Mortality and major adverse cardiac events in women with breast cancer receiving radiotherapy: a 10-year cohort study of patients and population controls

Background

Treatment for breast cancer (BC) frequently involves radiotherapy. Guidelines recommend screening for cardiac adverse events starting 10 years after radiotherapy. The rationale for recommending this interval is unclear and informed the objective of this study.

Objectives

Study cardiovascular event rates in the first decade following curative radiotherapy for breast cancer, the time frame before guidelines recommend screening.

Methods

We performed a monocentric, retrospective study enrolling all women with unilateral BC in 2007–2008, who received radiotherapy as part of their curative treatment. We compared event rates during 10 years follow-up with an age and risk factor-matched control population (FLEMENGHO population).

Results

We included 1095 BC patients (median age 55y, IQR: 47–66y). Two hundred and eighteen (19.9%) women died. Cancer and cardiovascular mortality accounted for 107 (49.1%) and 22 (10.1%) deaths, respectively. The incidence of coronary artery disease was similar compared to age and risk-matched women [risk ratio 0.75 (95% CI 0.48–1.18)], yet heart failure (HF) [risk ratio 1.97 (95% CI 1.19–3.25)] and atrial fibrillation or flutter (AF) (risk ratio 1.82 (95% CI 1.07–3.08) occurred more often. Age [HR 1.040 (95% CI 1.012–1.069)], tumor grade [HR 1.646 (95% CI 1.103–2.458)], and neo-adjuvant treatment setting [HR 3.079 (95% CI 1.432–6.620)] were risk factors for mortality; hormonal therapy [HR 0.007 (95% CI 0.001–0.042)] proved protective. Risk factors for MACE were mean heart dose [HR 1.079 (95% CI 1.012–1.151], hormonal therapy, history of cardiovascular disease [HR 2.771 (95% CI 1.253–6.126)], and Mayo Clinic Cardiotoxicity Risk Score [HR 2.547 (95% CI 1.538–4.217)]. While mean heart dose [HR 1.141 (95% CI 1.017–1.282)] and cardiovascular history [HR 3.374 (95% CI 1.259–9.043] clearly associated with new onset HF, only a trend towards higher AF burden with increasing mean heart dose could be observed.

Conclusions

Ten-year mortality following curative treatment for unilateral BC was mainly cancer-related. HF and AF constituted significantly increased risks in the first decade following irradiation. Mean heart dose, pre-existing cardiovascular diseases, and Mayo Clinic Cardiotoxicity Risk Score were risk factors for early cardiac mortality and adverse events and should guide early dedicated cardio-oncological follow-up.

Funding Acknowledgement

Type of funding sources: None.

Incidence of cardiovascular events in patients treated with immune checkpoint inhibitors

Background

In rare cases, immune checkpoint inhibitors (ICIs) cause immune-mediated myocarditis. However, the true incidence of other major adverse cardiovascular events (MACE) following ICI treatment remains unknown, mainly because late occurring side effects are rarely reported in prospective clinical trials.

Purpose

To identify the incidence and risk factors of MACE in a real-life ICI-treated cancer cohort and to compare the incidence with non-ICI-treated cancer patients and population controls.

Methods

In total, 672 ICI-treated patients were included. The primary endpoint was MACE, a composite of acute coronary syndrome, heart failure, stroke and transient ischemic attack. Secondary outcomes were acute coronary syndrome and heart failure separately. Incidence rates were compared between groups after matching according to age, sex, cardiovascular history and cancer type.

Results

Incidence of MACE was 10.3% during a median time of follow-up of 13 months (IQR 6 to 22). In multivariable analysis, a history of heart failure (hazard ratio (HR): 2.27; 95% confidence interval (CI): 1.03 to 5.04; p=0.043) and valvular heart disease (HR 3.01; 95% CI: 1.05 to 8.66; p=0.041) remained significantly associated with MACE.

