cardiac output and work, and lower systemic vascular resistance, both supine and upright (p < 0.05 for all). Subjects with higher HR also showed lower supine and upright aortic pulse pressure and augmentation index, and increased resting pulse wave velocity (p < 0.001). Upright stroke volume decreased less in subjects with highest resting HR (p < 0.05), and cardiac output decreased less in subjects with lowest resting HR (p < 0.009), but clear hemodynamic differences between the tertiles persisted both supine and upright.

Conclusions

Supine and upright hemodynamic profile associated with higher resting HR is characterized by higher cardiac output and lower systemic vascular resistance. Higher resting HR was associated with reduced central wave reflection, in spite of elevated BP and arterial stiffness. The increased cardiac workload, higher BP and arterial stiffness, may explain why higher HR is associated with less favourable prognosis in populations.

Trial registration

ClinicalTrials.gov, NCT01742702

Metabolic syndrome may be associated with increased arterial stiffness even in the absence of hypertension: a study in 84 cases and 82 controls

OBJECTIVE

To evaluate the hemodynamic characteristics of metabolic syndrome (MetS) in the absence and presence of hypertension.

MATERIALS/METHODS

Altogether 166 subjects without previously diagnosed cardiovascular disease, diabetes, or antihypertensive medication, were allocated to four groups: control, hypertension only, MetS without hypertension, and MetS with hypertension (mean age 44-46 years). Cut-point for hypertension was blood pressure ≥140/90 mmHg. Other criteria of MetS were as defined by Alberti et al. 2009. Hemodynamic variables were measured using whole-body impedance cardiography and pulse wave analysis.

RESULTS

Pulse wave velocity was higher in hypertensive and normotensive subjects with MetS than controls (p<0.05), and in the hypertensive MetS group than subjects with hypertension only (p<0.05). Aortic pulse pressure was higher in the two hypertensive groups than the two normotensive groups (p<0.05). Systemic vascular resistance index was higher in the hypertensive than normotensive MetS group (p<0.05), and in the group with hypertension alone than in controls (p<0.05). Heart rate was higher in the hypertensive Mets group than in controls and subjects with hypertension only (p<0.05). Cardiac index did not differ, while stroke index was lower in both groups with MetS than groups without MetS. Augmentation pressure was higher in the hypertensive MetS group than in controls and normotensive MetS group (p<0.05).

CONCLUSIONS

Pulse wave velocity, an acknowledged marker of arterial stiffness, was associated with MetS even in the absence of hypertension. This emphasizes the importance of the prevention and treatment of MetS.

Comparison of the effects of esomeprazole and fundoplication on airway responsiveness in patients with gastro-oesophageal reflux disease

INTRODUCTION

Gastro-oesophageal reflux disease (GORD) is suggested to cause or aggravate several respiratory conditions. Studies with proton pump inhibitors have resulted in only minor improvements in pulmonary outcomes in patients with GORD. It has been speculated that operative treatment of GORD might be more efficient as it also diminishes non-acidic reflux.

OBJECTIVES

To compare the effects of esomeprazole 40 mg bid and fundoplication on airway responsiveness, forced expiratory volume in 1 s (FEV1), exhaled nitric oxide (NO) and respiratory symptoms in patients with moderate-to-severe GORD.

METHODS

Sixty-nine GORD patients had methacholine inhalation challenge performed on them, and FEV1, exhaled NO and respiratory symptoms were measured at baseline, after a 3-month treatment with esomeprazole and 3 months after fundoplication. Primary outcome variable was dose-response slope (DRS), i.e. decline in FEV1 during methacholine challenge divided with the amount of methacholine administered (%/μmol). Pre-defined subgroup analysis was performed among those with concomitant asthma (n = 12).

RESULTS

There was no improvement in DRS, FEV1 or exhaled NO after esomeprazole treatment or fundoplication. Cough and dyspnoea measured with visual analog scale improved with esomeprazole treatment (P < 0.001), and further after fundoplication (P < 0.001). Among those with concomitant asthma, significant improvements in St George Respiratory Questionnaire (SGRQ) scores could be seen after fundoplication.

CONCLUSIONS

Neither esomeprazole treatment nor fundoplication diminishes airway responsiveness or exhaled NO, or improves FEV1 in patients with GORD. Improvements in respiratory symptoms and SGRQ scores after GORD treatments could be detected. However, as this was not a placebo-controlled study, the findings in these secondary endpoints should not be emphasised. ClinicalTrials.cov: NCT00994708.

Allelic variant of NOS1AP effects on cardiac alternans of repolarization during exercise testing

INTRODUCTION

A repolarization abnormality manifested as T-wave alternans (TWA) in electrocardiogram (ECG) predicts cardiovascular mortality. A common variant in the NOS1AP gene is associated with mortality and QT interval duration, possibly in a gender-specific manner, but data is lacking on potential association with TWA. This study tested association between rs10494366 in NOS1AP and both TWA and 4-year mortality.

MATERIAL AND METHODS

A total of 1963 Finnish Cardiovascular Study participants (36.6% female, 57.1 ± 13.0 years) were genotyped and their maximal TWA values were measured from continuous ECG recordings during clinical exercise test at rest, exercise and recovery.

RESULTS

We observed a significant gender-specific effect of NOS1AP genotype on TWA. In all subjects, there was no statistically significant difference between the three genotypes (TT, TG, GG) in the responses of TWA over the entire exercise test (time-by-genotype interaction p = 0.057). In women, after adjustment for age, coronary heart disease and β-blocker medication status, changes of TWA over different phases of exercise test were significantly associated with NOS1AP genotype (time-by-genotype interaction p = 0.001). In men, NOS1AP rs10494366 was not associated with TWA. During follow-up (mean 47 months), 113 patients died. NOS1AP rs10494366 was not a statistically significant predictor of mortality.

CONCLUSION

The NOSIAP variant rs10494366 influences TWA and TWA response during clinical exercise test in females. Gender-specific effects have also been previously reported for the influence of the variant on QT interval. If replicated, these findings should prompt studies to further elucidate the mechanisms underlying the gender differences in NOS1AP effects on repolarization.

