Emergency front of neck access in the management of acute airway obstruction secondary to postoperative neck haematoma

Airway compromise is the most significant complication of a postoperative neck haematoma. Here, we report the management of a case of complete airway obstruction secondary to an acute neck haematoma arising after radical neck dissection, partial glossectomy and a free flap reconstruction. The patient deteriorated precipitously and required immediate emergency surgical front of neck access to secure the airway. Drawing on our experience of this case, we propose a mental model to inform the emergency airway management of postoperative neck haematoma following all types of surgery.

Association of Pressure Wave Reflections With Left Ventricular Mass: a Systematic Review and Meta-Analysis

BACKGROUND

Pressure wave reflections (PWRs) within the circulation are assessed at various arterial sites by various noninvasive methods. We aimed at reviewing the conflicting data regarding the hypothesis that higher PWRs are associated with higher left ventricular mass and tested whether this association stands for all available indices of PWRs, all (proximal or distal to the heart) sites of assessment, and is modified by sex, age and heart rate.

METHODS

Based on a predefined protocol applying the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines, we identified eligible for meta-analysis data regarding: augmentation index, augmentation pressure, backward pressure (Pb), reflection index, and their association with left ventricular mass index (19 studies, total population n=8686).

RESULTS

We found statistically significant associations, independent from blood pressure level, for all indices of PWRs at all arterial sites (carotid augmentation index; odds ratio; standardized beta coefficient [β]: 0.14 [95% CI, 0.07% to 0.21%], per SD increase), radial augmentation index (β: 0.21; 0.11 to 0.31), central augmentation pressure (β: 0.15; 0.03 to 0.27), central Pb (β: 0.23; 0.05 to 0.42), and central reflection index (β: 0.14; 0.06 to 0.22), except for aortic augmentation index as estimated by generalized transfer functions. Meta-regression analysis showed that the association between carotid augmentation index and left ventricular mass was higher among populations with higher heart rate (P=0.036, beta: 0.017 [95% CI, 0.001 to 0.033]) and tended to be higher in middle-aged (P=0.07, beta: -0.001; -0.021 to 0.001).

CONCLUSIONS

A clinically meaningful association between PWRs and left ventricular mass, assessed at either central or peripheral arterial sites by most available methods was shown, suggesting that PWR reduction strategies might be useful. Based on the present evidence, such trials should target middle-aged populations with high normal heart rate.

51 Restructuring of the UK Vascular Services: Does the Hub and Spoke Model Affect Patient Mortality in Ruptured AAAs?

Aim

Ruptured Abdominal Aortic aneurysms (rAAA) are a fatal vascular condition. In 2018, The Get It Right First Time Programme (GRIFT) recommended the restructuring of vascular services in England to a Hub and Spoke model where AAA repairs should be performed in higher volume centres, the hub sites. This study aims to assess the mortality rates in patients presenting at hub versus spoke sites in the Merseyside region.

Method

We conducted a retrospective review, 1st January 2017 to 31st December 2020, recognising 110 patients with a rAAA presenting to hub and spoke sites in the Merseyside Region. We determined if there was any association in mortality and the presenting site. We also assessed the mean time to theatre for both Hub and Spoke patients.

Results

41 patients presented to Hub site and 69 patients to the spoke sites. 81% underwent operative intervention and 19% died in A+E or were palliated. 57% of those who underwent an intervention survived. Overall mortality rate in hospital was 53% (58 patients). There was no association between mortality and transfer from a spoke site (p = 0.58). The median time to theatre for Hub patients was 160 minutes from presentation and 315 minutes from Spoke sites. Time to theatre had no overall effect on mortality (p = 0.1)

Conclusions

This study indicates that the GRIFT programme does not have a negative effect on mortality irrespective of time taken to theatre. Therefore, transferring patients to a specialist hub site will positively influence patient outcomes.

Superiority of 24-Hour Aortic Over 24-Hour Brachial Pressure to Associate With Carotid Arterial Damage on the Basis of Pressure Amplification Variability: the SAFAR Study

BACKGROUND

Evidence suggests marginal superiority of static aortic systolic blood pressure (aSBP) compared with brachial SBP regarding the association with organ damage and prognosis of cardiovascular disease. The noninvasive 24-hour aSBP assessment is feasible and associates better with presence of left ventricular hypertrophy compared with 24-hour brachial systolic blood pressure. We aimed at comparing the association of 24-hour aSBP and 24-hour brachial systolic blood pressure with indices of arterial damage and examining the role of 24-hour SBP amplification variability (within-subjects' SD) in this association.

METHODS

Consecutive subjects referred for cardiovascular disease risk assessment underwent 24-hour aortic and brachial ambulatory BP monitoring using a validated oscillometric device (Mobil-O-Graph). Arterial damage was assessed by carotid intima-media thickness and detection of carotid and femoral atheromatosis (plaque presence).

RESULTS

Cross-sectionally 501 individuals (aged 54±13 years, 57% men, 80% hypertensives) were examined. Multivariable analysis revealed superiority of 24-hour aSBP regarding the association with intimal-medial thickness, carotid hypertrophy and carotid-but not femoral-atheromatosis. In receiver operator characteristics analysis, 24-hour aBP displayed a higher discriminatory ability-compared to 24-hour brachial systolic blood pressure-for the detection of both carotid hypertrophy (area under the curve, 0.662 versus 0.624, P<0.05) and carotid atheromatosis (area under the curve, 0.573 versus 0.547, P<0.05). This effect was more prominent in individuals with above-median 24-hour SD of SBP amplification.