Cumulative incidence rates were significantly higher in the matched ICI group (rate at full range of follow-up (rate): 8.51; 95% CI: 6.18 to 11.4) compared with the cancer cohort not exposed to ICI (rate: 5.20; 95% CI: 3.56 to 7.35; p=0.032) and the population controls (rate: 2.55; 95% CI: 2.16 to 2.99; p<0.001) mainly driven by a higher risk of heart failure events (Figure 1).

Conclusions

Cardiovascular events during and after ICI treatment are more common than currently appreciated. Patients at risk are those with a history of cardiovascular disease. Compared with matched cancer and population controls, MACE incidence rates are significantly higher, suggesting a potential harmful effect of ICI treatment besides the underlying risk.

Funding Acknowledgement

Type of funding sources: None.

Abstract P032: Body Position And The Effects Of Active Hypertension Treatment On Orthostatic Hypotension: Results From The SYS-EUR Trial

Background: We recently demonstrated that more intensive BP treatment lowered risk of orthostatic hypotension (OH) measured with a seated-to-standing protocol. However, seated-to-standing OH assessments are less sensitive than supine-to-standing and could miss clinically relevant OH.

Objectives: Using data from the Systolic Hypertension in Europe (SYS-EUR) trial, we examined the effect of active hypertension treatment (vs placebo) on OH based on the difference in BP from 3 body positions (supine, seated, or standing).

Methods: SYS-EUR was a multi-center, randomized trial that enrolled adults with isolated systolic hypertension (systolic blood pressure 160-219 mmHg, diastolic blood pressure<95 mmHg). Participants underwent blood pressure measurement in three positions: supine, seated, and standing. Using differences in BP between the 3 body positions (seated minus supine, standing minus seated, and standing minus supine), we defined OH as a drop in SBP≥20 mm Hg or DBP ≥10 mm Hg.

Results: Among 4,673 participants (mean age 70.2 ± 6.7 yrs, 66.9% female) with 43,809 BP measurements, OH was present in 6.4% of measures with supine-to-seated, 4.3% with seated-to-standing, and 9.8% with supine-to-standing protocols, respectively ( Figure ). Compared with placebo, active BP treatment was not associated with OH, ORs being 0.81 (95% CI: 0.63, 1.04) with seated-to standing, 0.96 (95% CI: 0.73, 1.26) with supine-to-seated, and 1.00 (95% CI: 0.82, 1.21) with supine-to-standing protocols.

Conclusion: Regardless of protocol, active hypertension treatment did not increase risk of OH, reinforcing evidence that OH should not be viewed as a complication of hypertension treatment.

Incidence of Cardiovascular Events in Patients Treated With Immune Checkpoint Inhibitors

PURPOSE

In rare cases, immune checkpoint inhibitors (ICIs) cause immune-mediated myocarditis. However, true incidence of other major adverse cardiovascular events (MACEs) after ICI treatment remains unknown, mainly because late occurring side effects are rarely reported in prospective clinical trials. The aims of this study were (1) to identify incidence and risk factors of MACE in a real-life ICI-treated cancer cohort and (2) to compare incidence rates with patients with cancer who are not treated with ICIs and population controls.

METHODS

In total, 672 patients treated with ICIs were included. The primary end point was MACE, a composite of acute coronary syndrome, heart failure (HF), stroke, and transient ischemic attack. Secondary outcomes were acute coronary syndrome and HF separately. Incidence rates were compared between groups after matching according to age, sex, cardiovascular history, and cancer type.

RESULTS

The incidence of MACE was 10.3% during a median follow-up of 13 (interquartile range 6-22) months. In multivariable analysis, a history of HF (hazard ratio 2.27; 95% CI, 1.03 to 5.04; P = .043) and valvular heart disease (hazard ratio 3.01; 95% CI, 1.05 to 8.66; P = .041) remained significantly associated with MACE. Cumulative incidence rates were significantly higher in the ICI group compared with the cancer cohort not exposed to ICI and the population controls, mainly driven by a higher risk of HF events.

