Frequency of office blood pressure measurements and the seasonal variability of blood pressure: results of the Hungarian Hypertension Registry

PURPOSE

Hypertension is a major public health problem, thus, its timely and appropriate diagnosis and management are crucial for reducing cardiovascular morbidity and mortality. The aim of the new Hungarian Hypertension Registry is to evaluate the blood pressure measurement practices of general practitioners (GPs), internists and cardiologists in outpatient clinics, as well as to assess the seasonal variability of blood pressure.

MATERIALS AND METHODS

Omron M3 IT devices were used during four-month periods between October 2018 and April 2023 in GP practices and in hypertension clinics. The blood pressure data were then transmitted online from the monitors' cuffs to a central database using the Medistance system of Omron.

RESULTS

Family physicians (n = 2491), and internists/cardiologists (n = 477) participated in the study. A total of 4804 821 blood pressure measurements were taken during 10 four-month evaluation periods. In the ten periods, the daily average number of measurements was between 3.0 and 5.6. Following ESH diagnostic criteria, the proportion of subjects in optimal, normal and high-normal blood pressure categories were 14, 13.4 and 16.7%, respectively. Altogether 56% of the measurements belonged to stage 1, stage 2 or stage 3 hypertension categories (31.6, 17.1 and 7.4%, respectively). On average, a difference of 5/2 mmHg was observed between winter and summer data in systolic and diastolic blood pressures, respectively. The average systolic blood pressure values were higher in GP practices with more than 2000 patients than in the ones with less than 1500 patients (141.86 mmHg versus 140.02 mmHg, p < 0.05).

CONCLUSION

In conclusion, the low daily average number of blood pressure measurements indicates a limited blood pressure screening awareness/capacity in the case of Hungarian family physicians. In GP practices with more patients, blood pressure is usually less well-controlled. These results suggest that the further promotion of home blood pressure monitoring is necessary.

Cohort Profile: the European Unified Registries On Heart care Evaluation and Randomised Trials (EuroHeart) - Acute Coronary Syndrome and Percutaneous Coronary Intervention

AIMS

The European Unified Registries On Heart care Evaluation And Randomized Trials (EuroHeart) aims to improve the quality of care and clinical outcomes for patients with cardiovascular disease. The collaboration of acute coronary syndrome/percutaneous coronary intervention (ACS/PCI) registries is operational in seven vanguard European Society of Cardiology member countries.

METHODS AND RESULTS

Adults admitted to hospitals with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) are included, and individual patient-level data collected and aligned according to the internationally agreed EuroHeart data standards for ACS/PCI. The registries provide up to 155 variables spanning patient demographics and clinical characteristics, in-hospital care, in-hospital outcomes, and discharge medications. After performing statistical analyses on patient data, participating countries transfer aggregated data to EuroHeart for international reporting.Between 1st January 2022 and 31st December 2022, 40 021 admissions (STEMI 46.7%, NSTEMI 53.3%) were recorded from 192 hospitals in the seven vanguard countries: Estonia, Hungary, Iceland, Portugal, Romania, Singapore, and Sweden. The mean age for the cohort was 67.9 (standard deviation 12.6) years, and it included 12 628 (31.6%) women.

CONCLUSION

The EuroHeart collaboration of ACS/PCI registries prospectively collects and analyses individual data for ACS and PCI at a national level, after which aggregated results are transferred to the EuroHeart Data Science Centre. The collaboration will expand to other countries and provide continuous insights into the provision of clinical care and outcomes for patients with ACS and undergoing PCI. It will serve as a unique international platform for quality improvement, observational research, and registry-based clinical trials.

Incidence and predictors of heart failure with improved ejection fraction category in a HFrEF patient population

AIMS

The aim of the study was to assess the incidence and predictive factors of the development of heart failure with improved ejection fraction (HFimpEF) category during a 1 year follow-up period in a heart failure with reduced ejection fraction (HFrEF) patient population managed in a heart failure outpatient clinic.

METHODS AND RESULTS

The study evaluated data from patients enrolled in the Hungarian Heart Failure Registry (HHFR). The incidence and predictive factors of the development of the HFimpEF category after 1 year follow-up were assessed in the group of patients who had HFrEF at baseline. We evaluated the incidence and predictors of the development of HFimpEF after a 1 year follow-up in relation to time since diagnosis of HFrEF in patients diagnosed within 3 months, between 3 months and 1 year, and beyond 1 year. The predictive factors of the development of HFimpEF were analysed using univariate and multivariate logistic regression analysis. Of the 833 HFrEF patients enrolled in the HHFR, the development of HFimpEF was observed in 162 patients (19.5%) during 1 year follow-up. In the whole patient population, independent predictors of the development of HFimpEF were female gender [odds ratio (OR): 1.73; 95% confidence interval (CI): 1.01-2.96; P < 0.05], non-ischaemic aetiology (OR: 1.95; 95% CI: 1.15-3.30; P < 0.05), and left ventricular end-diastolic diameter (LVEDD) <60 mm (OR: 2.04; 95% CI: 1.18-3.51; P < 0.05). The 1 year incidence of HFimpEF decreased in relation to time since diagnosis of HFrEF. The incidence of HFimpEF was 27.1% in patients diagnosed within 3 months, 18.4% in patients diagnosed between 3 months and 1 year, and 12.2% in patients diagnosed beyond 1 year. Non-ischaemic aetiology (OR: 4.76; 95% CI: 1.83-12.4; P < 0.01) and QRS width (OR: 0.81; 95% CI: 0.71-0.94; P < 0.01) for patients diagnosed within 3 months, LVEDD (OR: 0.54; 95% CI: 0.32-0.90; P < 0.05) and left atrial diameter ≤45 mm (OR: 5.44; 95% CI: 1.45-20.4; P < 0.05) for patients diagnosed between 3 months and 1 year, and LVEDD < 67 mm (OR: 2.71; 95% CI: 1.07-6.88; P < 0.05) for patients diagnosed beyond 1 year were found to be independent predictive factors.

CONCLUSIONS

In our study, in this HFrEF patient population managed in a heart failure outpatient clinic, the 1 year incidence of HFimpEF was found to be ~20%. The 1 year incidence of HFimpEF decreased in relation to time since diagnosis of HFrEF. The most important predictors of the development of HFimpEF were female sex, non-ischaemic aetiology, narrower QRS width, and smaller diameter of the left ventricle and left atrium.

2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA)

DOCUMENT REVIEWERS

Luis Alcocer (Mexico), Christina Antza (Greece), Mustafa Arici (Turkey), Eduardo Barbosa (Brazil), Adel Berbari (Lebanon), Luís Bronze (Portugal), John Chalmers (Australia), Tine De Backer (Belgium), Alejandro de la Sierra (Spain), Kyriakos Dimitriadis (Greece), Dorota Drozdz (Poland), Béatrice Duly-Bouhanick (France), Brent M. Egan (USA), Serap Erdine (Turkey), Claudio Ferri (Italy), Slavomira Filipova (Slovak Republic), Anthony Heagerty (UK), Michael Hecht Olsen (Denmark), Dagmara Hering (Poland), Sang Hyun Ihm (South Korea), Uday Jadhav (India), Manolis Kallistratos (Greece), Kazuomi Kario (Japan), Vasilios Kotsis (Greece), Adi Leiba (Israel), Patricio López-Jaramillo (Colombia), Hans-Peter Marti (Norway), Terry McCormack (UK), Paolo Mulatero (Italy), Dike B. Ojji (Nigeria), Sungha Park (South Korea), Priit Pauklin (Estonia), Sabine Perl (Austria), Arman Postadzhian (Bulgaria), Aleksander Prejbisz (Poland), Venkata Ram (India), Ramiro Sanchez (Argentina), Markus Schlaich (Australia), Alta Schutte (Australia), Cristina Sierra (Spain), Sekib Sokolovic (Bosnia and Herzegovina), Jonas Spaak (Sweden), Dimitrios Terentes-Printzios (Greece), Bruno Trimarco (Italy), Thomas Unger (The Netherlands), Bert-Jan van den Born (The Netherlands), Anna Vachulova (Slovak Republic), Agostino Virdis (Italy), Jiguang Wang (China), Ulrich Wenzel (Germany), Paul Whelton (USA), Jiri Widimsky (Czech Republic), Jacek Wolf (Poland), Grégoire Wuerzner (Switzerland), Eugene Yang (USA), Yuqing Zhang (China).

Mortality on DOACs Versus on Vitamin K Antagonists in Atrial Fibrillation: Analysis of the Hungarian Health Insurance Fund Database

PURPOSE

Limited real-world data are available on the survival of patients treated with vitamin K antagonists (VKAs) versus with direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (AF). In this nationwide registry, we analyzed the mortality risk of patients with nonvalvular AF taking DOACs versus VKAs, with a special attention to the early treatment period.