CONCLUSIONS

Our results suggest that 24-hour aSBP assessment may be of significant value in clinical practice to detect site-specific arterial damage on the basis of pressure amplification variability and should be prospectively examined in clinical trials.

Prostaglandins in renovascular and renal hypertension

PG A1, B1, E2, F1,2alpha and PRA have been measured in 8 hypertensive patients with unilateral renal arterial stenosis, 7 hypertensive patients with unilateral renal atrophy and 20 control normotensive subjects. PRA and PGA1 were significantly increased in patients with renovascular hypertension but not in patients with atrophy. PGE2 and PGF1,2alpha were increased in both groups of patients, especially on the stenotic or atrophic side. The increase of PGA1 and PGE2, represents a secondary antihypertensive, diuretic and natriuretic mechanism, the increase of PGF1,2alpha a direct hypertensive mechanism.

[JNC 8 is released… but this is not the JNC 8! New US guidelines for the management of hypertension]

During year 2013, several recommendations for the management of hypertension were published: recommendations of the French and European Societies of Hypertension and two recommendations from the USA, those from the ACC/AHA/CDC groups and those from the JNC 8. The recommendations of the JNC 8 are not, strictly speaking, the recommendations of JNC 8, since they are neither endorsed by their sponsor: the National Heart, Lung and Blood Institute (NHLBI), nor by any other supervisor. They only commit their authors. Just before the publication of the JNC 8, "competing" recommendations, jointly produced by the AHA, ACC and CDC, were jointly published in Hypertension and in the Journal of American College of Cardiology, with different preferred treatment choices and significantly different algorithms. The authors of the JNC 8 have only included in their literature review randomized controlled trials of sufficient power. Randomized controlled trials are clearly the gold standard of comparative trials in medicine, but can they summarize all the knowledge? The authors of the JNC 8 propose in subjects over 60, a therapeutic threshold and target blood pressure of 150/90mmHg. This original threshold is poorly supported by the evidence and possibly increases the risk of physicians' inertia. The issue of experts' conflicts of interest has greatly changed the rules of drafting guidelines for clinical practice. Knowing that the vast majority of clinical trials is promoted by drug industry, could guidelines be strictly without any conflict of interest? Finally, recommendations for practice should have as primary, if not unique, objective to improve the practice.

Total arterial compliance estimated by a novel method and all-cause mortality in the elderly: the PROTEGER study

Aortic stiffness, assessed by carotid-to-femoral pulse wave velocity (PWV), often fails to predict cardiovascular (CV) risk and mortality in the very elderly. This may be due to the non-linear association between PWV and compliance or to blood pressure decrease in the frailest subjects. Total arterial compliance (C T) is the most relevant arterial property regarding CV function, compared to local or regional arterial stiffness. A new method for C T estimation, based on PWV, was recently proposed. We aimed to investigate the value of C T to predict all-cause mortality at the elderly. PWV was estimated in 279 elderly subjects (85.5 ± 7.0 years) who were followed up for a mean period of 12.8 ± 6.3 months. C T was estimated by the formula C T = k × PWV(-2); coefficient k is body-size dependent based on previous in silico simulations. Herein, k was adjusted for body mass index (BMI) with a 10 % change in BMI corresponding to almost 11 % change in k. For a reference BMI = 26.2 kg/m(2), k = 37. Survivors (n = 185) and non-survivors (n = 94) had similar PWV (14.2 ± 3.6 versus 14.9 ± 3.8 m/s, respectively; p = 0.139). In contrast, non-survivors had significantly lower C T than survivors (0.198 ± 0.128 versus 0.221 ± 0.1 mL/mmHg; p = 0.018). C T was a significant predictor of mortality (p = 0.022, odds ratio = 0.326), while PWV was not (p = 0.202), even after adjustment for gender, mean pressure and heart rate. Age was an independent determinant of C T (p = 0.016), but not of PWV. C T, estimated by a novel method, can predict all-cause mortality in the elderly. C T may be more sensitive arterial biomarker than PWV regarding CV risk assessment.

Blood pressure control with a single-pill combination of indapamide sustained-release and amlodipine in patients with hypertension: the EFFICIENT study

OBJECTIVE

Despite antihypertensive treatment, most hypertensive patients still have high blood pressure (BP), notably high systolic blood pressure (SBP). The EFFICIENT study examines the efficacy and acceptability of a single-pill combination of sustained-release (SR) indapamide, a thiazide-like diuretic, and amlodipine, a calcium channel blocker (CCB), in the management of hypertension.

METHODS

Patients who were previously uncontrolled on CCB monotherapy (BP≥140/90 mm Hg) or were previously untreated with grade 2 or 3 essential hypertension (BP≥160/100 mm Hg) received a single-pill combination tablet containing indapamide SR 1.5 mg and amlodipine 5 mg daily for 45 days, in this multicenter prospective phase 4 study. The primary outcome was mean change in BP from baseline; percentage of patients achieving BP control (BP<140/90 mm Hg) was a secondary endpoint. SBP reduction (ΔSBP) versus diastolic BP reduction (ΔDBP) was evaluated (ΔSBP/ΔDBP) from baseline to day 45. Safety and tolerability were also assessed.

