Effect of a novel calcium channel blocker on abnormal nocturnal blood pressure in hypertensive patients

The authors examined the effect of cilnidipine, a unique L/N-type calcium channel blocker, on abnormal nocturnal blood pressure (BP) dipping in Japanese hypertensive patients in the real world. The Ambulatory Blood Pressure Control and Home Blood Pressure (Morning and Evening) Lowering by N-Channel Blocker Cilnidipine (ACHIEVE-ONE), a large-scale clinical study, was designed to evaluate the effects of cilnidipine in daily medical practice. Among the study, 24-hour ambulatory BP data were obtained from 615 patients and classified according to their nocturnal dipping status as extreme dippers, dippers, nondippers, or risers. A 12-week treatment with cilnidipine significantly reduced 24-hour BP in all groups (P<.001). Changes in nocturnal systolic BP (SBP) from baseline were -17.9 mm Hg from 154.6 mm Hg in risers and -11.9 mm Hg from 142.1 mm Hg, -6.6 mm Hg from 128.5 mm Hg, and 0.1 mm Hg from 115.8 mm Hg in nondippers, dippers, and extreme dippers, respectively. Changes from baseline in nocturnal SBP reduction rate were 8.2% in risers (P<.001) but -7.0% in extreme dippers (P<.001), while no change was observed in the nighttime SBP reduction rate for the total patients (-0.2%±9.6%, P=.617). Cilnidipine partially, but significantly, restored abnormal nocturnal dipping status toward a normal dipping pattern in hypertensive patients.

Mediastinal leiomyosarcoma concurrent with intra-aortic thrombosis

We report a case of a large intra-aortic thrombosis in an 83-year-old woman concurrent with metastatic mediastinal leiomyosarcoma. Imaging studies incidentally detected a mediastinal malignant tumour metastasising to bilateral adrenals and an extensive intra-aortic mass that was suspected to be intra-aortic thrombosis. One month later massive embolism developed in the lower limb and her condition deteriorated rapidly resulting in death. Autopsy revealed diffused proliferation of highly pleomorphic atypical cells accompanied by necrosis in the mediastinum tumours and bilateral adrenal glands. Leiomyosarcoma metastasising to bilateral adrenals was confirmed by the results of immunostaining. The intra-aortic mass suggested that the fragmented thrombus might be the cause of a sudden lower-limb embolism. Microscopic examination showed that the mass lesion in the aortic arch was composed of a blood clot containing neutrophils. We report this case because leiomyosarcoma arising from the mediastinum and, especially, associated with an extraordinarily large intra-aortic thrombosis is very rare.

Enhancement of cardiac performance by bilevel positive airway pressure ventilation in heart failure

BACKGROUND

Recent studies have reported the clinical usefulness of positive airway pressure ventilation therapy with various kinds of pressure support compared with simple continuous positive airway pressure (CPAP) for heart failure patients. However, the mechanism of the favorable effect of CPAP with pressure support can not be explained simply from the mechanical aspect and remains to be elucidated.

METHODS AND RESULTS

In 18 stable chronic heart failure patients, we performed stepwise CPAP (4, 8, 12 cm H(2)O) while the cardiac output and intracardiac pressures were continuously monitored, and we compared the effects of 4 cm H(2)O CPAP with those of 4 cm H(2)O CPAP plus 5 cm H(2)O pressure support. Stepwise CPAP decreased cardiac index significantly in patients with pulmonary arterial wedge pressure (PAWP) <12 mm Hg (n = 10), but not in those with PAWP ≥12 mm Hg (n = 8). Ventilation with CPAP plus pressure support increased cardiac index slightly but significantly from 2.2 ± 0.7 to 2.3 ± 0.7 L min(-1) m(-2) (P = .001) compared with CPAP alone, regardless of basal filling condition or cardiac index.

CONCLUSIONS

Our results suggest that CPAP plus pressure support is more effective than simple CPAP in heart failure patients and that the enhancement might be induced by neural changes and not simply by alteration of the preload level.