METHODS

The Hungarian National Health Insurance Fund (NHIF) database was searched to identify patients treated with VKA or DOAC as a thromboembolic prophylaxis for nonvalvular AF between 2011 and 2016. The overall and the early (0-3, 4-6, and 7-12 months) mortality risks with the 2 types of anticoagulation were compared. A total of 144,394 patients with AF treated with either a VKA (n = 129,925) or a DOAC (n = 14,469) were enrolled.

FINDINGS

A 28% improvement in 3-year survival with DOAC treatment compared with VKA treatment was shown. Mortality reduction with DOACs was consistent across different subgroups. However, younger patients (30-59 years old) initiated on DOAC therapy had the greatest RRR (53%) in mortality. Furthermore, DOAC treatment also yielded a benefit of greater magnitude (HR = 0.55; 95% CI, 0.40-0.77, P = 0.001) in the lower (0-1) CHA₂DS₂-VASc score segment and in those with fewer (0-1) bleeding risk factors (HR = 0.50, CI 0.34-0.73, P = 0.001). The RRR in mortality with DOACs was 33% within the first 3 months, and 6% in the second year.

IMPLICATIONS

Thromboembolic prophylaxis with DOACs in this study yielded significantly lower mortality compared with VKA treatment in patients with nonvalvular AF. The largest benefit was shown in the early period after treatment initiation, as well as in younger patients, those with a lower CHA₂DS₂-VASc score, and those with fewer bleeding risk factors.

Ankle Brachial Index is a strong predictor of mortality in hypertensive patients: results of a five-year follow-up study

BACKGROUND

In the hypertensive population, the peripheral arterial disease (PAD) is considered one of the target organ damages. Ankle Brachial Index (ABI) measurement represents the widely accepted clinical method that may objectively detect the presence of PAD. The study aimed to assess how PAD revealed by ABI predicts mortality in patients with hypertension.

METHODS

In the follow-up time (5 years period) of the Hungarian ERV Study, a large scale, multicenter observational study, recruiting hypertensive subjects between 50-75 years, the association of PAD with the survival time was analysed. Several multivariate, interval-censored survival models were developed to assess this association.

RESULTS

Among the 21892 enrolled hypertensive patients, the prevalence of PAD (ABI≤0.9) was 14.4%. The crude death rate was 5.44% (1190 cases) over the available observational period. In multivariate models male sex, myocardial infarction in patients' history, diabetes, renal failure, PAD and cardiovascular risk (SCORE risk) were significantly associated with mortality. Lower ABI showed a continuous, close to linear association with worse survival. PAD was predictive for mortality risk in all SCORE patient groups.

CONCLUSIONS

Low ABI is a strong predictor of mortality in hypertensive patients between the age 50-75, even after adjustment for several potential confounders. The association is linear, with no apparent cut-off, suggesting that ABI should be handled as a continuous variable. The detection of PAD in hypertensives may contribute to the determination of total cardiovascular risk in hypertensive population.

Spatial analysis of factors impacting lower limb major amputation rates in Hungary

Summary: Background: Lower limb major amputations represent a substantial public health burden in Hungary, where previous research revealed markedly high rates with significant spatial variations. Therefore, we aimed to assess to what extent healthcare and socio-economic factors in the local environment explain the regional disparity. Patients and methods: In a retrospective cohort analysis, based on the healthcare administrative data of the Hungarian population, lower limb major amputations were identified from 1st of January 2017 to 31st of December 2019. The permanent residence of the amputees on the local administrative level (197 geographic units) was used to identify potential healthcare (outpatient care, revascularisation activity) and socio-economic (educational attainment, local infrastructure and services, income and employment) determinants of amputations. Spatial effects were modelled using the spatial Durbin error regression model. Results: 10,209 patients underwent 11,649 lower limb major amputations in the observational period. In our spatial analysis, outpatient care was not associated with local amputation rates. However, revascularisation activity in a geographic unit entailed an increased rate of amputations, while revascularisations in the neighbouring areas were associated with a lower rate of amputations, resulting in an overall neutral effect (β=−0.002, 95% CI: −0.05 – 0.04, p=0.96). The local socio-economic environment had a significant direct inverse association with amputations (β=−7.45, 95% CI: −10.50 – −4.42, p<0.0001) . Our spatial model showed better performance than the traditional statistical modelling (ordinary least squares regression), explaining 37% of the variation in amputations rates. Conclusions: Regional environmental factors explain a substantial portion of spatial disparities in amputation practice. While the socio-economic environment shows a significant inverse relationship with the regional amputation rates, the impact of the local healthcare-related factors (outpatient care, revascularisation activity) is not straightforward. Unravelling the impact of the location on amputation practice requires complex spatial modelling, which may guide efficient healthcare policy decisions.

Aspects of antithrombotic and anticoagulant therapies in patients undergoing endovascular procedures for lower extremity arterial disease

Összefoglaló. A népesség öregedése, a meghatározó cardiovascularis rizikótényezők - mint a cukorbetegség - egyre nagyobb arányú előfordulása, a csökkenő akut cardiovascularis halálozás az alsó végtagi verőérszűkület növekvő megjelenésével jár. Ezzel együtt szaporodnak a beavatkozást igénylő, jelentős életminőség-romlást, illetve végtag-veszélyeztetettséget okozó, súlyosabb esetek. Ilyenkor az alsó végtagi revascularisatio szüksége merül fel, ami az utóbbi évtizedben az endovascularis beavatkozások számának növekedéséhez vezetett. A beavatkozások technikai sikere mellett újabb szűkületek, elzáródások veszélyével kell számolni. Ennek hátterében az atherosclerosis progressziója mellett a beavatkozáshoz köthető, kontrollált érfalsérülés indukálta vascularis remodelling (neointima-hyperplasia), valamint thromboticus tényezők állnak. Az ér-nyitvamaradás hosszú távú biztosításának feltétele a fenti folyamatok megelőzésére alkalmazott optimális gyógyszeres kezelés. Ennek biztosítása elengedhetetlen a beavatkozást megelőzően, periprocedurálisan, majd az érintett betegkör hosszú távú gondozása során. A gyógyszeres terápiás lehetőségek közül az antithromboticus, antikoaguláns terápiának kiemelt jelentősége van. Az ezen hatású gyógyszerek alkalmazását igen nehézzé teszi (i) a thromboticus elzáródás kiújulása és a potenciális vérzés közötti dinamikusan változó egyensúly bizonytalansága, (ii) az egyéb társbetegségek kapcsán felmerülő terápiás szempontok egyidejű érvényesítése, valamint (iii) a napi ellátásban támpontot adó tudományos bizonyítékok relatív hiánya. Az összefoglaló tanulmány a fenti gyógyszerterápiás terület legújabb eredményeit kísérli meg elemezni. Orv Hetil. 2022; 163(3): 98-108. Summary. The aging of the population, the increasing prevalence of important risk factors of atherosclerosis, like diabetes, and the declining mortality of acute cardiovascular conditions lead to increased peripheral arterial disease incidence. At the same time, cases showing a severe decline in quality of life or danger of limb loss get more prevalent that demands vascular interventions. In such cases, revascularization is recommended, and consequently, in the last decade, an expansion in endovascular procedures can be seen. Considering these procedures, besides a technical success, the risk of new stenosis or occlusion may be imminent. This may be accounted for the progression of atherosclerosis and the controlled vascular injury caused by the procedure itself that induces vascular remodeling (neointima hyperplasia) and thrombotic hyperactivity. The long-term vascular patency is closely associated with the success of an optimal medical treatment strategy. Its effect is considered essential prior to the endovascular procedure, perioperatively, and in the phase of long-term follow-up of the affected patients. In this scenario, antithrombotic and anticoagulant therapy regimes bear particular relevance. The use of this kind of drugs is challenged by (i) the uncertainty of dynamic changes of balance between the thrombotic reocclusion and the risk of bleeding, (ii) the interplay of treatment strategy related to concomitant diseases, (iii) the relative lack of high-level scientific pieces of evidence guiding daily routine. The narrative review makes an effort to provide new findings and an analysis of this therapeutic field. Orv Hetil. 2022; 163(3): 98-108.