CONCLUSION

Cardiovascular events during and after ICI treatment are more common than currently appreciated. Patients at risk are those with a history of cardiovascular disease. Compared with matched cancer and population controls, MACE incidence rates are significantly higher, suggesting a potential harmful effect of ICI treatment besides the underlying risk.

Exploring the relation between methylxanthines and plasma lipids in two population-based studies

Background

Chronic intake of caffeinated beverages might be associated with plasma lipids via disturbed lipid metabolism. Previous investigations have been limited by the use of self-reported caffeine intake instead of measured caffeine, whereas the associations between plasma lipids and other methylxanthines (paraxanthine, theobromine, theophylline) are unknown. Here, we investigated the associations of plasma lipids with caffeine and its metabolites in plasma and urine in two European populations.

Methods

Individuals were selected from the general population of North Belgium (FLEMENGHO) and Switzerland (SKIPOGH). Total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides were measured in plasma using standard enzymatic methods. Plasma and 24h urinary caffeine, paraxanthine, theophylline, and theobromine excretions were measured using ultra-high performance liquid chromatography tandem mass spectrometry. We used mixed models to explore the associations of methylxanthines with plasma lipids while adjusting for major confounders.

Results

Overall, 1946 FLEMENGHO participants (911 men, age 45.9±15.2 years) and 990 SKIPOGH participants (467 men, age 47.1±17.3 years) were included. Mean plasma total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides in FLEMENGHO/SKIPOGH were 5.37/5.06, 3.12/3.12, 1.43/1.50, and 2.4/1.02 mmol/L. In both cohorts, adjusted mean total cholesterol, LDL cholesterol, and HDL cholesterol, increased with quartile of plasma caffeine, with stronger associations in men. Similar positive associations were observed for paraxanthine and theophylline. Similar associations were observed using 24h urine excretions in SKIPOGH.

Conclusions

Plasma and urinary caffeine, paraxanthine, and theophylline were positively associated with plasma lipids in men, whereas there were fewer meaningful associations in women. The increase in plasma lipids might mitigate the overall beneficial impact of caffeinated beverages on health.

Key messages

Caffeine constitutes one of the most widely consumed biological active substances. Plasma concentration and urinary excretion of caffeine and its derived metabolites is positively associated with plasma lipids.

Associations of Ambulatory Blood Pressure With Urinary Caffeine and Caffeine Metabolite Excretions

Intake of caffeinated beverages might be associated with reduced cardiovascular mortality possibly via the lowering of blood pressure. We estimated the association of ambulatory blood pressure with urinary caffeine and caffeine metabolites in a population-based sample. Families were randomly selected from the general population of Swiss cities. Ambulatory blood pressure monitoring was conducted using validated devices. Urinary caffeine, paraxanthine, theophylline, and theobromine excretions were measured in 24 hours urine using ultrahigh performance liquid chromatography tandem mass spectrometry. We used mixed models to explore the associations of urinary excretions with blood pressure although adjusting for major confounders. The 836 participants (48.9% men) included in this analysis had mean age of 47.8 and mean 24-hour systolic and diastolic blood pressure of 120.1 and 78.0 mm Hg. For each doubling of caffeine excretion, 24-hour and night-time systolic blood pressure decreased by 0.642 and 1.107 mm Hg (both P values <0.040). Similar inverse associations were observed for paraxanthine and theophylline. Adjusted night-time systolic blood pressure in the first (lowest), second, third, and fourth (highest) quartile of paraxanthine urinary excretions were 110.3, 107.3, 107.3, and 105.1 mm Hg, respectively ( P trend <0.05). No associations of urinary excretions with diastolic blood pressure were generally found, and theobromine excretion was not associated with blood pressure. Anti-hypertensive therapy, diabetes mellitus, and alcohol consumption modify the association of caffeine urinary excretion with systolic blood pressure. Ambulatory systolic blood pressure was inversely associated with urinary excretions of caffeine and other caffeine metabolites. Our results are compatible with a potential protective effect of caffeine on blood pressure.