RESULTS

Mean baseline BP of 196 patients (mean age 52.3 years) was 160.2/97.9 mm Hg. After 45 days, mean SBP decreased by 28.5 mm Hg (95% CI, 26.4 to 30.6), while diastolic BP decreased by 15.6 mm Hg (95% CI, 14.5 to 16.7). BP control (<140/90 mm Hg) was achieved in 85% patients. ΔSBP/ΔDBP was 1.82 in the overall population. Few patients (n = 3 [2%]) reported side effects, and most (n = 194 [99%]) adhered to treatment.

CONCLUSION

In patients who were previously uncontrolled on CCB monotherapy or untreated with grade 2 or 3 hypertension, single-pill combination indapamide SR/amlodipine reduced BP effectively--especially SBP--over 45 days, and was safe and well tolerated.

TRIAL REGISTRATION

Clinical Trial Registry-India CTRI/2010/091/000114.

[Orthostatic hypotension: marker of severity and management of antihypertensive treatment]

Orthostatic Hypotension (OH) is an independent predictor of cardiovascular disease and of all-cause mortality. It is a marker of poor prognosis in older and middle-aged patients. It should be primarily sought, at diagnosis of hypertension, at therapeutic modification, and when suspected by symptoms. One must make therapeutic decisions in older patients, based on measured blood pressure in standing position. Before blaming the antihypertensive treatment, one must search for other contexts favoring orthostatic hypotension. The antihypertensive treatment in older patients should: be initiated with low dosages and subsequent dose titration, be associated to lifestyle changes, not be associated to medications that have the potential to induce Orthostatic Hypotension, include a clear information about Orthostatic Hypotension (recognition, preventive measures…).

Cardiovascular and renal outcome in recipients of kidney grafts from living donors: role of aortic stiffness

BACKGROUND

Cardiovascular (CV) risk remains high in renal transplant patients despite a clear improvement conferred by transplantation. This risk is attributed mostly to recipient-related risk factors. Donor vascular characteristics, such as arterial stiffness, have been poorly investigated in this regard.

METHODS

Recipients of living-related (n = 75) and living-unrelated (n = 20) kidney grafts were recruited at a mean time of 107 ± 41 months after transplantation for baseline evaluation and follow-up for the occurrence of the following composite outcome: myocardial infarction, stroke, CV death, doubling of serum creatinine or development of end-stage renal disease (ESRD). At inclusion, recipients and their corresponding donors underwent complete history, physical examination, laboratory tests and non-invasive measurement of aortic pulse wave velocity (PWV).

RESULTS

During a mean follow-up of 56 ± 18 months, 20 recipients doubled their serum creatinine, of whom 16 reached ESRD, and 9 suffered of a new CV event (5 of which were fatal). Cox proportional hazards regression analysis showed that, in addition to recipient-related parameters, such as the presence of CV event and the estimated glomerular filtration rate at inclusion, donor aortic PWV was a strong and independent predictor of the composite recipient outcome.

CONCLUSIONS

Donor large artery stiffness may predict recipient CV and graft outcome. This finding demonstrates the tight link that exists between the vascular system and the kidneys and suggests that donor contribution to recipient outcome goes beyond simple parameters like age, gender and even familial or non-familial donor type.

[Hypertension and cardiovascular risk: the J-curve concept]

The optimization of the pharmacologic treatment in hypertensive patients is encouraged by four reports: the high prevalence of hypertension and more particularly in the elderly, the lack of blood pressure control in more than half of patients, the frequency of the association to other cardiovascular risk factors and the existence of a residual risk under treatment. All these factors are combined to raise the cardiovascular risk in hypertensive patients. Several interventional studies highlighted a reduction of the cardiovascular risk proportional to the reduction of blood pressure under treatment. Thus arose the question of the optimal blood pressure: the guidelines propose values lower than 140/90 mmHg for the non-complicated essential hypertension and lower than 130/80 mmHg in secondary prevention, for the patients with diabetes or renal impairment. However, this strict blood pressure goal for the high cardiovascular risk patients is not confirmed by clinical trials, strict blood pressure goal being potentially deleterious. The concept of «the lower the better» tends to be abandoned. Since more than three decades, the assumption of a paradoxical increase of the cardiovascular morbidity and mortality associated with a high reduction of blood pressure (the «J-Curve» concept) remains the subject of many studies and controversies.

Can ambulatory blood-pressure monitoring provide reliable indices of arterial stiffness?

BACKGROUND

The use of ambulatory recordings of blood pressure (BP) was proposed to estimate arterial stiffness (AS). We compared the relative value of the ambulatory AS index (AASI), and of the slope of pulse pressure (PP) according to mean BP (MBP) obtained from 24-h ambulatory BP monitoring, to the monitoring of the arrival time of Korotkoff sounds (QKD interval) in the prediction of cardiovascular (CV) events.

METHODS

Twenty-four-hour ambulatory BP and QKD monitoring were recorded at baseline, before antihypertensive treatment of hypertensive patients in our Bordeaux cohort. From these recordings, the AASI, the PP/MBP slope, and the theoretical value of the QKD for a systolic pressure of 100 mm Hg and a heart rate of 60 beats/min (QKD100-60) were calculated. The patients were then given antihypertensive treatment and followed by their family physicians, who were unaware of the QKD, AASI, and PP/MBP slope results. Regular updates on patients were obtained. The reproducibility of measurements was studied in 38 normal subjects evaluated on two occasions.