Arterial tension time reflects subclinical atherosclerosis, arterial stiffness and stroke volume

OBJECTIVE

To introduce and evaluate a new haemodynamic parameter known as arterial tension time (ATT) and study whether ATT is associated with traditional cardiovascular risk factors as well as with indices of arterial stiffness, cardiac pump function and subclinical atherosclerosis.

METHODS

  Arterial tension time was measured from the whole-body impedance cardiography (ICG) signal and defined as the time difference between the onset of arterial distension induced by stroke volume (SV) and maximal integrated arterial distension. As measures of subclinical atherosclerosis and arterial stiffness, carotid artery intima-media thickness (IMT), Young's elastic modulus (YEM), arterial stiffness index (ASI) and carotid artery compliance (CAC) were assessed with ultrasound in 336 Finnish adults (aged 46-76 years, 43·2% men) participating in the Health 2000 Survey. In addition, pulse wave velocity (PWV) and stroke volume index (SI), as indices of arterial stiffness and cardiac pump function, were assessed with ICG.

RESULTS

  Arterial tension time was associated inversely with PWV, IMT, YEM and ASI (P<0·002 for all) and directly with SI and CAC (P<0·001 for both). Age, systolic blood pressure, diastolic blood pressure and fasting glucose were independent determinants of decreased ATT (P<0·04 for all). Moreover, accumulation of cardiovascular risk factors was associated with the decrease in ATT (P for trend <0·001).

CONCLUSION

Decreased ATT was associated with increased arterial stiffness, increased subclinical atherosclerosis and decreased SV. Current results suggest that ATT provides simultaneous information on several aspects of cardiovascular structure and function and could possibly serve as a new integrated parameter for cardiovascular risk stratification.

Metabolic syndrome in childhood and increased arterial stiffness in adulthood: the Cardiovascular Risk In Young Finns Study

OBJECTIVE. We conducted the present study to examine the associations of two different paediatric metabolic syndrome (MetS) definitions and recovery from childhood MetS with arterial pulse wave velocity (PWV), an index of arterial stiffness, measured in adulthood. METHODS. A total of 945 subjects participated in the base-line study in 1986 (then aged 9-18 years) and the adult follow-up in 2007 (then aged 30-39 years). Cardiovascular risk factor data were available at both base-line and follow-up. In the follow-up study, arterial PWV was measured using a whole-body impedance cardiography device. RESULTS. Subjects suffering from MetS in childhood (prevalence 11.1%-14.1%) had higher arterial PWV after 21-year follow-up when compared with those not afflicted by the syndrome in childhood (P < 0.007). An increasing number of the MetS components in childhood were associated with increased PWV in adulthood (P for trend = 0.005). Subjects who recovered from the MetS during the 21-year follow-up period had lower PWV than those with persistent MetS (P < 0.001). CONCLUSION. MetS in childhood predicted increased arterial stiffness in adulthood, and recovery from childhood MetS was associated with decreased arterial PWV in adulthood. The current results emphasize the importance of the prevention and controlling of MetS risk factors both in childhood and adulthood.

Systemic hemodynamics in relation to glucose tolerance: the Health 2000 Survey

The influence of impaired glucose metabolism--that is, impaired fasting glucose, impaired glucose tolerance (IGT), and type 2 diabetes mellitus diabetes (DM2)--on systemic hemodynamics is largely unknown. Therefore, we investigated the associations of glucose metabolism disturbances with stroke index (SI), cardiac index, systemic vascular resistance index (SVRI), arterial pulse wave velocity (PWV), and heart rate among Finnish adults (N = 389; mean age, 58.3 ± 7.9 years) participating in the Health 2000 Survey. Systemic hemodynamic parameters were measured using the whole-body impedance cardiography device, and an oral glucose tolerance test (OGTT) was performed to evaluate glucose tolerance status. We found a decreasing trend for SI and increasing trends for SVRI and PWV according to the worsening of glucose tolerance (P for trend < .003 for all). In pairwise comparisons, SI was lower in the impaired fasting glucose group (P = .041) and the IGT group (P < .001) as compared with the normal glucose tolerance (NGT) group. Systemic vascular resistance index was higher in the IGT group (P = .045) and the DM2 group (P = .043) than in the NGT group. Subjects with IGT or DM2 had higher arterial PWV (10.7 ± 0.2 m/s, P < .001 and 11.7 ± 0.5 m/s, P = .001, respectively) than subjects with NGT (9.5 ± 0.1 m/s). Moreover, 2-hour glucose in OGTT was an independent determinant of SVRI and PWV (P < .001 and P = .005, respectively) in multivariable linear regression models. In conclusion, the present study demonstrates that glucose intolerance, even without DM2, associates with several adverse changes in systemic hemodynamics and that 2-hour glucose in OGTT is an independent determinant of SVRI and PWV. These findings support the systematic evaluation of glucose tolerance status in the estimation of cardiovascular risk among the middle-aged population.

Reduced systemic vascular resistance in healthy volunteers with presyncopal symptoms during a nitrate-stimulated tilt-table test

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Nitrates may facilitate syncope through various pathways, but the precise mechanism of nitrate-induced syncope is still under debate. The purpose of the present study was to compare the underlying haemodynamic mechanisms in subjects without and with presyncopal symptoms during a nitroglycerin-stimulated tilt-table test.

WHAT THIS STUDY ADDS

A major decrease in systemic vascular resistance was documented in subjects with presyncope during 0.25 mg nitroglycerin-stimulated tilt-table test, in the absence of changes in cardiac output. These findings indicated that even a small dose of nitroglycerin significantly decreased arterial resistance and cardiac afterload. AIMS The mechanism of nitrate-induced syncope remains controversial. We examined the haemodynamic changes in healthy volunteers during nitroglycerin-stimulated tilt-table test.

METHODS

Continuous radial pulse wave analysis, whole-body impedance cardiography and plethysmographic finger blood pressure were recorded in a supine position and during head-up tilt in 21 subjects with presyncopal symptoms (6 male/15 female, age 43 ± 3 years) after 0.25 mg sublingual nitroglycerin and 21 control subjects (6 male/15 female, age 43 ± 2 years). The drug was administered in the supine position and a passive head-up tilt followed 5 min later. Additionally, nitroglycerin was only administered during head-up tilt in 19 subjects and the haemodynamics were recorded.