[Technology to improve adherence in community pharmacy: a literature review]

INTRODUCTION

Drug-related problems are very common and they need some specific attention. Improper use of medication as well as poor adherence leads to side effects, interaction, increased healthcare costs,...

AIM

What technologies can be used in community pharmacies to improve drug adherence?

METHOD

Articles were found in scientific databases Pubmed, Embase and CINAHL using a fixed search strategy.

RESULTS

In this review 21 studies were included. The different technologies were compared with each other. Reminders using sms or smartphone were the most effective.

CONCLUSION

There are already plenty of reminder systems (SMS, Email, internet, smartphone) and practical tools (medication dispensers, MEMS) available in community pharmacies. A major hurdle is the lack of the infrastructure. There needs to be invested in systems were patients are confronted with their own drug use.

Associations of urinary cadmium with age and urinary proteins: further evidence of physiological variations unrelated to metal accumulation and toxicity

BACKGROUND

The current risk assessment for environmental cadmium (Cd) largely relies on the assumption that urinary Cd (U-Cd) is a reliable biomarker of the Cd body burden. Recent studies have questioned the validity of this assumption.

OBJECTIVES

We studied the lifetime trend of U-Cd as a function of diuresis, gender, smoking status, and protein tubular reabsorption. We also analyzed the associations between U-Cd and urinary proteins.

METHODS

Cd, retinol-binding protein, and albumin were measured in the urine of six cohorts of the general population of Belgium, with a mean age ranging from 5.7 to 88.1 years (n = 1,567). Variations of U-Cd with age were modeled using natural cubic splines.

RESULTS

In both genders, U-Cd decreased to a minimum (~ 0.20 μg/L) at the end of adolescence, then increased until 60-70 years of age (~ 0.60 μg/L in never-smokers) before leveling off or decreasing. When U-Cd was expressed in micrograms per gram of creatinine, these variations were amplified (minimum, 0.15 µg/g creatinine; maximum, 0.70 µg/g creatinine) and much higher U-Cd values were observed in women. We observed no difference in U-Cd levels between never-smokers and former smokers, and the difference with current smokers did not increase over time. Lifetime curves of U-Cd were higher with increasing urinary retinol-binding protein or albumin, a consequence of the coexcretion of Cd with proteins.

CONCLUSIONS

At low Cd exposure levels, U-Cd and age are associated through nonlinear and nonmonotonic relationships that appear to be driven mainly by recent Cd intake and physiological variations in the excretion of creatinine and proteins.

A battery of DNA effect biomarkers to evaluate environmental exposure of Flemish adolescents

The present paper deals with the evaluation of a battery of genotoxicity biomarkers in healthy Flemish adolescents and their relation with common pollutants occurring in their life environment. DNA damage as reflected by the comet assay appeared to be most sensitive to ozone (partial r(2) = 0.102, p < 0.00001), and to a lesser extent to ortho-cresol (partial r(2) = 0.055; p = 0.001) and 1-hydroxy-pyrene (1-OH-pyrene, partial r(2) = 0.031; p = 0.013). 8-hydroxy-deoxyguanosine (8-OHdG) was only related to ortho-cresol (r(2) = 0.069; p < 0.007). Interestingly, the comet assay results and urinary 8-OHdG concentrations were positively correlated with a Pearson r = 0.21 (p = 0.003, N = 200). Logistic regression models revealed significant relations between chromatid breaks and 1-OH-pyrene (relative risk (RR): 1.58; p = 0.008), and t,t-muconic acid (RR: 1.71; p = 0.014). There was no correlation between micronucleus formation or occurrence of chromosomal or chromatid breaks on the one hand and comet or 8-OHdG results on the other hand. Thus, in this study the comet assay on whole blood samples and urine 8-OHdG measurements especially appeared sensitive biomarkers for assessing the genetic effects of environmental pollutants to which adolescents may be exposed.