RESULTS

The reproducibility of the AASI and the PP/MBP slope was less than that of BP over 24 h and of QKD100-60. The cohort comprised 469 patients. With an average follow-up of 70+/-39 months, 62 CV complications, including 13 deaths, were recorded. In the monovariate analysis, age, PP over 24 h, QKD100-60, AASI, and the PP/MBP slope were significantly related to the occurrence of complications. In the multivariate analysis, when age and PP over 24 were included in the model, only QKD100-60 remained significantly linked to CV events.

CONCLUSIONS

Our data support the value of the AASI as an indirect estimate of AS and as an element in the evaluation of CV risk in hypertensive patients. However, the reproducibility of this index is less, and its predictive value for complications is poorer, than that of QKD100-60, a parameter that we believe is more closely linked to AS.

Prevention of stroke and myocardial infarction by amlodipine and Angiotensin receptor blockers: a quantitative overview

In the present quantitative overview of outcome trials, we investigated the efficacy of amlodipine or angiotensin receptor blockers in the prevention of stroke and myocardial infarction in patients with hypertension, coronary artery disease, or diabetic nephropathy. The analysis included 12 trials of 94 338 patients. The analysis of trials involving an amlodipine group showed that amlodipine provided more protection against stroke and myocardial infarction than other antihypertensive drugs, including angiotensin receptor blockers (-19%, P<0.0001 and -7%, P=0.03) and placebo (-37%, P=0.06 and -29%, P=0.04). The analysis of trials involving an angiotensin receptor blocker group showed contrasting results between trials versus amlodipine and trials versus other antihypertensive drugs for stroke (+19% versus -25%; P<0.0001) and myocardial infarction (+21% versus +1%; P=0.03). The results of 3 trials comparing an angiotensin receptor blocker with placebo were neutral (P> or =0.14). The within-trial between-group difference in achieved systolic pressure ranged from -1.1 to +4.7 mm Hg for trials involving an amlodipine group and from -2.8 to +4.0 mm Hg for trials involving an angiotensin receptor blocker group. The metaregression analysis correlating odds ratios with blood pressure differences showed a negative relationship (regression coefficients: -3% to -8%), which reached statistical significance (regression coefficient: -6%; P=0.01) for stroke in trials involving an amlodipine group. In conclusion, blood pressure differences largely accounted for cardiovascular outcome.

Carotid Intima-Media Thickness and Antihypertensive Treatment

BACKGROUND AND PURPOSE

Hypertension promotes carotid intima-media thickening. We reviewed the randomized controlled trials that evaluated the effects of an antihypertensive drug versus placebo or another antihypertensive agent of a different class on carotid intima-media thickness.

METHODS

We searched the PubMed and the Web of Science databases for randomized clinical trials, published in English before 2005, and included 22 trials.

RESULTS

In 8 trials including 3329 patients with diabetes or coronary heart disease, antihypertensive treatment initiated with an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, or a calcium-channel blocker (CCB), compared with placebo or no-treatment, reduced the rate of intima-media thickening by 7 microm/year (P=0.01). In 9 trials including 4564 hypertensive patients, CCBs, ACE inhibitors, an angiotensin II receptor blocker or an alpha-blocker, compared with diuretics or beta-blockers, in the presence of similar blood pressure reductions, decreased intima-media thickening by 3 microm/year (P=0.03). The overall beneficial effect of the newer over older drugs was largely attributable to the decrease of intima-media thickening by 5 microm/year (P=0.007) in 4 trials of CCBs involving 3619 patients. In 5 trials including 287 patients with hypertension or diabetes, CCBs compared with ACE inhibitors did not differentially affect blood pressure, but attenuated intima-media thickening by 23 microm/year (P=0.02). The treatment induced changes in carotid intima-media thickness correlated with the changes in lumen diameter (P=0.02), but not with the differences in achieved blood pressure (P>0.53).

CONCLUSIONS

CCBs reduce carotid intima-media thickening. This mechanism might contribute to their superior protection against stroke.

[Antioxidant supplements and risk of hypertension in the SU.VI.MAX trial: relationship to plasma antioxidants]

The object of this work was to determine the risk of hypertension after 6.5 years'- follow-up of supplementation in vitamins and antioxidant minerals at nutritional doses in the SU.VI.MAX trial. The authors also studied the association with plasma concentrations of antioxidants at inclusion and at long term. This was a randomised nutritional primary prevention study including 5086 adults of the SU.VI.MAX trial. After 6.5 years' follow-up, no effect of supplementation on the risk of developing hypertension could be shown compared with the placebo group: odds ratios (OR IC 95%): 1.04 (0.87-1.23) in men and 1.10 (0.95-1.29) in women. Besides, in the male 2nd and 3rd tertiles of serum beta-carotene levels at inclusion the risk of hypertension was lower [multivariate OR: 0.70 (0.44-1.12) and 0.53 (0.33-0.86) for placebo, and 0.59 (0.37-0.94) and 0.67 (0.42-1.07) for the supplemented groups]. The authors conclude that, despite a reverse relationship in men between the plasma concentrations of beta-carotene and the risk of hypertension, supplementation in antioxidants at nutritional doses had no effect on the risk of developing hypertension after 6.5 years' follow-up.