May Measurement Month 2019: an analysis of blood pressure screening results from Hungary

Cardiovascular diseases are not only the leading causes of mortality in Hungary but also the mortality rate is twice as high as the European Union average, so screening programmes identifying subjects with elevated blood pressure (BP) are of utmost importance. May Measurement Month (MMM) is an annual global initiative that began in 2017 aimed at raising awareness of high BP. Hungary joined the 3rd campaign of MMM in 2019 and an overview of the results are presented in this paper. An opportunistic cross-sectional survey of participants aged ≥18 years was carried out in May 2019. Hypertension was defined as systolic BP ≥140 mmHg and diastolic BP ≥90 mmHg or treatment for hypertension, statistical analysis followed the standard MMM protocol. In Hungary, 55 sites were set up in primary and secondary care facilities, in pharmacies, and in malls across all regions, in both cities and villages. Out of 2766 individuals screened, 1286 participants (46.5%) had hypertension. Out of 1869 participants not on antihypertensive medication, 389 (20.8%) had elevated BP. In the case of treated individuals (n = 897), 420 (46.8%) had uncontrolled hypertension. Almost every 2nd subject of the screened cohort had hypertension (treated and controlled, treated and uncontrolled, or untreated). In the untreated cohort, every 5th subject had elevated BP, whilst among patients on antihypertensive medication, every second had uncontrolled BP. By identifying almost one-third of the whole screened cohort with the possibility of newly diagnosed or uncontrolled hypertension, our results confirm the importance of BP screening campaigns.

Usefulness of a Novel Electrocardiographic Score to Estimate the Pre-Test Probability of Acute Pulmonary Embolism

According to our experience the 12-lead electrocardiogram (ECG) may be used to estimate the pretest probability of acute pulmonary embolism (acPE). To this end, we devised a novel ECG score (nECGs) composed of 5 known ECG criteria, best characterizing the key pathogenetic steps of acPE. A retrospective derivation cohort including 136 patients with acPE and a prospective validation cohort including 149 consecutive patients were used to devise and validate the nECGs. The latter cohort consisted of 76 patients with acPE and 73 controls presenting with characteristic symptoms of acPE, in whom the work-up ruled out acPE. We compared the diagnostic value of our nECGs with those of another ECG score (Daniel-ECG-score) and of the best prediction rules (3 Wells score and 2 Geneva score variants). The sensitivity (98.7%), negative predictive value (98%), test accuracy (84.4%) and the negative likelihood ratio (LR) (0.019) of the nECGs were superior to those of all other investigated methods. There was no between-groups difference in the positive LR. The specificity (69%) of the nECGs was inferior to those of the Daniel-ECG-score and Wells scores and did not differ or was superior to those of the Geneva score variants. The positive predictive value (77.3%) of the nECGs was superior to those of the 2 Geneva scores and did not differ from those of the other methods. In conclusion, the nECGs due to its superior sensitivity, negative predictive value, test accuracy, and negative LR estimated the pretest probability of acPE better than the Daniel-ECG-score and the prediction rules.

A cilostazol diabeteses betegekben is javítja az életminőséget és az alsó végtagi funkcionális kapacitást

Bevezetés: A claudicatio intermittens jelentős negatív hatással van a betegek életminőségére. A különböző revascularisatiós eljárások és a noninvazív orvosi kezelések javíthatják a betegek járását. A cilostazol I.A ajánlással rendelkezik a claudicatio intermittens kezelésére. Célkitűzés: Vizsgálatunk célja a 3 hónapos cilostazolkezelésnek az egészséggel kapcsolatos életminőségre és az alsó végtag funkcionális kapacitására gyakorolt hatásának értékelése a klinikai gyakorlatban, claudicatio intermittensben szenvedő diabeteses (DM) és nem diabeteses (NDM) betegek körében. Módszer: A tanulmány multicentrikus, beavatkozással nem járó vizsgálat, amelybe 812, ambuláns kezelés alatt álló, perifériás verőérbetegségben szenvedő beteg (Fontaine II. stádium, átlagéletkor: 67,17 év, férfi/nő: 58,25/41,75%, 318 diabeteses) került beválasztásra, akik cilostazolkezelést kaptak (50 vagy 100 mg naponta kétszer) 3 hónapig. Az életminőséget az EQ-5D-3L-kérdőívvel, a funkcionális kapacitást a WELCH-kérdőívvel értékeltük. A fájdalommentes és maximális járástávolságnak, valamint a boka-kar indexnek a mérése megtörtént a vizsgálat indulásakor és a 3 hónapos kezelés után. Eredmények: A vizsgálat befejezése után az EQ-5D-index javult (kiindulási érték: NDM –0,45 ± 0,22, DM –0,48 ± 0,23, 3. hónap: –0,24 ± 0,18, –0,27 ± 0,19; p<0,0001), és a WELCH-pontszám szintén szignifikánsan nőtt (kiindulási érték: NDM 20 ± 14, DM 18 ± 14; 3. hónap: 33 ± 19, 29 ± 16; p<0,0001) mindkét betegcsoportban. Mind a fájdalommentes, mind a maximális járástávolság nőtt: NDM 59,2% (medián: 50,0%), 46,58 (medián: 40,51%), és DM 42,85% (medián: 43,33%), 41,61% (medián: 34,68%) (p<0,001). Következtetés: 3 hónapos cilostazolkezelés javította az életminőséget és az alsó végtagi funkcionális kapacitást claudicatio intermittensben szenvedő betegekben, diabetes esetén is. A WELCH-kérdőív hasznos eszköznek bizonyult a klinikai gyakorlatban a claudicatio kezelése során a járóképesség értékelésére. Orv Hetil. 2020; 161(38): 1637–1645.

A summary of data of screening of the lower limb peripheral arterial diseases in the region of Northern Hungary

INTRODUCTION

The screening tool for diagnosing lower extremity arterial disease (LEAD) is the assessment of the ankle-brachial index (ABI). In patients at risk for LEAD, the purpose of screening is to avoid major adverse limb events, such as amputation. However, resting ABI can easily produce a false negative result.

AIM

In light of this, our goal was to test the usefulness of an easily performed, fast and cost-effective screening method and to determine the proportion of subjects without definitive diagnoses among patients screened in general practice (with special attention to groups having negative ABI with symptoms and patients with non-compressible arteries).

METHOD

680 patients were screened from the region of Northern Hungary. We used the Edinburgh Questionnaire, recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing.

RESULTS

34% complained about lower extremity claudication; 23% had abnormal ABI values; 14% of the patients within the normal ABI range had complaints of dysbasia; 12% were in the non-compressible artery group. The ABI-negative symptomatic group's risk factor profile showed a close similarity to the clear LEAD-positive and non-compressible artery groups.

CONCLUSION

The percentage of LEAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups. When screening purposely for LEAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is a high clinical suspicion of LEAD in spite of normal ABI values, further assessment may be considered. Orv Hetil. 2020; 161(33): 1381-1389.

Regional variation of lower limb major amputations on different geographic scales - a Hungarian nationwide study over 13 years

Background: The incidence of lower limb major amputations is an important healthcare quality indicator, as it reflects all efforts aimed to prevent limb loss. Analysis of within-country regional variations in incidence may reveal the sources of disparities in care. Materials and methods: Based on the data of the Hungarian healthcare beneficiary population from 2004 to 2016, the incidence of lower limb major amputations and its spatial variations was determined regionally on four levels of geographic resolution. Variability and autocorrelation were quantified on different resolutions. Results: A total of 56,468 lower limb major amputation procedures were identified in 49,528 patients over the observation period. Marked regional variations were detected at all geographic scale levels. In the case of county-level and local administrative level, the systematic component of variation was 0.03 and 0.09, respectively. Only half of the variation at local administrative level was explained by county. Conclusions: Lower limb major amputations show marked regional variations on the different geographic levels of resolution. The more granular the assessment, the higher the regional variation was. Assumingly, this observation is partially a mathematical necessity but may also be related to the different characteristics of care at a given level of spatial aggregation. The decomposition of the variance of amputation rates indicates that the potential explanatory factors contributing to spatial variability are multiple and may be interpreted on different levels of geographic resolution. Addressing the unwarranted variations and resolving the issues that contribute to high lower limb major amputation rates needs further explorative analysis.

The combined effect of regular alcohol consumption and smoking on blood pressure and on the achievement of blood pressure target values in treated hypertensive patients

INTRODUCTION

The combined effect of alcohol consumption and smoking on hypertension in hypertensive patients is still not completely clear, although both are known to be cardiovascular risk factors.

AIM

The aim of our study was to compare the blood pressure, the achievement of target blood pressure and heart rate of non-smokers and non-drinkers in the middle-aged hypertensive patients with those who smoke and drink regularly.

METHOD

From the database of the Hungarian Hypertension Registry, 12 615 patients (6341 men and 6274 women) aged 45-64 years were included in the current analysis, who self-reported smoking habit and alcohol consumption.