ESH-ESC Guidelines for the Management of Hypertension

The following is a brief statement of the 2003 European Society of Hypertension (ESH)-European Society of Cardiology (ESC) guidelines for the management of arterial hypertension. The continuous relationship between the level of blood pressure and cardiovascular risk makes the definition of hypertension arbitrary. Since risk factors cluster in hypertensive individuals, risk stratification should be made and decision about the management should not be based on blood pressure alone, but also according to the presence or absence of other risk factors, target organ damage, diabetes, and cardiovascular or renal damage, as well as on other aspects of the patient's personal, medical and social situation. Blood pressure values measured in the doctor's office or the clinic should commonly be used as reference. Ambulatory blood pressure monitoring may have clinical value, when considerable variability of office blood pressure is found over the same or different visits, high office blood pressure is measured in subjects otherwise at low global cardiovascular risk, there is marked discrepancy between blood pressure values measured in the office and at home, resistance to drug treatment is suspected, or research is involved. Secondary hypertension should always be investigated. The primary goal of treatment of patient with high blood pressure is to achieve the maximum reduction in long-term total risk of cardiovascular morbidity and mortality. This requires treatment of all the reversible factors identified, including smoking, dislipidemia, or diabetes, and the appropriate management of associated clinical conditions, as well as treatment of the raised blood pressure per se. On the basis of current evidence from trials, it can be recommended that blood pressure, both systolic and diastolic, be intensively lowered at least below 140/90 mmHg and to definitely lower values, if tolerated, in all hypertensive patients, and below 130/80 mmHg in diabetics. Lifestyle measures should be instituted whenever appropriate in all patients, including subjects with high normal blood pressure and patients who require drug treatment. The purpose is to lower blood pressure and to control other risk factors and clinical conditions present. In most, if not all, hypertensive patients, therapy should be started gradually, and target blood pressure achieved progressively through several weeks. To reach target blood pressure, it is likely that a large proportion of patients will require combination therapy with more than one agent. The main benefits of antihypertensive therapy are due to lowering of blood pressure per se. There is also evidence that specific drug classes may differ in some effect or in special groups of patients. The choice of drugs will be influenced by many factors, including previous experience of the patient with antihypertensive agents, cost of drugs, risk profile, presence or absence of target organ damage, clinical cardiovascular or renal disease or diabetes, patient's preference.

Neurobehavioural investigations in adolescents exposed to environmental pollutants

Environmental exposures to industrial pollutants have been associated with lowered intelligence and behavioural problems. The Flemish Environmental and Health Study focussed on biomonitoring of exposure and associated health effects. This part of the study investigated neurobehavioural performance in adolescents in relation to lead (blood Pb), cadmium (urine Cd), polychlorinated biphenyls (PCB concentration of congeners 138, 153 and 180) and compounds with 'dioxin-like' activity (measured by the CALUX-assay). One-hundred and twenty girls and 80 boys (mean age 17.4 years) were enrolled. The NES battery was used to assess simple reaction time, switching attention, digit span forward, hand-eye coordination and symbol-digit substitution (SDS). Multiple regression analysis was performed to study dose-effect relationships between the neurobehavioural outcome variables and the exposure parameters in boys and girls. Slowing of SDS with increasing logPbB and logCdU was seen in boys only (PbB 39-1549nmol/L, CdU 0.02-0.40nmol/mmol creatinine). No dose-effect relations were found with serum PCB concentrations or CALUX-TEQs. Only one of several tests showed a performance decrease related to given environmental exposures to heavy metals. Further studies are needed to clarify whether the pattern of results reflects gender effects or the different exposure characteristics of boys and girls in our study.

Determinants of white-coat hypertension

BACKGROUND

The prevalence of white-coat hypertension (WCH) is considerable in patients referred with elevated office blood pressure. Failure to recognise this phenomenon can lead to the inappropriate use of antihypertensive medications. We undertook this study to determine the profile of patients with WCH.