Increased skin capillary density in treated essential hypertensive patients

BACKGROUND

Microvascular rarefaction is a hallmark of essential hypertension. We measured the skin capillary density in nondiabetic hypertensive subjects with effective antihypertensive treatment and evaluated possible correlations with arterial blood pressure (BP).

METHODS

This cross-sectional observational study included 76 (55 +/- 1 years) consecutive outpatients with essential hypertension under chronic antihypertensive drug treatment (BP < 140/90 mm Hg), 24 age- and sex-matched patients with recently discovered and never-treated hypertension and 70 normotensive (BP < 140/90 mm Hg) age- and sex-matched healthy controls. We used intravital video-microscopy to measure basal and maximal (during venous congestion) skin capillary densities in the dorsum of the fingers. Aortic stiffness was evaluated using pulse wave velocity and central aortic pressure calculated from radial artery applanation tonometry.

RESULTS

Baseline and maximal capillary densities (number/mm2) were significantly lower (59.6 +/- 2.0 and 62.0 +/- 1.9) in untreated than in treated hypertensive patients (74.0 +/- 1.4 and 79.4 +/- 1.5; P < .001) and than in normotensives (68.2 +/- 1.5 and 72.4 +/- 1.5; P < .001). Based on multiple regression analysis, after adjustment to tobacco consumption, aortic (and not brachial) systolic BP was inversely correlated with basal and postocclusive capillary densities in normotensive subjects. In hypertensives, this correlation disappears and capillary density was influenced by two independent variables, antihypertensive drug treatment and overweight.

CONCLUSIONS

In nondiabetic hypertensive patients, capillary density is reduced in association with a cluster of cardiovascular risk factors involving tobacco consumption and obesity. The finding of an increased capillary density in effectively treated antihypertensives suggests that a cause-to-effect relationship between BP and capillary density should be evaluated in a long-term prospective follow-up.

Early activation of internal medial smooth muscle cells in the rabbit aorta after mechanical injury: relationship with intimal thickening and pharmacological applications

1. Smooth muscle cells (SMC) participate in both inflammatory and dedifferentiation processes during atherosclerosis, as well as during mechanical injury following angioplasty. In the latter, we studied medial SMC differentiation and inflammation processes implicated early after de-endothelialization in relation to mechanical stresses. We hypothesized that activation of a subpopulation of SMC within the media plays a crucial role in the early phase of neointimal formation. 2. For this purpose, we used a rabbit model of balloon injury to study activation and differentiation of medial SMC in the early time after denudation and just before neointima thickening. Inflammation was evaluated by the expression of vascular cell adhesion molecule (VCAM)-1, integrin alpha4beta1 and nuclear factor (NF)-kB. Myosin isoforms and 2P1A2 antigen, a membrane protein expressed by rabbit dedifferentiated SMC, were used as markers of differentiation. 3. On day 2 after de-endothelialization, VCAM-1, alpha4beta1 and NF-kB were coexpressed by a well-defined subpopulation of SMC of the internal part of the media, in the vicinity of the blood stream. At the same time, the majority of SMC throughout the media expressed non-muscle myosin heavy chain-B (nm-MHC-B) and 2P1A2 antigen. On day 7, when intimal thickening appeared, SMC of the media were no longer activated, whereas some intimal SMC expressed the activation markers. Thus, after de-endothelialization, early dedifferentiation occurs in most of the medial SMC, whereas activation concerned only a subpopulation of SMC located in the internal media. Using the T-type voltage-operated calcium channel blocker mibefradil (0.1-1 micromol/L) in SMC culture, we showed that this agent exhibited an antiproliferative effect in a dose-dependent manner only on undifferentiated cells. 4. In conclusion, the results suggest that the activated SMC represent cells that are potentially able to migrate and participate in the intimal thickening process. Thus, the medial SMC inflammatory process, without any contribution of inflammatory cells, may represent a major mechanism underlying the development of intimal thickening following mechanical stress. In humans, inhibition of T-type calcium channels may be a tool to prevent the early proliferation step leading to neointimal formation.

Arterial Stiffness, Isolated Systolic Hypertension, and Cardiovascular Risk in the Elderly

Isolated systolic hypertension is an important cardiovascular risk factor in the elderly. In addition to systolic blood pressure, pulse pressure, pulse wave velocity, and carotid wave reflections are also strong cardiovascular risk factors in the elderly, as a consequence of the two main determinants of systolic hypertension: increased arterial stiffness and early wave reflections. Taken together, all these findings should help to optimize drug treatment, which has been shown to produce important but thus far insufficient beneficial effects on cardiovascular morbidity and mortality.

[Disseminated tuberculosis and profound thrombopenia]

Thrombocytopenia within the context of disseminated tuberculosis can lead to complications requiring rapid treatment. Although the origin is generally central, thrombocytopenia can arise from an immune disorder. We hereby report a case of disseminated tuberculosis associated with thrombocytopenia, which required, in addition to antituberculosis therapy initiated before bacteriological proof, corticosteroid treatment and multiple platelet transfusions. The discovery of anti-platelet antibodies along with the success of immunomodulator therapy confirmed the auto-immune origin of this thrombocytopenia.