A new electrocardiographic criterion to differentiate between Takotsubo cardiomyopathy and anterior wall ST-segment elevation acute myocardial infarction

Several studies have examined the ability of electrocardiography to differentiate between takotsubo cardiomyopathy (TC) and anterior wall acute ST-segment elevation myocardial infarction (AA-STEMI). In those studies, the magnitude of ST-segment elevation was not measured at the J point. The American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society guidelines recommend that the magnitude of ST-segment elevation should be measured at the J point. Accordingly, the aim of this study was to retrospectively examine whether electrocardiography, using the magnitude of ST-segment elevation measured at the J point, could differentiate 62 patients with TC from 280 with AA-STEMI. Patients with AA-STEMI were divided into following subgroups: 140 with left anterior descending coronary artery occlusions proximal to the first diagonal branch (AA-STEMI-P), 120 with left anterior descending occlusions distal to the first diagonal branch and proximal to the second diagonal branch (AA-STEMI-M), and 20 with left anterior descending occlusions distal to the second diagonal branch (AA-STEMI-D). TC had a much lower prevalence of ST-segment elevation ≥1 mm in lead V(1) (19.4%) compared to AA-STEMI (80.4%, p <0.01), AA-STEMI-P (80.7%, p <0.01), AA-STEMI-M (80%, p <0.01), and AA-STEMI-D (80%, p <0.01). ST-segment elevation ≥1 mm in ≥1 of leads V(3) to V(5) without ST-segment elevation ≥1 mm in lead V(1) identified TC with sensitivity of 74.2% and specificity of 80.6%. Furthermore, this criterion could differentiate TC from each AA-STEMI subgroup, with similar diagnostic values. In conclusion, using the magnitude of ST-segment elevation measured at the J point, a new electrocardiographic criterion is proposed with an acceptable ability to differentiate TC from AA-STEMI.

Simple standing test predicts and water ingestion prevents vasovagal reaction in the high-risk blood donors

BACKGROUND

One of the serious complications of blood donation is vasovagal reaction (VVR) with syncope. This study was performed to determine if the measurement of hemodynamic responses to standing before blood collection (BC) was useful to identify the high-risk donors for VVR and also examined the effect of 300 mL of water ingestion in the prevention of VVR.

STUDY DESIGN AND METHODS

Blood pressure and heart rate (HR) during 5 minutes of standing were examined before and after BC in 93 donors. Because HR increase of 6 of 7 donors who developed syncopal VVR during standing after BC was 15 beats per minute (bpm) or greater, those with HR increase of 15 bpm or greater were determined as high-risk donors (n = 31). In another group (n = 117), 45 donors were identified as high risk based on the HR response before BC (15 bpm). The effect of 300 mL of water ingestion 15 minutes before BC on hemodynamic responses to standing and the rate of VVR after BC were analyzed.

RESULTS

Water ingestion given to the high-risk donors of the second group reduced HR increase with standing before BC (-6.6 ± 13.6 bpm, p < 0.02 vs. HR increase before water ingestion) and significantly suppressed VVR rate (2 of 45 donors with high risk, 4.4%,p < 0.04 vs. the first group; 6 of 31 high-risk donors, 19.4%).

CONCLUSION

HR response to standing before BC may detect the high-risk donors for VVR. For the high-risk donors, 300 mL of water ingestion may be a simple and effective way of prevention against syncopal VVR.