METHODS

Baseline clinic and daytime ambulatory blood pressures were available from 5716 patients referred over a 22-year period. Individuals were considered to have WCH if they had an elevated clinic blood pressure measurement greater than 140/90 mmHg and normal daytime mean ambulatory blood pressure. Mean age was 53.6 years and 53.2% were female.

RESULTS

The overall prevalence of white-coat hypertension was 15.4%. A higher prevalence was seen amongst older adults, females, and non-smokers.

CONCLUSION

Multivariate logistic regression analysis confirmed these characteristics as independent predictors of WCH.

Ambulatory blood pressure measurement as a predictor of outcome in an Irish population: methodology for ascertaining mortality outcome

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) has proven to be a superior predictor of morbid events when compared to clinic or office blood pressure measurement (CBPM). The purpose of this study was to evaluate the predictive value of ABPM in a sample of 14 414 people referred for management of cardiovascular risk.

METHODS

In this paper we describe the methodology required to examine mortality outcome in the absence of a national unique identifier.

RESULTS

Using a computerized database of deaths we were able to establish that 1348 people had died by the end of the follow-up period (30 September 2002). Sixty-four percent of deaths were cardiovascular and in 207 subjects who had post-mortem examinations, 78% were cardiovascular.

CONCLUSIONS

The accurate identification of the cause of death in a large population will allow comparison of the relative predictive power of APBM and CBPM in an Irish population.

Task Force I: methodological aspects of blood pressure measurement

OBJECTIVE

To reach a consensus on important methodological aspects of blood pressure measurement.

METHODS

A Task Force on the methodological aspects of blood pressure measurement wrote this review after the Eighth International Consensus Conference on Blood Pressure Monitoring, in Sendai, Japan (28-31 October 2001). This consensus paper is based on the papers presented by Task Force I and on the discussion sessions, and is therefore representative of a broad spectrum of expert opinion.

POINTS OF CONSENSUS

Consensus was reached on the following five issues: (1) there is an urgent need for a simplified protocol for the validation of blood pressure measuring devices; (2) there is a need for a means of updating the "state of the market" for validated devices so that users can have easy access to this information; (3) new devices must be validated independently, and existing devices that have not been validated must be reappraised; (4) manufacturers should confirm when new models use algorithms which have been validated previously; (5) the Food and Drug Administration now accepts that when ambulatory blood pressure measurement is used in clinical short-term trials in which side-effects are not being assessed, a placebo arm is not required.

Hypertension in the Very Elderly Trial (HYVET): protocol for the main trial

A number of trials and meta-analyses have demonstrated clear benefits of blood pressure (BP) reduction in patients aged <80 years with regard to the reduction in stroke and cardiovascular events. However, a variety of studies have suggested that the positive relationship between BP and cardiovascular mortality is weakened or indeed reversed in the very elderly. Most intervention trials to date have either excluded or not recruited sufficient patients aged > or =80 years to determine whether there is a significant benefit from treatment in this age group. A meta-analysis of intervention trials that recruited patients aged > or =80 years has suggested a benefit in terms of stroke reduction but has also raised the possibility of an increase in total mortality. The benefit to risk ratio therefore needs to be clearly established before recommendations can be made for treating very elderly patients with hypertension. The Hypertension in the Very Elderly Trial (HYVET) pilot recruited 1283 patients aged > or =80 years and showed the feasibility of performing such a trial in this age group. It was a Prospective Randomised Open Blinded End-Points (PROBE) design but the main trial has additional pharmaceutical sponsorship to run a double-blind trial. Therefore, the main trial is a randomised, double-blind, placebo-controlled trial designed to assess the benefits of treating very elderly patients with hypertension. It compares placebo with a low dose diuretic (indapamide sustained release 1.5mg daily) and additional ACE inhibitor (perindopril) therapy if required. As in the pilot trial, the primary end-point is stroke events (fatal and non-fatal) and the trial is designed to determine whether or not a 35% difference occurs between placebo and active treatment. The main objective will be achieved with 90% power at the 1% level of significance. Secondary outcome measures will include total mortality, cardiovascular mortality, cardiac mortality, stroke mortality and skeletal fracture. 2100 patients aged > or =80 years are to be recruited and followed up for an average of 5 years. Entry BP criteria after 2 months of a single-blind placebo run-in period are a sustained sitting systolic BP (SBP) of 160 to 199mm Hg and a diastolic BP of 90 to 109mm Hg. The standing SBP must be >140mm Hg. The trial will be carried out in accordance with the principles of Good Clinical Practice. We describe in detail the protocol for the main trial and discuss the reasons for the changes from the pilot, the use of the drug regimen, and the BP criteria to be used in the trial.