Effect of supplementation with antioxidants upon long-term risk of hypertension in the SU.VI.MAX study: association with plasma antioxidant levels

OBJECTIVE

To assess the effects of supplementation with a combination of antioxidant vitamins and trace elements, at nutritional doses, upon the 6.5-year risk of hypertension in the SU.VI.MAX trial. To describe the association between baseline plasma antioxidant levels and the same long-term risk using observational data from the study.

SETTING

A total of 5086 adults from the SU.VI.MAX trial, a randomized primary prevention trial.

RESULTS

Compared with the placebo group, no effect of supplementation upon the 6.5-year risk of hypertension could be detected (odds ratio, 1.04 and 95% confidence interval, 0.87-1.23 in men; and odds ratio, 1.10 and 95% confidence interval, 0.95-1.29 in women). Furthermore, compared with men in the first tertile, those in the second and third tertiles of serum baseline levels of beta-carotene presented a lower risk of hypertension in both the placebo and supplementation groups. Multivariate-adjusted odds ratios (95% confidence interval) were 0.70 (0.44-1.12) and 0.53 (0.33-0.86) in the placebo group, and were 0.59 (0.37-0.94) and 0.67 (0.42-1.07) in the supplementation group. In women, a decreasing trend was observed with vitamin C levels and risk of hypertension in the intervention group. No association could be shown between vitamin E and trace element plasma levels and the risk of hypertension.

CONCLUSIONS

Despite an inverse association between baseline plasma levels of beta-carotene in men and the risk of developing hypertension, we could not demonstrate any beneficial effect of low-dose antioxidant supplementation upon the 6.5-year risk of hypertension in the randomized analysis.

Nouvelles stratégies thérapeutiques dans l’hypertension artérielle

The diagnosis of hypertension by blood pressure measurements taken in the physician's office has been called into question by several studies. The onset of cardiovascular events appears to correlate better with ambulatory blood pressure measurements than with those taken during consultation (either "white coat" or masked hypertension). While the US, WHO, French and European guidelines diverge as to the specific antihypertensive drug among the seven classes available should be chosen for first-line treatment, there is a consensus for specific choices as a function of the type of hypertension. In any case, most treatment trials show that more than two antihypertensive drugs are often necessary. Treatment can thus begin with two drugs. The optimal target blood pressure is defined by the US JNC7 according to whether the patient also has diabetes or a nephropathy. When hypertension is uncomplicated, the target level is 140/90 mmHg. In the case of diabetes or nephropathy, it is 130/80 mmHg. In all cases, diet and exercise changes are also necessary and it is essential that patients understand them if they are to comply with them. Diastolic blood pressure remains the most important figure for those younger than 50 years, but afterwards, systolic pressure is more relevant. Aortic pressure may be more closely associated with cardiovascular risk than the blood pressure measured at the brachial artery. The concept of comprehensive management is radically modifying our behavior : the hypertensive patient is now above all a patient at high cardiovascular risk and the treatments to consider must not be limited to antihypertensive drugs but must also include treatment of other cardiovascular risk factors (aspirin, statins, smoking cessation, etc.).

Relationship Between Arterial Stiffness and Cognitive Function in Elderly Subjects With Complaints of Memory Loss

Background and Purpose— To evaluate the relationship between arterial stiffness and cognitive function in a population of elderly subjects reporting memory loss.

Methods— We studied the association between cognitive function and arterial stiffness in 308 consecutive elderly subjects attending a geriatric outpatient clinic reporting memory impairment. Subjects were classified into 4 categories according to neuropsychological evaluation: normal cognitive function, mild cognitive impairment (MCI), Alzheimer disease (AD), or vascular dementia (VaD). Arterial stiffness was evaluated by carotid-femoral pulse wave velocity (PWV) measurement using Complior.

Results— In this population, 78±8 years of age (women 64%), AD was present in 41%, VaD in 6%, MCI in 27%, and 26% of subjects had normal cognitive function. After adjustment for age, gender, systolic blood pressure, education level, cardiovascular diseases, and antihypertensive therapy, a significant association was observed between PWV and cognitive status ( P <0.0001). PWV appears significantly higher in subjects with VaD (15.2±3.9 m/s) or AD (13.3±2.9 m/s) than in those without cognitive impairment (11.5±2.0 m/s; P <0.001). Moreover, PWV was higher in subjects with MCI (12.6±2.6 m/s) than in those without cognitive impairment (11.5±2.0 m/s; P =0.01). For each 2 m/s increment in PWV, the adjusted odds ratio (95% CI) was 1.73 (1.27 to 2.47) for AD and 3.52 (1.87 to 8.05) for VaD.

Conclusion— Our results showed a relationship between arterial stiffness and cognitive impairment, suggesting that functional changes of the arterial system could be involved in the onset of dementia (VaD or AD types).

Metabolic syndrome in relation to structure and function of large arteries: a predominant effect of blood pressure. A report from the SU.VI.MAX. Vascular Study

BACKGROUND

Metabolic syndrome (MetS) is associated with increased risk of cardiovascular disease. However, the contribution of MetS to intermediate cardiovascular endpoints such as structure and function alterations of large arteries is still unclear.

METHODS

A total of 917 middle-aged French men and women participating to the SUpplémentation en VItamines et Minéraux AntioXydants (SU.VI.MAX) Vascular study were included. Carotid-femoral pulse wave velocity was used to assess aortic stiffness. Carotid ultrasound examination included measurements (at sites free of plaques) of intima-media thickness (IMT) at the common carotid arteries (CCA) and assessment of atherosclerotic plaques in the extracranial carotid arteries.

