Morning blood pressure surge as a destabilizing factor of atherosclerotic plaque: role of ubiquitin-proteasome activity

Gray-Scale Median in Patients with Symptomatic and Asymptomatic Carotid Atherosclerosis-Risk Factors and Diagnostic Potential

BACKGROUND

The identification of clinical factors affecting the gray-scale median (GSM) and determination of GSM diagnostic utility for differentiating between symptomatic and asymptomatic internal carotid artery (ICA) stenosis.

METHODS

This study included 45 patients with asymptomatic and 40 patients with symptomatic ICA stenosis undergoing carotid endarterectomy (CEA). Echolucency of carotid plaque was determined using computerized techniques for the GSM analysis. Study groups were compared in terms of clinical risk factors, coexisting comorbidities, and used pharmacotherapy.

RESULTS

Mean GSM values in the symptomatic group were significantly lower than in the asymptomatic group (p < 0.001). Both in the univariate as well as in the multiple regression analysis, GSM was significantly correlated with D-dimers and fasting plasma glucose levels and tended to correlate with β-adrenoceptor antagonist use in the symptomatic group. In asymptomatic patients, GSM was associated with the presence of grade 2 and grade 3 hypertension, and tended to correlate with the use of metformin, sulfonylureas, and statin. Independent factors for GSM in this group remained as grade 3 hypertension and statin's therapy. The receiver operating characteristic (ROC) analysis revealed that GSM differentiated symptomatic from asymptomatic ICA stenosis with sensitivity and specificity of 73% and 80%, respectively.

CONCLUSION

The completely diverse clinical parameters may affect GSM in symptomatic and asymptomatic patients undergoing CEA, whose clinical characteristics were similar in terms of most of the compared parameters. GSM may be a clinically useful parameter for differentiating between symptomatic and asymptomatic ICA stenosis.

Morning blood pressure surge and intracranial atherosclerotic plaque characteristics: a high-resolution magnetic resonance vessel wall imaging study

OBJECTIVE

To investigate the relationship between morning blood pressure surge (MBPS) and intracranial atherosclerotic plaque burden and vulnerability.

METHODS

A total of 267 ischaemic stroke patients were retrospectively analysed. Sleep-trough and prewaking MBPS were calculated from ambulatory blood pressure monitoring (ABPM). Plaque characteristics, including intraplaque haemorrhage (IPH), maximum wall thickness (max WT), and stenosis degree, were obtained from high-resolution MR vessel wall imaging (HR-vwMRI). Linear and logistic regression were used to detect the association.

RESULTS

Subjects with the top tertile of sleep-trough MBPS (≥15.1 mmHg) had a lower prevalence (9.1% vs. 19.6%, P = .029) of severe stenosis (≥70%) than others. Subjects within the top tertile of prewaking MBPS (≥7.6 mmHg) had a lower percentage of IPH (27.3% vs. 40.4%, P = .035) than others. After adjusting for stroke risk factors (age, sex, diabetes, hyperlipidaemia, hyperhomocysteinaemia, smoking, and family stroke history) and 24-h mean systolic blood pressure, 10 mmHg sleep-trough MBPS increment was associated with 0.07mm max WT reduction, and the top tertile MBPS group was associated with a lower chance of severe stenosis (odd ratio = 0.407, 95% CI, 0.175-0.950). Additionally, an increased prewaking MBPS is associated with a lower incidence of IPH, with OR = 0.531 (95% CI, 0.296-0.952). Subgroup analysis demonstrated that the positive findings could only be seen in non-diabetic subjects.

CONCLUSION

Increment of MBPS is negatively associated with intracranial atherosclerotic plaque burden and vulnerability, and this relationship remains significant in the non-diabetic subgroup.

ADVANCES IN KNOWLEDGE

This study provided evidence that MBPS was associated with the intracranial atherosclerotic plaque burden and vulnerability on HR-vwMRI.

Association between glycated hemoglobin and functional outcomes in patients with intracranial large artery atherosclerotic disease-related acute ischemic stroke: identifying the magic number

Objective

This study aimed to investigate the effect of the glycated hemoglobin A1c (HbA1c) level on the functional outcome (FOC) in patients with intracranial large artery atherosclerotic disease (ICLAD)-related acute ischemic stroke (AIS).

Methods

This retrospective study enrolled patients with ICLAD-related AIS who were admitted to King Fahd University Hospital between January 2017 and September 2021. Patients were divided into two groups based on the optimal cutoff HbA1c level determined using receiver operating characteristic curve analysis-those with HbA1c ≤6.9% and those with HbA1c >6.9%. Demographic and other clinical characteristics were compared between the two groups using chi-square tests. The association between HbA1c and 90-day FOC was assessed using the chi-square test and odds ratios (ORs). Multivariate analysis was performed to adjust for confounding factors.