Out-patient versus in-hospital ambulatory 24-h blood pressure monitoring in heart transplant recipients

OBJECTIVE

To study the effect of the environment--in-hospital vs. out-patient situation--on blood pressure as measured by ambulatory blood pressure monitoring (ABPM).

PATIENTS AND METHODS

Twenty-four hour ABPM was performed sequentially in-hospital and again 9+/-3 days later on an out-patient basis, in 30 consecutive heart transplant recipients (27 men, median age 56 years, median time post-transplant 3 years). The same equipment was used on both occasions, without any interim change in medical treatment.

RESULTS

Both systolic and diastolic blood pressure were higher in-hospital than as an out-patient: +7+/-7 and +6+/-5 mm Hg respectively for the 24-h average (P<0.001). Daytime and night-time pressures were affected similarly. Depending on the specific cut-off values used, 37 to 87% of the individual patients were hypertensive in-hospital; 31 to 73% of these had an acceptable blood pressure as an out-patient. The converse was very rare (0 to 3% of the total group).

CONCLUSIONS

In heart transplant patients blood pressure as assessed from 24-h ABPM is lower in the home environment than during a hospital stay. The post-transplant attenuation of the circadian variation in blood pressure is not influenced by the environment. Checking an unsatisfactory in-hospital ABPM with an outpatient recording may obviate the need for an (intensified) antihypertensive treatment in a substantial number of patients.

Quality of life of elderly patients with isolated systolic hypertension: baseline data from the Syst-Eur trial. Syst-Eur Trial Investigators

OBJECTIVE

To describe measures of quality of life of elderly patients with isolated systolic hypertension at entry to a placebo-controlled randomized trial of antihypertensive treatment and to investigate factors associated with these.

DESIGN

Cross-sectional analyses at entry to a randomized controlled trial.

SETTING

Patients attending hypertension clinics or general practitioners' surgeries at 30 centres in 10 European countries.

PATIENTS

Six hundred and thirty-one patients aged 60 years or more, with a sitting systolic blood pressure during the run-in phase of 160-219 mmHg, a sitting diastolic blood pressure below 95 mmHg and a standing systolic blood pressure of 140 mmHg or more.

MAIN OUTCOME MEASURES

Cognitive function tests (Reitan Trail Making A and B), Brief Assessment Index (a measure of depressed mood) and four subscales from the Sickness Impact Profile (Ambulation, Social Interaction, Sleep and Rest and Housework).

RESULTS

Poor quality of life was generally associated with increasing age, previous treatment with antihypertensive drugs, presence of cardiovascular complications and, among women, high diastolic blood pressure, higher consumption of alcohol and high body mass index.

CONCLUSIONS

At entry to the trial there was considerable heterogeneity of patients in terms of measures of quality of life and cognitive performance. It remains to be determined whether these influence subsequent quality of life during randomized treatment.