RESULTS

Supine and upright haemodynamics were similar before nitroglycerin administration in the two groups. During the nitroglycerin-stimulated tilt test, aortic and radial mean blood pressure decreased significantly more in the presyncope group when compared with the controls (P= 0.0006 and P= 0.0004, respectively). The decreases in systemic vascular resistance (P= 0.0008) and heart rate (P= 0.002), and increase in aortic reflection time (P= 0.0002) were greater in the presyncope group, while the change in cardiac index was not different between the groups (P= 0.14). If nitroglycerin was administered during the upright tilt and not in supine position, the haemodynamic changes were quite corresponding.

CONCLUSIONS

Presyncopal symptoms during nitrate-stimulated tilt test were explained by decreased systemic vascular resistance and increased aortic reflection time, while cardiac output remained unchanged. These findings indicated reduced arterial resistance in nitroglycerin-induced presyncope.

Preoperative levosimendan infusion in combined aortic valve and coronary bypass surgery

BACKGROUND

Cardiopulmonary bypass may have detrimental effects on intestinal function and decrease the concentrations of the active, long-acting metabolites of levosimendan, an inodilator used to improve cardiac function. The aim of this study was to evaluate the haemodynamic effects of preoperative levosimendan in patients undergoing high-risk cardiac surgery.

METHODS

Twenty-four patients were randomized to receive levosimendan (12 µg bolus followed by an infusion of 0.2 µg kg(-1) min(-1)) or a placebo 24 h before surgery. The inclusion criteria were left ventricular ejection fraction (LVEF) <50% or LV hypertrophy indicated by a wall thickness of >12 mm. Haemodynamics were recorded every hour for 24 h (pulmonary artery catheter) and daily until postoperative day 4 (whole-body impedance cardiography). Doppler echocardiography with tissue Doppler imaging was used to assess systolic and diastolic cardiac function.

RESULTS

The cardiac index (CI) and stroke volume index (SI) were higher in the levosimendan group (LG) for the 4 day postoperative period (P<0.05); on the fourth postoperative day, the CI was 3.0 litre m(-2) min(-1) in the LG compared with 2.4 litre m(-2) min(-1) in the control group (CG) and the SI was 30 vs 25 ml m(-2), respectively. The LVEF measured at baseline and on the fourth postoperative morning decreased in the CG, but was maintained in the LG.

CONCLUSIONS

Levosimendan improved haemodynamics compared with a placebo in patients undergoing high-risk cardiac surgery. The concentrations of levosimendan's metabolites were higher compared with earlier studies using perioperative dosing.

Systemic hemodynamics in young adults with the metabolic syndrome: the Cardiovascular Risk in Young Finns Study

OBJECTIVE

We conducted the present study to examine associations of three different metabolic syndrome (MetS) definitions and their components to arterial stiffness, systemic vascular resistance, and left ventricular function at population level. In addition, the objective of the study was to examine associations of spontaneous recovery from MetS over 6 years' follow-up to systemic hemodynamics.

METHODS

The study population consisted of 1,741 Finnish young adults (aged 30-45 years) who had complete MetS risk factor and hemodynamic data available at 2007. Associations of spontaneous recovery from MetS to systemic hemodynamics was studied on a subpopulation of 1,391 subjects who had also complete MetS risk factor data available at 2001. Hemodynamic measurements were performed using a whole-body impedance cardiography device.

RESULTS

MetS and increasing number of MetS components were associated with lower stroke index (P < 0.001) and higher systemic vascular resistance index (P < 0.005) and arterial pulse wave velocity (P < 0.005). In MetS persistent group, stroke index was lower (P = 0.024), and pulse wave velocity was higher (P = 0.003) compared to MetS recovery group.

CONCLUSION

All current MetS definitions identify young adults with altered systemic hemodynamics, and recovery from MetS is associated with a favorable hemodynamic profile.

Importance of regional specificity of T-wave alternans in assessing risk for cardiovascular mortality and sudden cardiac death during routine exercise testing

BACKGROUND

T-wave alternans (TWA) indicates increased risk for life-threatening arrhythmias. However, the regional distribution and predictivity of TWA among precordial leads remain unknown.

OBJECTIVE

We analyzed the magnitude and prognostic power of TWA in precordial leads separately and in combination during routine exercise stress testing in the largest TWA study conducted to date.

METHODS

The Finnish Cardiovascular Study (FINCAVAS) enrolled consecutive patients (n = 3,598, 56 ± 13 [mean ± standard deviation] years old, 2,164 men, 1,434 women) with a clinically indicated exercise test with bicycle ergometer. TWA was analyzed with the time-domain modified moving average method.

RESULTS

During a follow-up of 55 months (interquartile range of 35-78 months), 231 patients died; 97 deaths were cardiovascular, and 46 were classified as sudden cardiac deaths (SCDs). In Cox analysis after adjustment for common coronary risk factors, each 20-μV increase in TWA in leads V1-V6 multiplied the hazard ratio for cardiovascular mortality by 1.486-fold (95% confidence interval [CI] 1.127-1.952; P = .005). Each 20-μV increase in TWA in lead V5 amplified the hazard ratio for cardiovascular mortality by 1.545 (95% CI 1.150-2.108; P = .004) and for SCD by 1.576 (95% CI 1.041-2.412; P = .033).

CONCLUSIONS

Maximum TWA monitored from anterolateral precordial lead V5 is the strongest predictor of cardiovascular mortality and SCD during routine exercise testing in our analysis. Higher TWA values indicate greater cardiovascular mortality and SCD risk, supporting the concept that quantification of TWA should receive more attention.

Apolipoprotein B is related to arterial pulse wave velocity in young adults: the Cardiovascular Risk in Young Finns Study

OBJECTIVE

Limited data are available regarding the relationship of apolipoproteins B (ApoB) and A-1 (ApoA-1) with arterial stiffness. We conducted the present study to determine whether adulthood ApoB and ApoA-1 are related to arterial pulse wave velocity (PWV). Moreover, we examined whether ApoB and ApoA-1 measured in young adulthood are predictive of PWV assessed 6 years later.