RESULTS

The mean age of the patients was 55.8 ± 5.7 years (males) and 56.1 ± 5.5 years (females). The percentage of regular smokers was 40.8% and 27.2% among men and women, respectively. 38.1% of males and 12.5% of females were regular alcohol drinkers. The ratio of patients reaching goal blood pressure values was higher in all investigated groups of females than males (p<0.001). Regular smokers and drinkers have lower percentage of reaching goal blood pressure values: 31.1% versus 46.6% in males (p<0.001) and 41.1% versus 49.8% in females (p<0.01), respectively. The average of pulse rate was higher in patients who are smokers and regular drinkers.

CONCLUSION

Regular alcohol consumption and smoking decrease the chance of reaching blood pressure goal values in middle-aged, treated hypertensive patients. Orv Hetil. 2020; 161(30): 1252-1259.

The potentials and importance of imaging in large-vessel vasculitis

According to the nomenclature of the Chapel Hill Consensus Conference, giant-cell arteritis and Takayasu's arteritis belong to the group of large-vessel vasculitis. Recognition of these diseases is primarily based on the clinical assessment and the use of various vascular imaging modalities. With regard to the latter one, significant technological advances have been observed in recent years, which allow not only to make a diagnosis but also to evaluate the extent of the disease and the degree of vascular inflammation. In addition, subsequent complications of vascular inflammation can be examined. Ultrasound, computed tomography, magnetic resonance imaging, and positron-emission tomography represent imaging modalities that are essential for recognizing affected patients and planning effective treatment and follow-up. The review of this topic may be of interest to a number of medical specialties that are potentially involved in the care of these patients. Orv Hetil. 2020; 161(23): 939-950.

Simple assessment of quality of life and lower limb functional capacity during cilostazol treatment – results of the SHort-tERm cIlostazol eFFicacy and quality of life (SHERIFF) study

Summary: Background: Symptomatic peripheral arterial disease (intermittent claudication) is a major cause of disability and mobility loss in older men and women and thus has a significant negative impact on the patients’ quality of life. Both surgical and endovascular revascularization procedures and noninvasive medical therapies, such as supervised training and drug treatment, can improve walking capacity. Cilostazol is the only drug having a class I (level of evidence A) recommendation for the treatment of intermittent claudication (IC). The aim of this study was to evaluate the effect of three-month cilostazol treatment on the health-related quality of life and on the lower limb functional capacity in patients with IC in the clinical practice. Patients and methods: The study was a multicenter, non-interventional trial, performed in Hungary in 2018. 812 PAD patients (Fontaine II stage, mean age: 67.17 years, male/female: 58.25/41.75 %) were enrolled, who received cilostazol (50 or 100 mg b.i.d.) for 3 months. 802 patients completed the study. Quality of life was evaluated with the EQ-5D-3L questionnaire functional capacity with the WELCH (Walking Estimated-Limitation Calculated by History) questionnaire. Pain-free and maximal walking distance, ankle-brachial index (ABI) were measured at baseline and after 3-month treatment. Results: Upon conclusion of the study, the EQ-5D-3L index improved (baseline: –0.46 ± 0.22, 3rd month: –0.26 ± 0.18; p < 0.0001) and there was a significant increase in the WELCH score as well (19 ± 14, 31 ± 18; respectively, p < 0.0001). Both pain-free and maximal walking distance improved significantly by 54.52 % (median: 53.85 %) and 42.5 % (median: 34.68 %); respectively (p < 0.001). Adverse events occurred in 10 patients, 1 patient stopped cilostazol treatment because of side effects. Conclusions: Three months cilostazol treatment significantly improved quality of life and lower limb functional capacity in patients with intermittent claudication. The WELCH questionnaire is a useful tool for the evaluation of intermittent claudication treatment in the clinical practice.

Screening of peripheral arterial disease in primary health care

Background and purpose

The screening tool for diagnosing lower extremity arterial disease is the assessment of the ankle-brachial index (ABI), which is widely used in general practice. However, resting ABI can easily produce a false negative result. In light of this, our goal was to determine the proportion of definitive diagnoses (peripheral arterial disease [PAD] confirmed or refuted) among patients screened in general practice, and the rate of cases in which the need for further specialized examination is necessary, with special attention to groups having non-compressible arteries and ABI negative symptomatic status. The aim of our work is to improve the efficiency of primary health care screening in PAD and reduce the extremely high domestic amputation ratio.

Patients and methods

Eight hundred and sixteen patients were screened. We used the Edinburgh Questionnaire and recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing.

Results

Thirty-three percent complained about lower extremity claudication; 23% had abnormal ABI values; 13% of the patients within the normal ABI range had complaints of dysbasia; and 12% were in the non-compressible artery group. The ABI-negative symptomatic group’s risk factor profile showed a close similarity to the clear PAD-positive and non-compressible artery groups.

Conclusion

The percentage of PAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups, together defined as the “murky zone”. When screening purposely for PAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is high clinical suspicion of PAD in spite of normal ABI values, further assessment may be considered.

May Measurement Month 2017: an analysis of blood pressure screening in Hungary-Europe

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. The cardiovascular mortality rate in Hungary is twice as high as the European Union average. In a recent Hungarian screening programme, among those volunteers who claimed to be healthy, BP was above 140/90 mmHg in 24% and 39% in women and men, while the control rate was 45% and 36% in women and men, respectively. May Measurement Month (MMM) is a global initiative by the International Society of Hypertension aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programmes worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017. BP measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. In Hungary, 97 sites were set-up in primary and secondary care facilities, in pharmacies and in malls. All regions, both cities and villages were involved. A total of 3967 individuals were screened. After multiple imputation, 2052 subjects (51.8%) had hypertension. 553 (22.4%) of untreated individuals had hypertension, and 666 (44.5%) of treated individuals had uncontrolled BP. More than 50% of the screened cohort had hypertension (treated and controlled, treated and uncontrolled or untreated). By identifying almost one-third of the screened cohort with the possibility of newly diagnosed or uncontrolled hypertension, the Hungarian part of MMM17 suggest that opportunistic screening can identify significant numbers with raised BP.

Is the spiked helmet sign the manifestation of long QT syndrome?

We present the case of a patient with Takotsubo syndrome developing simultaneous inferior, anterior spiked helmet sign (SHS) and macroscopic T-wave alternans (TWA) leading to torsade de pointes ventricular tachycardia (TdP VT). Based on our observations we propose that the SHS is a type of manifestation of critically prolonged QT(U).

[The potential role of oscillometric devices for ankle-brachial index measurements in clinical practice]

INTRODUCTION

Oscillometric devices in contrast to the traditional Doppler based method for ankle-brachial index measurements have promising advantages like no need for special training, faster performance, and operator independence.

AIM

Comparative assessment of the oscillometric and Doppler-based ankle-brachial index measurement.

METHOD

Ankle-brachial index measurements were performed by continuous wave Doppler and an automatic oscillometric device (BOSO ABI-system 100) in consecutive subjects. The comparative assessment was performed by Bland-Altman and ROC analysis.

RESULTS

The two kinds of measurements (734 measurements) showed a good agreement in the ankle-brachial index spectrum close to the cut-off value of 0.9. The agreement diminished below or above this value. The optimal oscillometric ankle-brachial index diagnostic cut-off value was 0.96.

CONCLUSIONS

The oscillometric device is not interchangeable for Doppler devices in the whole ankle-brachial index spectrum. Nevertheless, owing to its discriminative power, the oscillometric measurement potentially has an efficient role in the screening of asymptomatic patients. Orv Hetil. 2018; 159(5): 176-182.

[Adherence to medication after myocardial infarction and its impact on outcome: a registry-based analysis from the Hungarian Myocardial Infarction Registry]

INTRODUCTION AND AIM

The aim was to study the patients' adherence to some evidence-based medication (statins, beta blockers, platelet and RAS inhibitors) after suffering a myocardial infarction, and its impact on the outcome.

METHOD

Retrospective observational cohort study was carried out from the data of the Hungarian Myocardial Infarction Registry between January 1, 2013, and December 31, 2014. 14,843 patients were alive at the end of hospital treatment, from them, those who had no myocardial infarction or death until 180 days were followed for one year. The adherence was defined as the proportion of time from the index event to the endpoint (or censoring) covered with prescription fillings. The endpoint was defined as death or reinfarction. Information on filling prescriptions for statins, platelet aggregation inhibitors, beta blockers and ARB/ACEI-inhibitors were obtained. Multivariate regression was used to model adherence and survival time.

RESULTS

Good adherence (\>80%) to clopidogrel, statins, beta blockers, aspirin and ARB/ACEI was found in 64.9%, 54.4%, 36.5%, 31.7% and 64.0%, respectively. Patients treated with PCI during the index hospitalization had higher adherence to all medication (all p<0.01), except for beta-blocker (p = 0.484). Multivariate analysis confirmed that adherence to statins, to clopidogrel and ARB/ACEI-inhibitors was associated with 10.1% (p<0.0001), 10.4% (p = 0.0002) and 15.8% (p<0.0001) lower hazard of endpoint respectively for 25% points increase in adherence, controlling for age, sex, performing of PCI, 5 anamnestic data and date of index event. Adherence to aspirin and beta blockers was not significantly associated with the hazard.