RESULTS

Prevalence of the MetS defined by the National Cholesterol Education Program was 8.7%. Compared with subjects without MetS, subjects with MetS had significant higher mean values of CCA-IMT (P = .02) and pulse wave velocity (P = .0001). We found that MetS was not significantly related to the presence of carotid plaques. Blood pressure was the only MetS component associated with all vascular parameters. Addition of other MetS components in the multivariate models contributed poorly to the explained variance of these parameters.

CONCLUSIONS

The MetS is adversely associated with markers of early arterial dysfunction, such as CCA-IMT and arterial stiffness. Although the associations between MetS and these arterial parameters are related to insulin resistance, blood pressure was shown to be the most important MetS component in relation to structure and function of large arteries.

Different relation between 24-h blood pressure and distensibility at different peripheral arteries. Data from the European Lacidipine Study on Atherosclerosis (ELSA)

INTRODUCTION

The European Lacidipine Study on Atherosclerosis (ELSA) has been planned to investigate the effect of reduction in office and ambulatory blood pressure by lacidipine versus atenolol on carotid artery wall thickness in mild to moderate essential hypertensive patients with no metabolic abnormalities. One prespecified sub-study of ELSA focused on measurements of arterial distensibility in the carotid as well as in the radial artery to determine the relationship of functional arterial properties with office versus ambulatory blood pressure (BP) values as well as the correspondence between functional and structural arterial alterations.

METHODS

The sub-study was conducted on 124 patients recruited in four centres (Monza-Milan, Paris, Grenoble and Glasgow). BP was measured both by a mercury sphygmomanometer and by 24-h ambulatory monitoring. Common carotid artery wall thickness was measured by certified sonographers as described in the main study. Common carotid and radial artery distensibility were obtained by echotracking techniques, which allowed to relate changes in arterial diameter with systo-diastolic BP changes.

RESULTS

Carotid artery wall distensibility showed (1) a negative correlation with office and more so 24-h average systolic BP (r = -0.45 and -0.58, P < 0.008 and 0.001) but not with office or 24-h diastolic BP) and (2) a negative correlation with the corresponding wall thickness (r = -0.47, P < 0.005). In contrast, at the radial artery level distensibility and thickness showed no correlation with each other and with BP. Carotid (but not radial) artery distensibility also correlated with ambulatory systolic BP variability but the correlation was lost after adjustment for age and mean BP values.

CONCLUSION

These data suggest that stiffening of large elastic artery is reflected more by ambulatory than office BP elevations, systolic BP being much more important than diastolic. Alterations of large elastic arteries function is related to structural wall changes. Functional and structural properties of middle-size muscle arteries are independent of BP.

[Body composition and left ventricular geometry]

Left ventricular mass and cardiac output are, particularly in obesity, correlated with fat free body mass. We assessed the relationship between ventricular geometry and fat body mass in treated hypertensives with or without normalization of blood pressure We investigated 175 patients (age: 57 +/- 15 years, M/F: 111/64, Mean blood pressure (MBP): 111 +/- 18 mmHg, BMI: 27.02 +/- 3.70 kg/m2: 20.3-39.6 kg/m2) with measure of body composition (impedancemetry Analycor2) and echographic left ventricular mass (adjusted to height2.7: mass2.7). Multiple correlation with adjustment to age and MBP were performed in men (M) and in women (W). Mass2.7 is correlated with fat mass percentage in men (R partial R: 5.6, p=0.02). LV diastolic diameter is correlated with fat free body mass while interventricular septum is correlated with fat body mass but only in men. In summary, in hypertensives not selected on BMI or BP, fat body mass is weakly correlated to ventricular wall thickness in men, probably mediated by sympathetic tone, while fat free body mass is related to ventricular volume in both gender probably through the water volume particularly in vascular bed. In conclusion, both components of body composition are differently, and weakly, linked to ventricular geometry in hypertensive patients.

Etomidate Alters Calcium Mobilization Induced by Angiotensin II in Rat Aortic Smooth Muscle Cells

Etomidate is widely used for induction of anesthesia in the hemodynamically compromised patient, because of its moderate direct effect on arterial vasomotoricity and cardiac function, but its effect on blood pressure regulatory systems is not known. We studied the effect of etomidate (10(-8) to 10(-4) mol.L) on Ca++ mobilization elicited by angiotensin II (Ang II) in cultured aortic smooth muscle cells (VSMC) from 6-week-old Wistar Kyoto rats. Intracellular Ca++ (Cai++) variation was assessed in Fura 2-loaded VSMC, using fluorescent imaging microscopy. Ang II (10(-6) mol.L(-1))-induced transient Cai++ mobilization from internal stores was assessed in the absence of external Ca++. Ca++ influx was assessed upon reintroduction of external Ca++ (10(-3) mol.L(-1)). Etomidate moderately decreased both the amplitude (etomidate 10(-4) mol.L(-1): 68% of control value, P < 0.001) and the slope of Cai++ increase (56% of control, P < 0.001) from internal stores induced by Ang II. PD2 values (PD2 = -log(EC50)) for amplitude and slope were 6.4 +/- 0.7 and 6.0 +/- 0.3, respectively. Ang II-elicited Ca++ influx was also significantly decreased (45% of control, P < 0.001; PD2 = 5.5 +/- 0.3). Etomidate alters the Ca++ mobilization elicited by Ang II in rat aortic VSMC, suggesting that the vascular response to Ang II may be altered during etomidate anesthesia. However, this effect was observed at high concentration of etomidate, and may be limited when low doses of etomidate are used.