METHODS

The study population consisted of 1618 apparently healthy Finnish young adults (aged 30-45 years, 44.9% males) whose apolipoproteins, other cardiovascular risk factors and PWV were measured in 2007. In a sub-sample population, apolipoproteins and other cardiovascular risk factors had also been measured in 2001 (n=1264). PWV measurements were performed using a whole-body impedance cardiography device.

RESULTS

ApoB (p<0.001) and the ApoB/ApoA-1 ratio (p<0.001) were directly associated with PWV. ApoB and the ApoB/ApoA-1 ratio measured in young adulthood were also predictive of PWV measured 6 later (p<0.001 for both). These relations remained significant (p<0.006) in models adjusted for non-lipid risk factors. The areas under the receiver-operating characteristic (ROC) curves (AUC) were similar for ApoB and non-HDL cholesterol (2001: p for AUC comparison=0.15; 2007: p for AUC comparison=0.07) in detecting subjects with increased PWV (PWV≥90th percentile).

CONCLUSION

The present study suggests that elevation of ApoB or non-HDL cholesterol is associated with increased arterial stiffness in young adults.

Non-invasive measurement of the haemodynamic effects of inhaled salbutamol, intravenous L-arginine and sublingual nitroglycerin

AIMS

To examine the effects of salbutamol and L-arginine, two compounds acting largely on the endothelium, and the endothelium-independent agent nitroglycerin on blood pressure, arterial compliance, cardiac function and vascular resistance.

METHODS

Continuous radial pulse wave analysis, whole-body impedance cardiography, and plethysmographic blood pressure from fingers in the supine position and during head-up tilt were recorded in nine healthy subjects. Data were captured before and after L-arginine (10 mg mg(-1) min(-1)) or saline infusion, salbutamol (400 microg) or placebo inhalation, and sublingual nitroglycerin (0.25 mg) or placebo resoriblet.

RESULTS

The results of all measurements were comparable before drug administration. The effects of inhaled salbutamol were apparent in the supine position: systemic vascular resistance (-9.2 +/- 2.6%) and augmentation index (-4.0 +/- 1.5%) decreased, and heart rate (8.6 +/- 2.5%) and cardiac output (8.8 +/- 3.1%) increased. L-arginine had no clear effects on supine haemodynamics, but during head-up tilt blood pressure was moderately decreased and reduction in aortic reflection time prevented, indicating improved large arterial compliance. Nitroglycerin reduced supine vascular resistance (-6.7 +/- 1.8%) and augmentation index (-7.4 +/- 1.6%), and increased cardiac output (+9.2 +/- 2.7%). During head-up tilt, nitroglycerin increased cardiac output (+10.6 +/- 5.6%) and heart rate (+40 +/- 7.5%), decreased vascular resistance (-7.8 +/- 5.8%) and augmentation index (-18.7 +/- 3.2%), and prevented the decrease in aortic reflection time.

CONCLUSIONS

Inhaled salbutamol predominantly changed supine haemodynamics, whereas the moderate effects of L-arginine were observed during the head-up tilt. In contrast, small doses of nitroglycerin induced major changes in haemodynamics both supine and during the head-up tilt. Altogether, these results emphasize the importance of haemodynamic measurements in both the supine and upright positions.

Hemodynamic Adaptation during Pregnancy in Chronic Hypertension

OBJECTIVE

To assess hemodynamic and NT-proANP changes in women with chronic hypertension during pregnancy.

METHODS

Stroke volume index (SI), heart rate (HR), cardiac output index (CI), systemic vascular resistance index (SVRI), pulse wave velocity (PWV), and left cardiac work index (LCWI) were measured using whole-body impedance cardiography. Systolic blood pressure (SAP), mean arterial pressure (MAP), diastolic blood pressure (DAP), and pulse pressure (PP) were also measured. Arterial compliance was defined as the SI-to-PP ratio (SI/PP). Hemodynamic parameters and NT-proANP concentrations were assessed during the early and late second trimester, the third trimester, and after delivery in 20 women with essential hypertension and 30 normotensive women.

RESULTS

Arterial blood pressure, SVRI, and PWV remained higher during the whole study period in chronic hypertensive compared with healthy pregnancies. In the early second trimester, women with chronic hypertension had significantly lower SI and NT-proANP concentrations than did normotensive women.

CONCLUSION

The hemodynamics of chronic hypertension during pregnancy are characterized by persistent high vascular resistance. Lower SI and NT-proANP values found in chronic hypertensive pregnancies during the early second trimester may suggest a reduced intravascular volume increase during pregnancy.

Impaired exercise capacity predicts sudden cardiac death in a low-risk population: enhanced specificity with heightened T-wave alternans

AIMS

Because sudden cardiac death (SCD) is due to cardiac electrical instability, we postulated that prediction of this mode of death by exercise capacity will be enhanced by combined assessment with T-wave alternans (TWA), an index of repolarization abnormality.

MATERIAL AND METHODS

The Finnish Cardiovascular Study enrolled consecutive patients (n=2,044) with a routine clinically indicated exercise test. Exercise capacity was measured in metabolic equivalents (METs) and TWA by time-domain modified moving average method.

RESULTS

During 47.2+/-12.8-month follow-up (mean+/-SD) 120 patients died; 58 were cardiovascular deaths, and 29 were SCD. In multivariate analysis after adjustment for sex, age, smoking, use of beta-blockers, as well as other common coronary risk factors, the relative risk of patients whose exercise capacity was depressed (MET < 8) was 8.8 (95% CI 2.0-38.9, P=0.004) for SCD. The combination of low exercise capacity (MET < 8) and elevated TWA (> or =65 microV) yielded relative risks for SCD of 36.1 (6.3-206.0, P<0.001), for cardiovascular mortality of 21.1 (6.7-66.2, P<0.001), and for all-cause mortality of 7.8 (3.5-17.4, P<0.001) over patients with neither factor.