CONCLUSION

Higher adherence to some evidence-based medications was found to be associated with improved long term prognosis of the patients. Orv Hetil. 2017; 158(27): 1051-1057.

A diabeteses láb ischaemiás eredete. Epidemiológia, a diagnózis nehézségei, prevenciós és revascularisatiós lehetőségek

Abstract:

“Diabetic foot” as definition covers a multifactorial clinical condition. According to the recent epidemiological data, the role of lower limb ischemia is getting more influential over other pathological causes, like neuropathy, infections and bone or soft tissue deformity. In diabetes, vascular disease leads to increased risk for leg ulcers and minor or major amputations. The traditional diagnostic tools for recognition of peripheral arterial disease have limited value because of diabetes specific clinical manifestations. Available vascular centers with special expertise and diagnostic tools are the prerequisite for efficient diagnosis supporting timely recognition of peripheral arterial disease. In course of treatment of diabetic foot with ischemic origin, beyond effective medical treatment revascularization (open vascular surgery or endovascular procedures) has paramount importance for prevention of limb loss. Vascular teams of vascular specialists, vascular surgeons and interventional radiologist in dedicated centers in multidisciplinary cooperation with other professions represent public health issue in effective prevention. Orv. Hetil., 2017, 158(6), 203–211.

[Hungarian Heart Failure Registry 2015-2016. Preliminary results]

Heart failure is associated with a poor prognosis despite significant advances in the pharmacological and device therapy and incurs very high cost because of frequent hospitalizations. Therefore, professional high-quality care is essential for both patients and the healthcare system. The best way to evaluate the quality of care for a particular disease is the use of disease-specific registries. Until now, there has not been a registry evaluating characteristics and management of heart failure patients in Hungary. For that reason, the Hungarian Society of Cardiology initiated the set-up of the Hungarian Heart Failure Registry. The Aim of this paper is to present the goals, methods and first year results of the Hungarian Heart Failure Registry. The goal of the Registry is to create a modern, web-based database that summarizes the data of large number of patients who are currently or were previously admitted to hospital or who are currently or were previously patients in an outpatient department due to severe heart failure (NYHA III-IV). Currently 17 cardiology departments participate in the development of the Registry. The planned number of patients is 2000. Initially follow-up was planned for one year (pilot study). After the evaluation of the relevant experiences of the pilot study, long-term follow-up is planned. The Registry collects information about the type of heart failure (heart failure with reduced - LVEF≤45% - vs. preserved - LVEF>45% - ejection fraction), etiology, co-morbidities, diagnostic methods, treatment as well as morbidity and mortality. After the first year, assessing the baseline parameters of 698 patients enrolled in the Registry we found that the majority of patients (87.8%) has heart failure with reduced ejection fraction and in 39.8% of the patients heart failure has an ischaemic origin. The most frequent co-morbidity was hypertension followed by diabetes, renal insufficiency and COPD. The patients were treated with ACE inhibitors or ARBs in 94.4%, with beta blockers in 95.9%, and mineralocorticoid receptor antagonists in 73.9%. The mean dose of neurohormonal antagonists was higher than half of the target dose defined by current guidelines. The use of cardiac resynchronisation therapy was 11.7% and implantable cardioverter defibrillator was 25.8%. The pharmacological and device therapy of patients who were enrolled in the Registry until now was fit the current guidelines' recommendations. This, however, does not mean that the management of heart failure is without problems in our country but that high quality patient care is available with adequate heart failure treatment in cardiology departments dedicated to heart failure care. Orv. Hetil., 2017, 158(3), 94-100.

A szívinfarktus miatt kezelt betegek ellátása Magyarországon. A Nemzeti Szívinfarktus Regiszter 2015. évi adatainak elemzése

Abstract:

The authors summarize the most relevant data of myocardial infarction patients according to the National Myocardial Infarction Registry data base. In 2015 12,681 patients had 12,941 acute myocardial infarctions. Less than half of patients (44.4%) were treated with ST elevation myocardial infarction. National Ambulance Service was the first medical contact of more than half (51.4%) of patients with ST elevation infarction. Prehospital thrombolysis was occasionally done (0.23%), but 91.6% of the patients were treated in hospital with invasive facilities. The median of the ischaemic time (time between onset of symptoms and arrival at the invasive laboratory) was 223 minutes. Most of the patients (94%) with positive coronary arteriography were treated with percutaneous coronary intervention. The 30 day mortality of the whole group was 12.8% vs. 8.6% of patients treated with an invasive procedure. Conclusion: comparing the national and international registry data we conclude that we should analyse and decrease the prehospital delay time to improve the patient care in Hungary. Orv. Hetil., 2017, 158(3), 90–93.

A cilostazol hatékony és biztonságos lehetőség a claudicatio intermittens kezelésére. A NOCLAUD vizsgálat eredményei

Abstract:

Intermittent claudication can seriously impair the patients’ quality of life. Cilostazol was registered in Hungary in 2014. This study aimed to evaluate the efficacy and safety of cilostazol in patients with intermittent claudication. 1405 patients were enrolled to the 6 months, multicenter, non-interventional trial. From the 1331 patients, who completed the study, the data of 674 patients were subjected to efficacy analysis. Pain free and maximal walking distance and the 6 minute walking test improved significantly at 3 months (78.65%, 65.23%, 56.09%; respectively, p<0.001), and a further increase was observed after 6 months treatment (129.74%, 107.2, 80.38% respectively, p<0.001). Adverse events occured in 7.26% of the patients. The most frequent adverse events were headache, diarrhea, dizziness, tachycardia or palpitation. 24 patients (1.7%) stopped cilostazol treatment because of side effects. 6 month cilostazol treatment significantly increased the walking distance in patients with intermittent claudication, without important safety problems. Orv. Hetil., 2017, 158(4), 123–128.

[Peripheral arterial disease and diabetes related lower limb amputations. Presentation of the epidemiological data and the analysis of potentialities in preventive strategy]

Lower limb amputation as one of the most devastating consequences of peripheral arterial disease and diabetes mellitus needs peculiar attention. This review aims at comparing Hungarian and international amputation data. Realizing the great variability of the global amputation incidence and trends data, the main determinants of this variety are assessed. These factors involve methodological differences in reporting, demographic, epidemiological, economic, societal and cultural variation of the affected populations and differences in the health care service. The amputation hazard can be considered as an example of lifetime risk that can be characterized by complex interaction of contionuously changing risk factor pattern. In that sense an effective preventive strategy planning needs complex measure implementations that associate with multidisciplinary approach, timely complex preventive interventions and centralized vascular care. Research and development on amputation field shows clear priority that can contribute to the better understanding of this extremely complex scenario with significant public health consequences. Orv. Hetil., 2016, 157(32), 1266-1274.

[Quality of life and burden of disease in peripheral arterial disease: a study among Hungarian patients]

INTRODUCTION

Peripheral arterial disease may occur in about of 14% of patients with high blood pressure, of which 1-3% suffer from chronic critical limb ischemia. Literature data on the quality of life according to the Fontaine stages are very limited.

AIM

The aim of this study was to assess the quality of life of Hungarian patients with peripheral arterial disease regarding Fontaine stages II, III and IV.

METHODS

The study was based on a cross-sectional survey, which was carried out in four angiologic centres. One hundred and two respondents with peripheral arterial disease (43% woman) were evaluated. The average age of the patients was 70 years (SD-10).

RESULTS

Based on the EQ-5D index, the results of the quality of life assessment with respect to Fontaine stages II, III and IV were 0.66, 0.35 and 0.18, respectively. In each stage the EQ-5D values were lower than the values of the age-matched average population. The results of the Pain Visual Analogue Scale (0-100 mm) were 38, 65 and 71 mm in Fontaine stages II, III and IV, respectively, and this showed a strong correlation with the EQ-5D (R = -0.68). In stage Fontaine IV the quality of life of the patients was significantly lower among those who had pain at rest and ALSO ulcer on the leg.

CONCLUSIONS

Peripheral disease with clinical symptoms causes significant reduction in quality of life which can be measured with EQ-5D. It becomes worse as we move along the Fontaine stages. While measuring the health gain in stage Fontaine IV, the health gain from the reduction of pain in rest and partial recovery from ulcer should be taken into account.