Characterisation of hypertensive patients according to 24 H peripheral resistance

To clarify whether a circadian rhythm of peripheral resistance exists in humans and whether hypertensive patients represent a homogeneous category in this respect, 15 normotensives aged 31 +/- 4 years and 30 hypertensives aged 41 +/- 13 years were confined to bed for 22 h and forearm flow recorded automatically. Night-time BP values were higher in hypertensive patients (Group B) whose night/day ratios of mean BP were below the 95% C.I. of the normal regression of the normotensives, than in those falling within the 95% C.I. (Group A). Forearm resistance was lower during sleep than during waking in Group A and in the normotensive controls, paralleling the nocturnal blood pressure fall. On the contrary, in the Group B hypertensives, despite a comparable night-time BP decrease, forearm resistance was higher during sleep than during waking.

Limitations of the difference between clinic and daytime blood pressure as a surrogate measure of the 'white-coat' effect. Syst-Eur investigators

BACKGROUND

The difference between clinic and ambulatory average daytime blood pressures is frequently taken as a surrogate measure of the 'white-coat effect' (i.e. the pressor reaction triggered in the patient by the physician's visit).

OBJECTIVE

To assess the reproducibility of this difference and its relationship with clinic and average ambulatory daytime blood pressure levels.

DESIGN AND METHODS

These issues were addressed with two large groups of subjects in whom both clinic and ambulatory blood pressures were measured, namely 783 outpatients with systolic and diastolic essential hypertension [Group 1, aged 50.8+/-9.4 years (mean +/- SD)], participating in standardized Italian trials of antihypertensive drugs, and 506 elderly patients (group 2, age 71+/-7 years) with isolated systolic hypertension, participating in the European Syst-Eur trial.

RESULTS

The clinic-daytime blood pressure difference for the essential systolic and diastolic hypertensive patients (group 1) was 13.6+/-14.3 mmHg for systolic and 9.1+/-8.6 mmHg for diastolic blood pressure (P always < 0.01). This difference for the elderly patients with isolated systolic hypertension (group 2) was 21.2+/-16.0 mmHg for systolic and only 1.3+/-10.2 mmHg for diastolic blood pressure (P < 0.01 and P < 0.05, respectively). In both studies little or no systematic clinic-daytime difference could be observed for heart rate. The reproducibility of the clinic-daytime blood pressure difference, tested for 108 essential systolic and diastolic hypertensive patients from group 1 and 128 isolated systolic hypertensives from group 2, was invariably lower than that both of daytime and of clinic blood pressure values. Finally, the clinic-daytime blood pressure difference was progressively higher for increasing levels of clinic blood pressure and progressively lower for higher levels of ambulatory daytime blood pressure.

CONCLUSIONS

Thus, the clinic-daytime blood pressure difference has a limited reproducibility; depends not only on clinic but also on daytime average blood pressure, which means that its size is a function of the blood pressure criteria employed for selection of the patients in a trial; and is never associated with a systematic clinic-daytime difference in heart rate, which further questions its use as a reliable surrogate measure of the true pressor response induced in the patient by the doctor's visit.

Relationship of tachycardia with high blood pressure and metabolic abnormalities: a study with mixture analysis in three populations

Faster resting heart rate has been shown to be associated with a higher risk of developing hypertension and a greater incidence of cardiovascular morbidity and mortality. The aim of this study was to investigate the distribution of heart rate and its relationship with blood pressure and other cardiovascular risk factors in three populations. One European general population (Belgian study), one North American general population (Tecumseh study), and one European hypertensive population (HARVEST trial) were studied. Within each population, mixture analysis was used to investigate whether a mixture of two normal distributions explained the variance in heart rate better than a single distribution. In the men of all populations, mixture analysis identified a larger subpopulation of subjects with normal heart rate and a smaller one with fast heart rate. The subgroups with tachycardia had higher blood pressure and lipid levels than those with normal heart rate. In the populations in which they were measured, fasting insulin and postload glucose were also higher in the men with faster heart rate. A subgroup with tachycardia could also be singled out among the women from Tecumseh, but no relation between heart rate and blood pressure could be found. These findings show that in Western societies, high heart rate pertains to a distinct subgroup of subjects, who are more frequently men and exhibit the characteristic features of the insulin resistance syndrome. Sympathetic overactivity is likely to be the mechanism underlying this clinical condition.