CONCLUSIONS

Reduced exercise capacity, particularly in combination with heightened TWA, indicating enhanced cardiac electrical instability, powerfully predicts risk for SCD in patients referred for exercise testing.

Effect of common KCNE1 and SCN5A ion channel gene variants on T-wave alternans, a marker of cardiac repolarization, during clinical exercise stress test: the Finnish Cardiovascular Study

T-wave alternans (TWA) in electrocardiography (ECG) is a marker of cardiac repolarization, the molecular regulation of which is incompletely understood. High TWA and prolonged QT intervals are both associated with ventricular arrhythmias and sudden death. Therefore, we tested the hypothesis of whether the same mutations that influence the QT interval also affect TWA variation. We examined the effect of 3 ion channel gene single nucleotide polymorphisms (SNPs), rs1805127, rs727957 KCNE1, and rs1805124 SCN5A, on TWA during a clinical exercise test. A total of 2008 subjects from the Finnish Cardiovascular Study underwent an exercise test with online ECG recording. TWA was measured by using the time-domain, modified moving average method. Maximum values at rest, during maximal exercise, and during recovery were used as outcome measures in statistical analysis. Moreover, 4-year survival data were collected and ion channel SNPs were determined. TWA was lowest in subjects with the TT genotype of rs1805127 during all phases of the exercise test (RANOVA main effect for genotype, P = 0.018). The result remained significant after adjustment for age, existing coronary heart disease, and beta-blocker medication status (RANCOVA, P = 0.035). Of the polymorphisms studied, only rs1805127 had a significant association with mortality (P = 0.047). The most common G-C haplotype, formed by rs727957 and rs1805127, was associated with TWA (RANOVA, P = 0.007) but not with mortality. The rs1805124 polymorphism was not associated with TWA. The common KCNE1 gene variant rs1805127 is associated with TWA during an exercise test in a Finnish population, which provides additional evidence that KCNE1 genetics may influence cardiac repolarization and cardiovascular mortality.

Predicting arterial stiffness with ambulatory blood pressure: an 11-year follow-up

No prospective data have been published on whether ambulatory blood pressure (BP) works better than casual measurements in predicting arterial stiffness. This study with 11-year follow-up was launched to evaluate the usefulness of ambulatory intra-arterial BP in predicting pulse wave velocity (PWV). Ninety-seven previously healthy men were recruited from a routine physical check-up at baseline. BP was measured with standard cuff and intra-arterial ambulatory methods. Sixty-seven subjects with no antihypertensive medication were enrolled for a visit after a follow-up of 11 years. Arterial stiffness was estimated with PWV derived with impedance cardiography. Ambulatory 24-h systolic blood pressure (SBP) (r = 0.30, P = 0.01), 24-h mean arterial pressure (r = 0.27, P = 0.03), 24-h pulse pressure (r = 0.27, P = 0.03) and daytime SBP (r = 0.26, P = 0.03) were the best BP variables in predicting future PWV. Casual BP values did not bear significant correlations with future PWV. In hierarchical regression analysis, the best predictive value for future PWV was achieved with the model including ambulatory 24-h SBP, smoking (number of cigarettes) and age (adjusted R(2) = 0.26). In conclusion, to our knowledge, this is the only prospective follow-up study to show that ambulatory BP is superior to casual BP measurement in predicting future PWV.

The prognostic value of haemodynamic parameters in the recovery phase of an exercise test. The Finnish Cardiovascular Study

We tested the hypothesis that the change from the peak to recovery values of systolic arterial pressure (SAP recovery) and rate-pressure product (RPP recovery) can be used to predict all-cause and cardiovascular mortality, as well as sudden cardiac death (SCD) in patients referred to a clinical exercise stress test. As a part of the Finnish Cardiovascular Study (FINCAVAS), consecutive patients (n=2029; mean age+/-SD=57+/-13 years; 1290 men and 739 women) with a clinically indicated exercise test using a bicycle ergometer were included in the present study. Capacities of attenuated SAP recovery, RPP recovery and heart rate recovery (HRR) to stratify the risk of death were estimated. During a follow-up (mean+/-s.d.) of 47+/-13 months, 122 patients died; 58 of the deaths were cardiovascular and 33 were SCD. In Cox regression analysis after adjustment for the peak level of the variable under assessment, age, sex, use of beta-blockers, previous myocardial infarction and other common coronary risk factors, the hazard ratio of the continuous variable RPP recovery (in units 1000 mm Hg x b.p.m.) was 0.85 (95% CI: 0.73-0.98) for SCD, 0.87 (0.78-0.97) for cardiovascular mortality, and 0.87 (0.81 to 0.94) for all-cause mortality. SAP recovery was not a predictor of mortality. The relative risks of having HRR below 18 b.p.m., a widely used cutoff point, were as follows: for SCD 1.28 (0.59-2.81, ns), for cardiovascular mortality 2.39 (1.34-4.26) and for all-cause mortality 2.40 (1.61-3.58). In conclusion, as a readily available parameter, RPP recovery is a promising candidate for a prognostic marker.

Potassium channel KCNH2 K897T polymorphism and cardiac repolarization during exercise test: The Finnish Cardiovascular Study

OBJECTIVE

Cardiac repolarization is regulated, in part, by the KCNH2 gene, which encodes a rapidly activating component of the delayed rectifier potassium channel. The gene expresses a functional single nucleotide polymorphism, K897T, which changes the biophysical properties of the channel. The objective of this study was to evaluate whether this polymorphism influences two indices of repolarization--the QT interval and T-wave alternans (TWA)--during different phases of a physical exercise test.

MATERIAL AND METHODS

The cohort consisted of 1,975 patients undergoing an exercise test during which on-line electrocardiographic data were registered. Information on coronary risk factors and medication was recorded. The 2690A>C nucleotide variation in the KCNH2 gene corresponding to the K897T amino acid change was analysed after polymerase chain reaction with allele-specific TaqMan probes.