Role of endocannabinoids and cannabinoid-1 receptors in cerebrocortical blood flow regulation

Background

Endocannabinoids are among the most intensively studied lipid mediators of cardiovascular functions. In the present study the effects of decreased and increased activity of the endocannabinoid system (achieved by cannabinoid-1 (CB1) receptor blockade and inhibition of cannabinoid reuptake, respectively) on the systemic and cerebral circulation were analyzed under steady-state physiological conditions and during hypoxia and hypercapnia (H/H).

Methodology/Principal Findings

In anesthetized spontaneously ventilating rats the CB1-receptor antagonist/inverse agonist AM-251 (10 mg/kg, i.v.) failed to influence blood pressure (BP), cerebrocortical blood flow (CoBF, measured by laser-Doppler flowmetry) or arterial blood gas levels. In contrast, the putative cannabinoid reuptake inhibitor AM-404 (10 mg/kg, i.v.) induced triphasic responses, some of which could be blocked by AM-251. Hypertension during phase I was resistant to AM-251, whereas the concomitant CoBF-increase was attenuated. In contrast, hypotension during phase III was sensitive to AM-251, whereas the concomitant CoBF-decrease was not. Therefore, CoBF autoregulation appeared to shift towards higher BP levels after CB1-blockade. During phase II H/H developed due to respiratory depression, which could be inhibited by AM-251. Interestingly, however, the concomitant rise in CoBF remained unchanged after AM-251, indicating that CB1-blockade potentially enhanced the reactivity of the CoBF to H/H. In accordance with this hypothesis, AM-251 induced a significant enhancement of the CoBF responses during controlled stepwise H/H.

Conclusion/Significance

Under resting physiological conditions CB1-receptor mediated mechanisms appear to have limited influence on systemic or cerebral circulation. Enhancement of endocannabinoid levels, however, induces transient CB1-independent hypertension and sustained CB1-mediated hypotension. Furthermore, enhanced endocannabinoid activity results in respiratory depression in a CB1-dependent manner. Finally, our data indicate for the first time the involvement of the endocannabinoid system and CB1-receptors in the regulation of the cerebral circulation during H/H and also raise the possibility of their contribution to the autoregulation of CoBF.

[Effectiveness of prostanoids in patients with critical leg ischemia]

Prostanoids (alprostadil and iloprost) are used for the treatment of patients with critical limb ischemia in whom revascularization procedure is inadequate or proved to be unsuccessful. According to a Cochrane analysis (CD006544) prostanoids differ in their effects on rest-pain relief and ulcer healing.

OBJECTIVES

To study the efficacy and safety of prostanoids for critical limb ischemia.

METHODS

Systematic literature search and meta-analysis (mixed treatment comparison) was performed.

RESULTS

Seven randomized controlled trials including 964 patients were analyzed. Compared to placebo, both alprostadil (OR: 3.2 95% CI: 1.7-5.5 and OR: 1.8 95% CI: 0.6-4.3) and iloprost (OR: 2.7 95% CI: 1.7-4.2 and OR: 2.5 95% CI: 1.0-5.4) were more efficacious with regard to rest-pain relief and ulcer healing and the difference between the two prostanoids was not significant (OR: 1.2 95% CI: 0.7-1.9 and OR: 0.74 95% CI: 0.3-1.5). Adverse events occurred significantly more often with both drugs compared to placebo, however, they were less frequent with alprostadil than with iloprost (OR 0.2 95% CI: 0.1-0.3).

CONCLUSIONS

Prostanoids have favorable effect on rest-pain relief and ulcer healing in critical limb ischemia, without statistically significant difference between the two available drugs. The Cochrane study (CD006544) reported mistaken results due to defaults in the analysis.

Arterial Stiffness in Hemodialysis: Which Parameter to Measure to Predict Cardiovascular Mortality?

In previous studies, different parameters of arterial stiffness were related to cardiovascular mortality in hemodialysis patients, but their relative prognostic value has not previously been evaluated in 1 cohort. Carotid-femoral pulse wave velocity (PWV), the carotid augmentation index, carotid pulse pressure (CPP) and carotid-brachial pulse pressure amplification (AMP) were measured in 98 patients before and after hemodialysis. Patients were followed for a median of 29 months (1–34) and the association of these parameters with cardiovascular mortality were assessed using log-rank tests and Cox proportional hazards regressions. During follow-up, 25 patients died of cardiovascular causes. Increasing pre- and postdialysis PWV tertiles and decreasing predialysis AMP tertiles were significantly related to cardiovascular mortality (p = 0.012 and 0.011 for PWV, respectively; < 0.001 for AMP). Neither the carotid augmentation index nor carotid pulse pressure were related to cardiovascular mortality. The adjusted hazard ratios for 1 m/s higher pre- and postdialysis PWV were 1.24 (1.07–1.44) and 1.17 (1.06–1.28), respectively. The hazard ratio for 10% lower predialysis AMP was 1.41 (1.03–1.92). When included in the same model, both predialysis PWV and AMP remained significantly associated with cardiovascular mortality. Among different stiffness parameters, PWV is consistently related to cardiovascular mortality, irrespective of the timing of measurement. Predialysis AMP seems to provide additional prognostic information.

Intracardiac calcification is a marker of generalized atherosclerosis

Aortic valve calcification (AVC) and carotid artery calcification (CAC) are considered to be markers of generalized atherosclerosis. However, the role of intracardiac calcification (ICC) (valvular and perivalvular calcification) is unclear. The objective of this retrospective study was to analyze the relationship between ICC and CAC, risk factors, and clinical atherosclerotic disease. Risk factors included age, sex, diabetes mellitus, hypercholesterolemia, and hypertension; clinical atherosclerosis comprised stroke, coronary artery disease, and peripheral artery disease. Between January 1, 2001, and January 1, 2004, all consecutive patients were enrolled into the study who underwent both carotid ultrasonography and transthoracic echocardiography examinations within 2 months. Patients with renal failure, substantial aortic stenosis, and carotid artery occlusion were excluded. There were 320 patients (104 men; mean +/- SEM age, 66.6 +/- 0.76 years). Positive results on carotid ultrasonography are defined as any CAC. Patients were categorized as having mild, moderate, or severe CAC. Positive results on transthoracic echocardiography were defined as any ICC; AVC was defined as mitral anulus calcification (MAC) or both. Intracardiac calcification was found in 181 patients, AVC in 51 patients, MAC in 48 patients, and calcification of both structures in 82 patients. Using multiple logistic regression analysis, ICC (odds ratio, 1.9), age (10-year periods) (odds ratio, 2.0), and the presence of peripheral artery disease (odds ratio, 1.7) were independent predictors of CAC. Carotid ultrasonography results were positive in 227 patients. For CAC, the sensitivities of AVC, MAC, both, and any ICC were 52.4%, 52.0%, 33.5%, and 71.2%, respectively, and the specificities were 84.9%, 87.1%, 92.5%, and 78.5%, respectively. The extension of ICC as 0, 1 location (AVC or MAC) , or 2 locations (AVC and MAC) was associated with the severity of CAC (P < .001, tau = 0.42). There was no difference between patients with AVC vs patients with MAC in the presence of different stages of CAC (P = .62). Intracardiac calcification (MAC or AVC) is an independent predictor of CAC as a marker of atherosclerosis, although the lack of ICC does not rule out atherosclerosis. Intracardiac calcification is related to CAC, with high specificity. The extension of ICC is related to the severity of atherosclerosis. Based on our results, antiatherothrombotic therapy should be considered in patients with ICC even before obtaining a positive carotid ultrasonography result.

[Noninvasive assessment of endothelial function in hemodialyzed hypertensive patients by laser Doppler flowmetry]

BACKGROUND

End stage renal disease and hypertension are associated with higher cardiovascular mortality. Endothelial dysfunction plays an important role in the pathogenesis of cardiovascular diseases. The authors investigated the endothelium-dependent and -independent vasodilation in the forearm skin microcirculation and the plasma markers of endothelial damage in hypertensive hemodialysed patients and in normotensive control subjects.

METHODS

Laser Doppler flowmetry with iontophoresis of acetylcholine and sodium nitroprusside and the postocclusive reactive hyperemia test was performed in 22 normal control subjects and in 21 hemodialysed patients with hypertension. Levels of endothelin-1, big-endothelin, and von Willebrand Factor were measured, as well.

RESULTS

The average hyperemic response to the two doses of acetylcholine iontophoresis was 474 +/- 83%; 836 +/- 97% in the control subjects, and 160 +/- 26%; 360 +/- 67% in the hemodialysed patients group (p < 0.05). The vasodilation after the two doses of sodium nitroprusside was 381 +/- 60%, 782 +/- 81% in the control group and 186 +/- 42%; 379 +/- 63% in the dialysed patients group (p < 0.05 compared to control, respectively). The average peak flow during the postocclusive reactive hyperemia test was significantly lower in hemodialysed hypertensives (234 +/- 48%) compared to healthy control subjects (434 +/- 36%, p < 0.05). Levels of endothelin-1, big endothelin, von Willebrand Factor and von Willebrand Factor activity were significantly higher in the patient group compared to the control subjects.