Results

A total of 140 patients were included in the analysis. A significant association was observed between the HbA1c level and FOC. Compared to patients with HbA1c ≤6.9%, patients with HbA1c >6.9% were more likely to have an unfavorable FOC [p = <0.001, OR = 2.05, 95% confidence interval (CI) = 1.33-3.14]. The association between HbA1c >6.9% and unfavorable FOC was sustained even after adjusting for confounding factors (p = 0.008) and atherosclerosis risk factors (p = 0.01). HbA1c >6.9% was also associated with higher ORs for in-hospital complications (p = 0.06, OR = 1.34, 95% CI = 1.02-1.77) and mortality (p = 0.07, OR = 1.42, 95% CI = 1.06-1.92) although these associations did not attain significant p-values.

Conclusion

HbA1c >6.9% was significantly associated with unfavorable FOC in ICLAD-related AIS. However, further studies with larger sample sizes are required to verify whether HbA1c is an independent predictor of poor FOC. Nevertheless, targeting HbA1c <7% should be the goal of physicians when managing patients at high risk of ICLAD.

Correlation of blood pressure levels at different time periods throughout the day with total CSVD burden and MRI imaging markers

Purpose

Hypertension is an important risk factor for atherosclerotic cerebral small vessel disease (CSVD). Higher blood pressure is associated with a higher CSVD burden and the presence of relevant magnetic resonance imaging (MRI) markers. However, the effect of blood pressure level on CSVD burden and imaging markers including white matter hyperintensity (WHM), lacune, enlarged perivascular spaces (EPVS), and cerebral microbleed (CMB) remains unknown. The purpose of this study was to investigate the correlation between blood pressure level and CSVD burden at different time periods throughout the day.

Methods

In total, 144 in-patients with CSVD (66.4 ± 9.8 years, 50% male) were enrolled and underwent brain MRI, and 24-h ambulatory blood pressure was assessed. Patients were categorized into five groups according to their MRI-evaluated total CSVD burden scores (0-4). Spearman's correlation analysis was performed to examine the correlation between blood pressure levels at different time periods and the total CSVD score or the markers of periventricular WMH, deep WMH, lacune, EPVS, and CMB.

Results

Of the 144 patients, 83.3% (120/144) harbored one or more CSVD markers of interest. The systolic blood pressure (SBP) of 24-h, daytime, nighttime, and morning differed significantly among the five groups. The SBP levels increased significantly with the total CSVD scores during 24 h (P = 0.018), daytime (P = 0.018), and nighttime (P = 0.035). Spearman's correlation analysis demonstrated that the SBP of 24 h, daytime, nighttime, and morning and the diastolic blood pressure (DBP) of 24 h and morning positively and significantly correlated with the total CSVD score (P < 0.05). A logistic regression analysis indicated that both morning SBP and DBP were independent risk factors for total CSVD burden (OR = 1.13, 95% CI: 1.02-1.23, P = 0.015; OR = 1.19, 95% CI: 1.06-1.33, P = 0.005). Spearman's correlation analysis indicated a significant positive correlation between morning SBP and higher deep WMH Fazekas score (r = 0.296, P < 0.001), EPVS grade in the basal ganglia (r = 0.247, P = 0.003), and the presence of lacune (r = 0.173, P = 0.038) and CMB (r = 0.326, P < 0.001). Morning DBP only correlated positively with the presence of CMB (r = 0.292, P < 0.001).

Conclusion

Higher SBP signficantly correlated with total CSVD burden in patients with atherosclerotic CSVD. Early morning blood pressure level is an important indicator to reflect the severity of CSVD patients.

Intracranial Carotid Arteriosclerosis Mediates the Association Between Blood Pressure and Cerebral Small Vessel Disease

BACKGROUND

Intracranial arteriosclerosis could explain the association between blood pressure (BP) and cerebral small vessel disease (CSVD). Therefore, we tested whether intracranial carotid artery calcification (ICAC) mediates the association between BP and CSVD and determined pathophysiological mechanisms based on ICAC subtypes.

METHODS

One thousand four hundred fifty-eight stroke-free participants from the Rotterdam Study (mean age, 68 years; 52% women) underwent nonenhanced computed tomography scans to quantify ICAC volume (mm³) between 2003 and 2015. ICAC was categorized into intimal and internal elastic lamina calcifications. CSVD included white matter hyperintensities volume, the presence of lacunes, and cerebral microbleeds visualized on magnetic resonance imaging. Office BP included systolic BP, diastolic BP, pulse pressure, and mean arterial pressure. Mediation analysis included a 2-way decomposition to determine the direct association between BP and CSVD and the indirect or mediated effect (negative or positive mediations expressed in %) of log-ICAC volume on such association.