RESULTS

Among all subjects, the QTc intervals did not differ between the three genotype groups (p> or =0.31, RANOVA). Women with the CC genotype tended to have longer QT intervals during the exercise test, but the difference was statistically significant only at rest (p = 0.011, ANOVA). This difference was also detected when the analysis was adjusted for several factors influencing the QT interval. No statistically significant effects of the K897T polymorphism on TWA were observed among all subjects (p = 0.16, RANOVA), nor in men and women separately.

CONCLUSIONS

The K897T polymorphism of the KCNH2 gene may not be a major genetic determinant for the TWA, but the influence of the CC genotype on QT interval deserves further research among women.

A new method for measuring the ballistocardiogram using EMFi sensors in a normal chair

Ballistocardiography is a non-invasive technique for the assessment of cardiac function. We built a measurement setup to measure the ballistocardiogram from a normal chair using EMFi sensors. The ballistocardiogram is recorded from a subject sitting on the chair. The measured signal is amplified by a specially-designed charge amplifier and digitized by a circulation monitor. A PC provides a user interface for the measurement devices, records the data and displays the results. Impedance cardiography and ECG serve as reference measurements for the ballistocardiography. To test the system, one healthy 24-year-old male and one healthy 22-year-old female were measured. It is concluded that the ballistocardiogram waveforms described in the literature can be recognized from the EMFi signal measured from a normal chair.

Heart rate variability derived from exercise ECG in the detection of coronary artery disease

The diagnostic performance of heart rate variability (HRV) analysis from exercise ECG in the detection of coronary artery disease (CAD) is unknown. Bicycle exercise ECG recordings from The Finnish Cardiovascular Study (FINCAVAS) of angiography-proofed CAD patients (n = 112) and a patient group with a low likelihood of CAD (n = 114) were analyzed. HRV parameters (SDNN, RMSSD, Poincaré SD1 and SD2) were calculated from 1 min segments before exercise, during exercise and after exercise. All the parameters were in addition calculated from heart rate (HR)-corrected RR-interval segments. The ST-segment depressions in each stage were also determined. The diagnostic performance of the parameters was evaluated with the area under the receiver operating characteristic (ROC) curve method. The uncorrected HRV parameters showed the best diagnostic performance in the recovery segments but the correlation with HR was also high (SDNN: 0.758/-0.64, RMSSD: 0.747/-0.60; area under the ROC/correlation coefficient). The HR correction decreased the correlation and the diagnostic performance in recovery segments (SDNN: 0.515/-0.12, RMSSD: 0.609/0.20). The diagnostic performance of ST-level at its best was higher than any of HRV parameters (ST-level: 0.795/0.36). According to the results, the HR correction decreased the diagnostic performance of the recovery phase. The HRV parameters calculated from 1 min segments of exercise test ECG were not as capable as traditional ST-segment analysis. In conclusion, the HRV analysis from exercise or recovery phase seems to be inadequate in the detection of CAD.

The influence of hemodynamic factors on left ventricular mass

We evaluated the relationship between the variability in the left ventricular mass index (LVMI) and different hemodynamic factors. LVMI was associated with blood pressure and, in one subgroup, strongly to arterial pulse wave velocity (PWV). High physical activity was connected to increased LVMI, and a combination of low stroke index (SI) and high heart rate (HR) to decreased LVMI.

T-wave alternans predicts mortality in a population undergoing a clinically indicated exercise test

AIMS

As a part of the Finnish Cardiovascular Study, we tested the hypothesis that T-wave alternans (TWA) predicts mortality in a general population of patients referred for a clinical exercise test.

METHODS AND RESULTS

A total of 1037 consecutive patients (mean age+/-SD of 58+/-13 years, 673 men and 364 women) with a clinically indicated exercise test and with technically successful electrocardiographic (ECG) data during a bicycle ergometer test were included in the study. Digital ECGs were recorded and TWA was analysed continuously with the time-domain modified moving average method. The maximum TWA value at heart rate (HR)<125 b.p.m. was derived and its capacity to stratify risk for all-cause death, cardiovascular death, and sudden cardiac death (SCD) was tested. During a follow-up of 44+/-7 months (mean+/-SD), 59 patients died; 34 were due to cardiovascular causes and 20 were due to SCD. In multivariate analysis after adjustment for age, sex, use of beta-blockers, functional class, maximal HR during exercise, previous myocardial infarction, and other common coronary risk factors, the relative risk of TWA>or=65 microV for SCD was 7.4 (95% CI, 2.8-19.4; P<0.001), for cardiovascular mortality 6.0 (95% CI, 2.8-12.8; P<0.001), and for all-cause mortality 3.3 (95% CI, 1.8-6.3; P=0.001).

CONCLUSION

Time-domain TWA analysis powerfully predicts mortality in a general population undergoing a clinical exercise test.

Pulse wave velocity reference values in healthy adults aged 26?75�years

The stiffening of arteries is associated with various cardiovascular diseases. Arterial stiffening can be studied utilizing arterial pulse wave velocity (PWV), but the absence of reliable reference values for PWV has limited its use in clinical practice. The aim of this study was to establish a range of reference values for PWV. PWV was examined by measuring the time difference of systolic pulse waves in arteries from the aortic arch to the popliteal artery using whole-body impedance cardiography (ICG). The study population consisted of 799 individuals (age range 25-76 years), 283 of whom had no evidence of cardiovascular disease, and a low burden of risk factors was selected to represent an apparently healthy population. In healthy study population, PWV was higher in males (8 x 9 +/- 1 x 8 m s(-1)) than females (8 x 1 +/- 2 x 0 m s(-1), P<0 x 001). Young males had lower PWV values than old males. Correspondingly, young females also had lower PWV values than old females. PWV was clearly associated with age, and PWV was higher in young and middle-aged males than in females. There was no statistically significant difference between old males and females in PWV. In conclusion, whole-body ICG provides a practical method for PWV measurement. Reference values can be useful in the clinical management of patients, especially in detecting early vascular disease or an increased risk of cardiovascular complications.

Natriuretic peptides and hemodynamics in preeclampsia

OBJECTIVE

The purpose of this study was to evaluate the relationship between natriuretic peptides (NT-proANP and NT-proBNP) and hemodynamic parameters in preeclampsia.