Left ventricular false-pseudo and pseudo aneurysm: serial observations by cardiac magnetic resonance imaging

A case of extensive inferior myocardial infarction complicated by a large ventricular aneurysm is presented. Magnetic resonance (MR) imaging 4 days after the onset showed a small protrusion from the necrotic inferior myocardium, which expanded 10 days after onset with a marked pericardial effusion. The follow-up examination by MR and CT imaging 6 months after the onset revealed a large ventricular aneurysm from the inferior cardiac wall. After the aneurysmectomy, the histological study revealed that the aneurysm wall was made up of 2 different types of walls; the peripheral part was a false-pseudo aneurysm and the central part was a pseudo aneurysm. From the serial MR imaging, it is considered that such an aneurysm is primarily formed from a small discontinuation of the LV wall followed by oozing type rupture. Finally, the ruptured central part of the LV wall, which was covered by the pericardium, formed a pseudo aneurysm and the stretched peripheral area, which contains myocardium, formed a false-pseudo aneurysm afterward and then they extended together. Thus, MR imaging provided the important information for the understanding of the formation process of the pseudo and false pseudo LV aneurysm.

Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea subjects the failing heart to adverse hemodynamic and adrenergic loads and may thereby contribute to the progression of heart failure. We hypothesized that treatment of obstructive sleep apnea by continuous positive airway pressure in patients with heart failure would improve left ventricular systolic function.

METHODS

Twenty-four patients with a depressed left ventricular ejection fraction (45 percent or less) and obstructive sleep apnea who were receiving optimal medical treatment for heart failure underwent polysomnography. On the following morning, their blood pressure and heart rate were measured by digital photoplethysmography, and left ventricular dimensions and left ventricular ejection fraction were assessed by echocardiography. The subjects were then randomly assigned to receive medical therapy either alone (12 patients) or with the addition of continuous positive airway pressure (12 patients) for one month. The assessment protocol was then repeated.

RESULTS

In the control group of patients who received only medical therapy, there were no significant changes in the severity of obstructive sleep apnea, daytime blood pressure, heart rate, left ventricular end-systolic dimension, or left ventricular ejection fraction during the study. In contrast, continuous positive airway pressure markedly reduced obstructive sleep apnea, reduced the daytime systolic blood pressure from a mean (+/-SE) of 126+/-6 mm Hg to 116+/-5 mm Hg (P=0.02), reduced the heart rate from 68+/-3 to 64+/-3 beats per minute (P=0.007), reduced the left ventricular end-systolic dimension from 54.5+/-1.8 to 51.7+/-1.2 mm (P=0.009), and improved the left ventricular ejection fraction from 25.0+/-2.8 to 33.8+/-2.4 percent (P<0.001).

CONCLUSION

In medically treated patients with heart failure, treatment of coexisting obstructive sleep apnea by continuous positive airway pressure reduces systolic blood pressure and improves left ventricular systolic function. Obstructive sleep apnea may thus have an adverse effect in heart failure that can be addressed by targeted therapy.

Augmented sympathetic neural response to simulated obstructive apnoea in human heart failure

Sleep apnoea in heart failure increases mortality risk, possibly as a result of greater activation of the sympathetic nervous system. In healthy subjects, simulated central apnoeas (holding breath) and obstructive apnoeas (Mueller manoeuvres) increase muscle sympathetic activity equally, primarily through chemoreceptor stimulation. In heart failure, however, Mueller manoeuvres cause greater reductions in blood pressure than breath holds. We hypothesized that in heart failure, the summation of arterial baroreceptor unloading and chemoreceptor stimulation would increase sympathetic activity more during obstructive than central apnoeas. Healthy human subjects and heart failure patients (seven of each) performed 15-s breath holds and 15-s Mueller manoeuvres. Breath holds evoked a progressive increase in muscle sympathetic nerve activity in both groups, but had no effect on blood pressure. In healthy subjects, breath holds and Mueller manoeuvres caused equal peaks in sympathetic activity. In contrast, in heart failure patients, Mueller manoeuvres caused a progressive decrease in blood pressure (P < 0.05) and greater increases in sympathetic activity than breath holds (P < 0.01). In heart failure, simulated obstructive apnoea elicits greater increases in sympathetic activity than simulated central apnoea, due to its additional hypotensive effect. These present findings offer novel insight into the potential role of sleep apnoea in augmenting sympathetic activity and accelerating disease progression in heart failure.