EFFECT OF PROPOFOL ON VASOCONSTRICTION AND CALCIUM MOBILIZATION INDUCED BY ANGIOTENSIN II DIFFERS IN AORTAS FROM NORMOTENSIVE AND HYPERTENSIVE RATS

1. Angiotensin (Ang) II is a potent vasopressor agent, involved in the short-term control of arterial blood pressure during anaesthesia. The aim of the present study was to test the hypothesis that propofol, a widely used intravenous anaesthetic agent, could alter the arterial response to AngII and to evaluate its effect in genetic hypertension. 2. We studied the effect of increasing concentrations of propofol (5.6 x 10-7 to 5.6 x 10-4 mol/L) on aortic ring maximal isometric tension elicited by AngII and on AngII-induced Ca2+ mobilization in aortic smooth muscle cells from Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHR). 3. Maximal tension developed by aortic rings from WKY rats was greater than that developed by rings from SHR. In both WKY rats and SHR, propofol at concentrations from 5.6 x 10-6 mol/L decreased maximal tension induced by AngII in a concentration-dependent manner. The magnitude of inhibition was higher in SHR than in WKY rats, whereas pD2 values were not different. In addition, Ca2+ mobilization induced by AngII was inhibited by propofol in a concentration-dependent manner, with the same magnitude and pD2 values. 4. These results suggest that the arterial response to AngII may be altered during propofol anaesthesia, particularly in hypertension.

Aortic pulse pressure is related to the presence and extent of coronary artery disease in men undergoing diagnostic coronary angiography: a multicenter study

BACKGROUND

In the general population, pulse pressure (PP) is a correlate of cardiovascular outcomes. Few data are available regarding the links between PP and documented coronary artery disease (CAD).

METHODS

From July 2000 to January 2002, a total of 1337 patients referred for a first diagnostic coronary angiogram at 75 participating centers were prospectively included. Of these individuals, 280 patients receiving no hypertensive therapy constituted the study population. Pulse pressure was recorded in the aortic root before angiography, and baseline characteristics, medical history, treatment used, and data from coronary angiography were recorded.

RESULTS

In the whole population, aortic PP strongly correlated with the presence and extent of CAD in univariate analyses. However, the correlation disappeared in multivariate analysis, and a strong interaction with gender was found. In women (n = 82), aortic PP was not an independent predictor of CAD. However, in men (n = 198) an independent correlation between aortic PP and CAD was found, together with age and hypercholesterolemia. In addition, PP was strongly correlated with the extent of CAD (no disease, 51 +/- 16 mm Hg; one or two stenoses, 54 +/- 18 mm Hg; and more than two stenoses: 64 +/- 20 mm Hg).

CONCLUSIONS

In this multicenter study, aortic PP was significantly correlated with the presence and extent of CAD in patients without antihypertensive therapy. This correlation, however, was independent of other risk factors for CAD in men but not in women.

Airway colonisation in long-term mechanically ventilated patients

OBJECTIVE

To evaluate the impact of continuous subglottic suctioning and semi-recumbent body position on bacterial colonisation of the lower respiratory tract.

DESIGN

A randomised controlled trial.

SETTING

The ten-bed medical ICU of a French university hospital.

PATIENTS

Critically ill patients expected to require mechanical ventilation for more than 5 days.

INTERVENTIONS

Patients were randomly assigned to receive either continuous suctioning of subglottic secretions and semi-recumbent body position or to receive standard care and supine position.

MEASUREMENTS AND RESULTS

Oropharyngeal and tracheal secretions were sampled daily and quantitatively cultured. All included patients were followed up from day 1 (intubation) to day 10, extubation or death. Ninety-seven samples of oropharynx and trachea were analysed (40 for the suctioning group and 57 for the control group). The median bacterial counts in trachea were 6.6 Log10 CFU/ml (interquartile range, IQR, 4.4-8.3) in patients who received continuous suctioning and 5.1 Log10 CFU/ml (IQR 3.6-5.5) in control patients. Most of the patients were colonised in the trachea after 1 day of mechanical ventilation (75% in the suctioning group, 80% in the control group). No significant difference was found in the daily bacterial counts in the oropharynx and in the trachea between the two groups of patients.

CONCLUSION

Tracheal colonisation in long-term mechanically ventilated ICU patients was not modified by the use of continuous subglottic suctioning and semi-recumbent body position.

[Primary aldosteronism. A risk factor for aortic dissection?]

Aortic dissection is a rare but severe disease. Numerous risk factors have been reported, all leading to an alteration of arterial structures, particularly extracellular matrix. Aortic dissection is a complication of arterial hypertension, whatever its origin. Primary aldosteronism, frequent cause of secondary arterial hypertension, is associated with arterial structural alterations, indirectly by a pressure factor, and directly by aldosterone, which modifies collagen contents and elastin/collagen ratios. In addition to the three previously reported cases, the three cases reported in the present paper lead to the hypothesis of a causal relationship between aldosteronism and aortic dissection. The need for hypertension screening and diagnosis of its potential causes, namely primary aldosteronism, is highlighted.