CONCLUSIONS

In hemodialysed hypertensive patients, both endothelium-dependent and -independent vasodilation are impaired. Markers of endothelial damage are elevated referring the progression of vascular disease.

Hemodynamic profile, responsiveness to anandamide, and baroreflex sensitivity of mice lacking fatty acid amide hydrolase

The endocannabinoid anandamide exerts neurobehavioral, cardiovascular, and immune-regulatory effects through cannabinoid receptors (CB). Fatty acid amide hydrolase (FAAH) is an enzyme responsible for the in vivo degradation of anandamide. Recent experimental studies have suggested that targeting the endocannabinergic system by FAAH inhibitors is a promising novel approach for the treatment of anxiety, inflammation, and hypertension. In this study, we compared the cardiac performance of FAAH knockout (FAAH-/-) mice and their wild-type (FAAH+/+) littermates and analyzed the hemodynamic effects of anandamide using the Millar pressure-volume conductance catheter system. Baseline cardiovascular parameters, systolic and diastolic function at different preloads, and baroreflex sensitivity were similar in FAAH-/- and FAAH+/+ mice. FAAH-/- mice displayed increased sensitivity to anandamide-induced, CB1-mediated hypotension and decreased cardiac contractility compared with FAAH(+/+) littermates. In contrast, the hypotensive potency of synthetic CB1 agonist HU-210 and the level of expression of myocardial CB1 were similar in the two strains. The myocardial levels of anandamide and oleoylethanolamide, but not 2-arachidonylglycerol, were increased in FAAH-/- mice compared with FAAH+/+ mice. These results indicate that mice lacking FAAH have a normal hemodynamic profile, and their increased responsiveness to anandamide-induced hypotension and cardiodepression is due to the decreased degradation of anandamide rather than an increase in target organ sensitivity to CB1 agonists.

Impairment of skin microvascular reactivity in hypertension and uraemia

BACKGROUND

Uraemia and hypertension are associated with higher risk for cardiovascular complications. Endothelial dysfunction plays an important role in the pathogenesis of cardiovascular diseases. The aim of the present study was to evaluate endothelial function in the forearm skin microcirculation of patients with essential hypertension, in hypertensive haemodialysis patients and in normotensive control subjects.

METHODS

We performed laser Doppler flowmetry with iontophoresis of acetylcholine (ACh) and of sodium nitroprusside (SNP) as well as the post-occlusive reactive hyperaemia test (PORH) in 16 normal control subjects (CONT), in 16 patients with essential hypertension (EHT) and in 16 haemodialysis patients with essential hypertension (DHT). Plasma levels of endothelin-1, big-endothelin and von Willebrand factor (vWF) were also measured.

RESULTS

The average hyperaemic response to the higher dose of ACh iontophoresis was 801+/-110% in CONT, 563+/-69 % in EHT and 308+/-64% in DHT (P<0.05, between all comparisons). Vasodilation to the higher dose of SNP was 791+/-79% in CONT, 633+/-72% in EHT and 355+/-69% in DHT (NS, P<0.001 compared with controls, respectively). The average peak flow during PORH was significantly lower in both the EHT and DHT groups compared with controls (294+/-39, 267+/-59 and 429+/-45%, respectively, P<0.05). Levels of endothelin-1, big endothelin, vWF and vWF activity were significantly higher in the DHT group (P<0.05, compared with controls).

CONCLUSIONS

In hypertensive haemodialysis patients, both endothelium-dependent and -independent vasodilation was impaired. The observed increase in plasma markers of endothelial damage indicated a progression of vascular disease.

Non-invasive assessment of microvascular endothelial function by laser Doppler flowmetry in patients with essential hypertension

The aim of the study was to investigate the endothelium-dependent vasodilation in the forearm skin using two non-invasive laser Doppler applications in patients with essential hypertension (EHT) and in normotensive (NT) control subjects. The effect of two consecutive doses of acetylcholine (ACh) and that of sodium nitroprusside (SNP) on the skin microcirculation, and thereafter the postocclusive reactive hyperaemic (PORH) response, were measured in 25 patients with essential hypertension and also in 25 control normotensive healthy subjects. The plasma von Willebrand factor (vWF) level and activity were also determined. The average peakflow in PORH was 287 +/- 31.5% (x +/- S.E.M.) in EHT and 410.28 +/- 35.08% in NT (P < 0.01). The average hyperaemic response to the two doses of ACh-iontophoresis was 206.36 +/- 33.97 and 568.76 +/- 54.23% in EHT and 444.24 +/- 80.28 and 804.12 +/- 93.07% in NT (P < 0.01, 0.05). The response to SNP was similar in the two groups. The vWF levels were 122.5 +/- 13.2 and 89.6 +/- 8.1% (P = 0.0595, NS), the activities were 80.8 +/- 5.5 and 68.9 +/- 6.1% (P = 0.157, NS) in EHT and in NT, respectively. These results demonstrate that essential hypertension is associated with endothelial dysfunction in the skin microcirculation of the forearm.

Cannabinoid antagonist SR-141716 inhibits endotoxic hypotension by a cardiac mechanism not involving CB1 or CB2 receptors

Endocannabinoids and CB1 receptors have been implicated in endotoxin (LPS)-induced hypotension: LPS stimulates the synthesis of anandamide in macrophages, and the CB1 antagonist SR-141716 inhibits the hypotension induced by treatment of rats with LPS or LPS-treated macrophages. Recent evidence indicates the existence of cannabinoid receptors distinct from CB1 or CB2 that are inhibited by SR-141716 but not by other CB1 antagonists such as AM251. In pentobarbital-anesthetized rats, intravenous injection of 10 mg/kg LPS elicited hypotension associated with profound decreases in cardiac contractility, moderate tachycardia, and an increase in lower body vascular resistance. Pretreatment with 3 mg/kg SR-141716 prevented the hypotension and decrease in cardiac contractility, slightly attenuated the increase in peripheral resistance, and had no effect on the tachycardia caused by LPS, whereas pretreatment with 3 mg/kg AM251 did not affect any of these responses. SR-141716 also elicited an acute reversal of the hypotension and decreased contractility when administered after the response to LPS had fully developed. The LPS-induced hypotension and its inhibition by SR-141716 were similar in pentobarbital-anesthetized wild-type, CB1(-/-), and CB1(-/-)/CB2(-/-) mice. We conclude that SR-141716 inhibits the acute hemodynamic effects of LPS by interacting with a cardiac receptor distinct from CB1 or CB2 that mediates negative inotropy and may be activated by anandamide or a related endocannabinoid released during endotoxemia.

[Cardiovascular effects of cannabinoids]

The psychoactive properties of cannabinoids, the biologically active constituents of the marijuana plant, have long been recognized. Recent research has revealed that cannabinoids elicit not only neurobehavioral, and immunological, but also profound cardiovascular effects. Similar effects can be elicited by the endogenous ligand arachidonyl ethanolamine (anandamide) and 2-arachidonoyl-glycerol. The biological effects of cannabinoids are mediated by specific receptors. Two cannabinoid receptors have been identified so far: CB1-receptors are expressed by different cells of the brain and in peripheral tissues, while CB2-receptors were found almost exclusively in immune cells. Through the use of a selective CB1 receptor antagonist and CB1 receptor-knockout mice the hypotensive and bradycardic effects of cannabinoids in rodents could be attributed to activation of peripheral CB1 receptors. In hemodynamic studies using the radioactive microsphere technique in anesthetized rats, cannabinoids were found to be potent CB1-receptor dependent vasodilators in the coronary and cerebrovascular beds. Recent findings implicate the endogenous cannabinoid system in the pathomechanism of haemorrhagic, endotoxic and cardiogenic shock. Finally, there is evidence that the extreme mesenteric vasodilation, portal hypertension and systemic hypotension present in advanced liver cirrhosis are also mediated by the endocannabinoid system. These exciting, recent research developments indicate that the endogenous cannabinoid system plays an important role in cardiovascular regulation, and pharmacological manipulation of this system may offer novel therapeutic approaches in a variety of pathological conditions.