STUDY DESIGN

This was a cross-sectional study of 19 preeclamptic, 15 chronic hypertensive, and 26 normotensive women in the third trimester of pregnancy. Stroke index (SI), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI), and left cardiac work index (LCWI) were derived by whole-body impedance cardiography. Systolic blood pressure (SAP), diastolic blood pressure (DAP), and mean arterial pressure (MAP) were measured. The plasma levels of NT-proANP and NT-proBNP were determined with radioimmunoassays.

RESULTS

NT-proANP and NT-proBNP concentrations were significantly higher in preeclamptic women compared to chronic hypertensive and normotensive pregnancies. Preeclamptic women had lower CI and HR and higher SAP, MAP, and SVRI than the control groups. In preeclampsia NT-proANP correlated significantly with SAP and SVRI; meanwhile, NT-proBNP correlated significantly with SVRI and CI. These correlations persisted in the subgroup of nonmedicated preeclamptic women, except in the case of NT-proBNP and CI.

CONCLUSION

High NT-proANP and NT-proBNP concentrations in preeclampsia reflect the strain on the heart caused by high afterload, rather than the function of the heart expressed as SI or CI.

Metabolic syndrome and arterial stiffness: the Health 2000 Survey

Metabolic syndrome and its components have been associated with arterial stiffness and cardiovascular disease. The objective of this study was to examine the independent influences of metabolic syndrome, its components, and other cardiovascular risk factors on arterial stiffness as well as to compare 2 definitions for metabolic syndrome (National Cholesterol Education Program [NCEP] and International Diabetes Federation [IDF]) in their ability to identify subjects with arterial stiffness. The study population consisted of 401 Finnish men and women aged 45 years and older who participated in a substudy of the Finnish population-based Health 2000 Survey. Pulse wave velocity (PWV) measured by whole-body impedance cardiography was used as a marker of elevated arterial stiffness. In multivariate models, systolic blood pressure, age, waist circumference, and fasting blood glucose (P < or = .001 for all) were independent determinants for PWV. In the models including metabolic syndrome instead of its components, the NCEP and IDF definitions were similarly associated with PWV (P < or = .01 for both), the other independent determinants being age, sex (P < .001 for both) and plasma C-reactive protein concentration (P = .016 and P = .005 in models containing the NCEP and IDF definitions, respectively). Systolic blood pressure, age, waist circumference, and fasting blood glucose level were independently associated with increased arterial stiffness. Metabolic syndrome determined increased arterial stiffness independently of other known cardiovascular risk factors. The NCEP and IDF definitions did not differ in their ability to identify subjects with increased arterial stiffness.

Age and Gender Biases in Secondary??Prevention of Coronary??Heart Disease in a Finnish??University Hospital Setting

BACKGROUND AND OBJECTIVES

Several studies have shown that treatment of coronary heart disease (CHD) does not meet the goals set in recommendations. The aim of this study was to investigate the adequacy of CHD drug treatment and secondary prevention measures, particularly with respect to age and gender biases, in a Finnish university hospital setting.

METHODS

The participant pool consisted of patients in FINCAVAS (Finnish Cardiovascular Study), which is a cohort study recruiting consecutive patients performing a clinical exercise test at Tampere University Hospital, Tampere, Finland. 802 patients (581 men, 221 women) with a prior diagnosis of CHD recruited between October 2001 and December 2004 were included in the analysis.

RESULTS

Only roughly 12% of both men and women had an optimal risk factor profile. High blood pressure and hypercholesterolaemia were more common in women than in men, whereas smoking was more frequent among men. Men used ACE inhibitors (32.9% vs 20.4%, respectively), beta-adrenoceptor antagonists (80.8% vs 68.3%, respectively) and aspirin (acetylsalicylic acid) [69.7% vs 58.8%, respectively] more frequently than women, but the frequency of use of these medications was also not at the recommended levels in men. Risk factor control is poorer in older than younger age groups.

CONCLUSIONS

CHD patients, particularly women, who performed an exercise stress test in a university hospital are suboptimally treated.

The Effects of Tamsulosin and Sildenafil in Separate and Combined Regimens on Detailed Hemodynamics in Patients With Benign Prostatic Enlargement

PURPOSE

We measured the detailed hemodynamic effects of tamsulosin and sildenafil separately and together in patients with benign prostatic enlargement.

MATERIALS AND METHODS

The supine effects of and responses to passive orthostasis (60 degrees for 8 minutes) were measured in 16 patients with benign prostatic enlargement with the finger blood pressure method and whole-body impedance cardiography. The medications, 100 mg sildenafil (single doses) and 0.4 mg tamsulosin (once daily for up to 14 days), were administered in a randomized, double-blind, crossover fashion.

RESULTS

Supine systolic arterial pressure decreased with sildenafil (mean +/- SEM -11 +/- 2 mm Hg) and sildenafil plus tamsulosin (-14 +/- 2 mm Hg) more than with placebo (-2 +/- 4 mm Hg, p <0.05). In comparison to placebo sildenafil plus tamsulosin decreased the systemic vascular resistance index (328 +/- 129 vs -241 +/- 134 dyn.sec/cm.m, p = 0.01). Tamsulosin alone did not cause any significant changes in comparison to placebo. Heart rate, diastolic arterial pressure, stroke index, cardiac index and arterial pulse wave velocity were not affected to a statistically significant degree by any of the treatments compared to placebo. Upon head-up tilt the drugs caused only 1 significant change in that diastolic arterial pressure was significantly higher (-2.7 vs -8.0 mm Hg, p = 0.04) in the placebo group than in the tamsulosin plus sildenafil group.

CONCLUSIONS

Tamsulosin does not disturb hemodynamics in patients with benign prostatic enlargement. Sildenafil decreases blood pressure with the patient supine but not during head-up tilt. The combination treatment also decreases the systemic vascular resistance index in the supine position.

The p22phox C242T gene polymorphism is associated with a reduced risk of angiographically verified coronary artery disease in a high-risk Finnish Caucasian population. The Finnish Cardiovascular Study

BACKGROUND

Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase is a major source of the superoxide anion, which may play an important role in the development of atherosclerosis and coronary artery disease (CAD). The p22phox, a component of the NADPH oxidase, is essential for the activation of this enzyme, and intensive expression of the p22phox has been reported in human atherosclerotic arteries. However, studies on the association of the C242T polymorphism in the p22phox gene with CAD have produced conflicting results, and the relation of this polymorphism with CAD is not well known in a population with acquired risk factors enhancing the NADPH-dependent superoxide production.

METHODS

As part of the Finnish Cardiovascular Study, a case-control study was conducted with 402 high-risk Finnish Caucasian patients undergoing coronary angiography. Genotyping was performed using the 5' nuclease TaqMan assay.

RESULTS

The prevalence of the T allele (TT + TC genotypes) was significantly lower among angiographically verified CAD patients (n = 250) than among control subjects (n = 152, P = .013). In contrast to subjects with the CC genotype, the T allele was found protective against CAD (odds ratio = 0.531, 95% CI 0.331-0.852, P = .009), and the results remained significant after adjustment for other significant coronary risk factors.

CONCLUSIONS

The T allele in the C242Tpolymorphism of the p22phox gene had a protective effect against the development of CAD despite the exposure of study subjects to risk factors related to excessive NADPH-dependent superoxide production.

Asymmetric dimethylarginine and hemodynamic regulation in middle-aged men

The goal of this study was to evaluate the role of asymmetric dimethylarginine (ADMA) in the regulation of hemodynamic functions in hypertensive men. It has been suggested that ADMA, as an endogenous nitric oxide synthase inhibitor, is linked to hypertension and vascular reactivity. Sixty-seven men aged 51.1 years (range, 45-55 years) were studied. Plasma ADMA and symmetric dimethylarginine were determined by high-performance liquid chromatography-tandem mass spectrometry. Blood pressure (BP) was measured by 24-hour ambulatory recordings and casual measurements. Hemodynamic regulation was assessed by noninvasive methods. The nitric oxide production was estimated based on plasma nitrate (NO(3)(-)) determination. Results showed that plasma arginine derivatives or l-arginine/ADMA ratio was not associated with BP values observed during 24-hour monitoring or in casual measurements. Systemic vascular resistance, pulse wave velocity, or cardiac output was not associated with plasma ADMA or plasma NO(3)(-) levels. No association was found between plasma ADMA and NO(3)(-) either. Interestingly, subjects on antihypertensive treatment had lower plasma ADMA concentrations than nontreated subjects (0.30+/-0.08 and 0.36+/-0.11 micromol/L, respectively, P=.04) despite higher BP values. In conclusion, these results suggest that plasma ADMA does not have a determinative role in the regulation of hemodynamic functions in Finnish middle-aged men.

Maternal haemodynamics in pre-eclampsia compared with normal pregnancy during caesarean delivery

OBJECTIVE

To determine how pre-eclampsia modifies maternal haemodynamics during caesarean delivery.

DESIGN

Prospective study.

SETTING

Tampere University Hospital, Finland.

POPULATION

Ten pre-eclamptic parturients and ten healthy parturients with uncomplicated pregnancies scheduled for elective caesarean section under spinal anaesthesia.

METHODS

Haemodynamic parameters were assessed by whole-body impedance cardiography noninvasively.

MAIN OUTCOME MEASURES

Stroke index (SI), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and mean arterial pressure (MAP) were recorded before operation, continuously during caesarean section, during the period of dissipation of anaesthesia and on the second to fifth postpartum day.

RESULTS

Baseline haemodynamics in women with pre-eclampsia differed significantly from healthy women in higher SVRI and MAP and lower SI and CI. In women with pre-eclampsia, preload infusion increased both SI and HR, causing a significant rise in CI, while in healthy parturients, only HR rose. In both the groups, spinal blockade reduced SVRI but CI remained stable. At the moment of delivery, CI increased in both groups. In uncomplicated pregnancies, both SI and HR increased, but in women with pre-eclampsia, SI was not altered and the rise in CI was due to an increase in HR only. After the reversal of anaesthesia, haemodynamics in the control group returned to baseline values, whereas in women with pre-eclampsia, SI and CI fell to levels that were significantly lower than the levels observed before surgery.

CONCLUSIONS

In women with pre-eclampsia, inability to increase SI at the moment of delivery may suggest dysfunction of the left ventricle to adapt to volume load caused by delivery and prompts concern for the increased risk of pulmonary oedema.

Ten-year prognosis of Puumala hantavirus-induced acute interstitial nephritis

Nephropathia epidemica (NE) is a hemorrhagic fever with renal syndrome caused by Puumala hantavirus. Its long-term prognosis is considered favorable. There are, however, some reports about subsequent hypertension, glomerular hyperfiltration, and proteinuria after previous hantavirus infection. Therefore, we studied 36 patients 5 and 10 years after acute NE, with 29 seronegative controls. Office blood pressure, ambulatory 24-h blood pressure (ABP), glomerular filtration rate (GFR), and proteinuria were examined. Hypertensive subjects were defined as those patients having increased ambulatory or office blood pressure, or receiving antihypertensive therapy. Office blood pressure was used to define hypertension only if ABP was not determined. At 5 years, the prevalence of hypertension was higher among NE patients than in controls (50 vs 21%, P=0.020). At 10 years, the difference between the groups was no more significant (39 vs 17%, P=0.098). Five years after NE, patients showed higher GFR (121+/-19 vs 109+/-16 ml/min/1.73 m(2), P=0.012) and urinary protein excretion (0.19 g/day, range 0.12-0.38 vs 0.14 g/day, range 0.09-0.24, P=<0.001) than controls. At 10 years, there were no more differences in GFR or protein excretion between the groups (GFR: 113+/-20 vs 108+/-17 ml/min/1.73 m(2), P=0.370; proteinuria: 0.14 g/day, range 0.07-0.24 vs 0.13 g/day, range 0.06-0.31, P=0.610). In conclusion, the 10-year prognosis of NE is favorable, as glomerular hyperfiltration and slight proteinuria detected at 5 years disappeared during the longer follow-up. However, the possibility exists that NE may predispose some patients to the development of hypertension.