CB(1) receptor antagonist SR141716A inhibits Ca(2+)-induced relaxation in CB(1) receptor-deficient mice

Mesenteric branch arteries isolated from cannabinoid type 1 receptor knockout (CB(1)(-/-)) mice, their wild-type littermates (CB(1)(+/+) mice), and C57BL/J wild-type mice were studied to test the hypothesis that murine arteries undergo high sensitivity Ca(2+)-induced relaxation that is CB(1) receptor dependent. Confocal microscope analysis of mesenteric branch arteries from wild-type mice showed the presence of Ca(2+) receptor-positive periadventitial nerves. Arterial segments of C57 control mice mounted on wire myographs contracted in response to 5 micromol/L norepinephrine and responded to the cumulative addition of extracellular Ca(2+) with a concentration-dependent relaxation that reached a maximum of 72.0 +/- 6.3% of the prerelaxation tone and had an EC(50) for Ca(2+) of 2.90 +/- 0.54 mmol/L. The relaxation was antagonized by precontraction in buffer containing 100 mmol/L K(+) and by pretreatment with 10 mmol/L tetraethylammonium. Arteries from CB(1)(-/-) and CB(1)(+/+) mice also relaxed in response to extracellular Ca(2+) with no differences being detected between the knockout and their littermate controls. SR141716A, a selective CB(1) antagonist, caused concentration-dependent inhibition of Ca(2+)-induced relaxation in both the knockout and wild-type strains (60% inhibition at 1 micromol/L). O-1918, a cannabidiol analog, had a similar blocking effect in arteries of both wild-type and CB(1)(-/-) mice at 10 micromol/L. In contrast, 1 micromol/L SR144538, a cannabinoid type 2 receptor antagonist, or 50 micromol/L 18alpha-glycyrrhetinic acid, a gap junction blocker, were without effect. SR141716A (1 to 30 micromol/L) was also assessed for nonspecific actions on whole-cell K(+) currents in isolated vascular smooth muscle cells. SR141716A inhibited macroscopic K(+) currents at concentrations higher than those required to inhibit Ca(2+)-induced relaxation, and appeared to have little effect on currents through large conductance Ca(2+)-activated K(+) channels. These data indicate that arteries of the mouse relax in response to cumulative addition of extracellular Ca(2+) in a hyperpolarization-dependent manner and rule out a role for CB(1) or CB(2) receptors in this effect. The possible role of a nonclassical cannabinoid receptor is discussed.

Hemodynamic effects of cannabinoids: coronary and cerebral vasodilation mediated by cannabinoid CB(1) receptors

Activation of peripheral cannabinoid CB(1) receptors elicits hypotension. Using the radioactive microsphere technique, we examined the effects of cannabinoids on systemic hemodynamics in anesthetized rats. The potent cannabinoid CB(1) receptor agonist HU-210 ([-]-11-OH-Delta(9) tetrahydrocannabinol dimethylheptyl, 10 microg/kg i.v.) reduced mean blood pressure by 57+/-5 mm Hg by decreasing cardiac index from 37+/-1 to 23+/-2 ml/min/100 g (P<0.05) without significantly affecting systemic vascular resistance index. HU-210 elicited a similar decrease in blood pressure following ganglionic blockade and vasopressin infusion. The endogenous cannabinoid anandamide (arachidonyl ethanolamide, 4 mg/kg i.v.) decreased blood pressure by 40+/-7 mm Hg by reducing systemic vascular resistance index from 3.3+/-0.1 to 2.3+/-0.1 mm Hg min/ml/100 g (P<0.05), leaving cardiac index and stroke volume index unchanged. HU-210, anandamide, and its metabolically stable analog, R-methanandamide, lowered vascular resistance primarily in the coronaries and the brain. These vasodilator effects remained unchanged when autoregulation was prevented by maintaining blood pressure through volume replacement, but were prevented by pretreatment with the cannabinoid CB(1) receptor antagonist SR141716A (N-[piperidin-1-yl]-5-[4-chlorophenyl]-1-[2,4-dichlorophenyl]-4-methyl-1H-pyrazole-3-carboxamide HCl; 3 mg/kg i.v.). Only anandamide and R-methanandamide were vasodilators in the mesentery. We conclude that cannabinoids elicit profound coronary and cerebral vasodilation in vivo by direct activation of vascular cannabinoid CB(1) receptors, rather than via autoregulation, a decrease in sympathetic tone or, in the case of anandamide, the action of a non-cannabinoid metabolite. Differences between the hemodynamic profile of various cannabinoids may reflect quantitative differences in cannabinoid CB(1) receptor expression in different tissues and/or the involvement of as-yet-unidentified receptors.

Endocannabinoids acting at vascular CB1 receptors mediate the vasodilated state in advanced liver cirrhosis

Advanced cirrhosis is associated with generalized vasodilation of unknown origin, which contributes to mortality. Cirrhotic patients are endotoxemic, and activation of vascular cannabinoid CB1 receptors has been implicated in endotoxin-induced hypotension. Here we show that rats with biliary cirrhosis have low blood pressure, which is elevated by the CB1 receptor antagonist SR141716A. The low blood pressure of rats with CCl4-induced cirrhosis was similarly reversed by SR141716A, which also reduced the elevated mesenteric blood flow and portal pressure. Monocytes from cirrhotic but not control patients or rats elicited SR141716A-sensitive hypotension in normal recipient rats and showed significantly elevated levels of anandamide. Compared with non-cirrhotic controls, in cirrhotic human livers there was a three-fold increase in CB1 receptors on isolated vascular endothelial cells. These results implicate anandamide and vascular CB1 receptors in the vasodilated state in advanced cirrhosis and indicate a novel approach for its management.

Leptin-regulated endocannabinoids are involved in maintaining food intake

Leptin is the primary signal through which the hypothalamus senses nutritional state and modulates food intake and energy balance. Leptin reduces food intake by upregulating anorexigenic (appetite-reducing) neuropeptides, such as alpha-melanocyte-stimulating hormone, and downregulating orexigenic (appetite-stimulating) factors, primarily neuropeptide Y. Genetic defects in anorexigenic signalling, such as mutations in the melanocortin-4 (ref. 5) or leptin receptors, cause obesity. However, alternative orexigenic pathways maintain food intake in mice deficient in neuropeptide Y. CB1 cannabinoid receptors and the endocannabinoids anandamide and 2-arachidonoyl glycerol are present in the hypothalamus, and marijuana and anandamide stimulate food intake. Here we show that following temporary food restriction, CB1 receptor knockout mice eat less than their wild-type littermates, and the CB1 antagonist SR141716A reduces food intake in wild-type but not knockout mice. Furthermore, defective leptin signalling is associated with elevated hypothalamic, but not cerebellar, levels of endocannabinoids in obese db/db and ob/ob mice and Zucker rats. Acute leptin treatment of normal rats and ob/ob mice reduces anandamide and 2-arachidonoyl glycerol in the hypothalamus. These findings indicate that endocannabinoids in the hypothalamus may tonically activate CB1 receptors to maintain food intake and form part of the neural circuitry regulated by leptin.

Systemic and portal hemodynamic effects of anandamide

The endogenous cannabinoid anandamide causes hypotension and mesenteric arteriolar dilation. A detailed analysis of its effects on systemic and portal venous hemodynamics had not yet been performed. We assessed the effects of anandamide (0.4-10 mg/kg) on systemic and portal hemodynamics with and without prior treatment with various antagonists. The specific antagonists used included SR-141716A, N(omega)-nitro-L-arginine methyl ester, indomethacin, and nordihydroguaiaretic acid. Anandamide produced a dose-dependent decrease in mean arterial pressure due to a drop in systemic vascular resistance (SVR) that was accompanied by a compensatory rise in cardiac output. Anandamide also elicited an increase in both portal venous flow and pressure, along with a decline in mesenteric vascular resistance (MVR). Pretreatment with 3 mg/kg SR-141716A, a CB(1) antagonist, prevented the decline of SVR and MVR from the lower dose of anandamide. Antagonism of nitric oxide synthetase, cyclooxygenase, or 5-lipoxygenase did not prevent the systemic nor the portal hemodynamic effects of anandamide. Furthermore, the use of R-methanandamide, a stable analog of anandamide, produced similar hemodynamic effects on the mesenteric vasculature, thereby implying that the effects of anandamide are not related to its breakdown products. Anandamide produced profound, dose-dependent alterations in both the systemic and portal circulations that could be at least partially blocked by pretreatment with SR-141716A.

Endocannabinoids as cardiovascular modulators

Cannabinoids, the bioactive constituents of the marijuana plant and their synthetic and endogenous analogs cause not only neurobehavioral, but also cardiovascular effects. The most important component of these effects is a profound decrease in blood pressure and heart rate. Although multiple lines of evidence indicate that the hypotensive and bradycardic effects of anandamide and other cannabinoids are mediated by peripherally located CB1 cannabinoid receptors, anandamide can also elicit vasodilation in certain vascular beds, which is independent of CB1 or CB2 receptors. Possible cellular mechanisms underlying these effects and the cellular sources of vasoactive anandamide are discussed.