RESULTS

BP and log-ICAC were correlated and were also associated with CSVD. In all participants, total log-ICAC volume mediated the association of diastolic BP (-14.5%) and pulse pressure (16.5%) with log-white matter hyperintensities. Internal elastic lamina log-ICAC volume mediated -19.5% of the association between diastolic BP and log-white matter hyperintensities; intimal log-ICAC volume did not mediate associations. For lacunes, total and internal elastic lamina log-ICAC volume mediated the association of diastolic BP (-40% and -45.8%) and pulse pressure (26.9% and 18.2%). We did not observe mediations for cerebral microbleeds.

CONCLUSIONS

Intracranial arteriosclerosis mediates the association between BP and CSVD. Internal elastic lamina calcification, considered a proxy of arterial stiffness, is the leading mechanism explaining the link between BP and CSVD.

Texture Analysis Based on Vascular Ultrasound to Identify the Vulnerable Carotid Plaques

Vulnerable carotid plaques are closely related to the occurrence of ischemic stroke. Therefore, accurate and rapid identification of the nature of carotid plaques is essential. This study aimed to determine whether texture analysis based on a vascular ultrasound can be applied to identify vulnerable plaques. Data from a total of 150 patients diagnosed with atherosclerotic plaque (AP) by carotid ultrasound (CDU) and high-resolution magnetic resonance imaging (HRMRI) were collected. HRMRI is the in vivo reference to assess the nature of AP. MaZda software was used to delineate the region of interest and extract 303 texture features from ultrasonic images of plaques. Following regression analysis using the least absolute shrinkage and selection operator (LASSO) algorithm, the overall cohort was randomized 7:3 into the training (n = 105) and testing (n = 45) sets. In the training set, the conventional ultrasound model, the texture feature model, and the conventional ultrasound-texture feature combined model were constructed. The testing set was used to validate the model’s effectiveness by calculating the area under the curve (AUC), accuracy, sensitivity, and specificity. Based on the combined model, a nomogram risk prediction model was established, and the consistency index (C-index) and the calibration curve were obtained. In the training and testing sets, the AUC of the prediction performance of the conventional ultrasonic-texture feature combined model was higher than that of the conventional ultrasonic model and the texture feature model. In the training set, the AUC of the combined model was 0.88, while in the testing set, AUC was 0.87. In addition, the C-index results were also favorable (0.89 in the training set and 0.84 in the testing set). Furthermore, the calibration curve was close to the ideal curve, indicating the accuracy of the nomogram. This study proves the performance of vascular ultrasound-based texture analysis in identifying the vulnerable carotid plaques. Texture feature extraction combined with CDU sonogram features can accurately predict the vulnerability of AP.

Elevated Glycated Hemoglobin Levels Are Associated With Poor Outcome in Acute Ischemic Stroke

Objective

Admission hyperglycemia is an established risk factor for functional outcome in patients with acute ischemic stroke. However, the association between glycated hemoglobin (HbA1c) and prognosis in patients with acute anterior circulation ischemic stroke (AACIS) remains controversial. This study aimed to explore whether elevated HbA1c levels are associated with functional outcome in AACIS patients.

Participants and Methods

We enrolled patients with AACIS hospitalized in the First Hospital Affiliated to Soochow University from March 2018 to January 2021. Patients were categorized into three groups based on baseline HbA1c: HbA1c ≤ 6.5%, 6.5% < HbA1c ≤ 8.0%, and HbA1c > 8.0%. Ninety-day modified Rankin Scale scores of 0–1 and 0–2 were defined as excellent and favorable functional outcome, respectively. Early neurological improvement was regarded as a reduction in the National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points compared with that on admission, or an NIHSS score of 0–1 at discharge. The association between HbA1c and clinical outcome in acute ischemic patients was assessed by logistic regression and adjusted for confounding factors. Subgroup analyses by TOAST classification were also conducted.

Results

The study included 326 patients. The proportion with favorable outcome was significantly lower in the HbA1c > 8.0% group than the HbA1c ≤ 6.5% group (30.4 vs. 55.2%; p < 0.01). Binary logistic regression analysis demonstrated that increasing HbA1c levels (as a continuous variable) were associated with reduced functional independence (adjusted OR = 0.739; 95% CI: 0.605–0.904; p = 0.003). In subgroup analyses, higher HbA1c was also associated with favorable outcome in large-artery atherosclerosis (LAA)-type patients (adjusted OR = 0.776; 95% CI: 0.614–0.981; p = 0.034), but not in LAA group.

Conclusions

HbA1c level was an independent predictor of worse functional outcome in patients with AACIS, particularly in those with LAA. For patients with anterior circulation atherosclerosis, strict adherence to a target HbA1c < 6.5% may be required.

Association of self-measured home, ambulatory, and strictly measured office blood pressure and their variability with intracranial arterial stenosis

OBJECTIVE

Hypertension and intracranial artery stenosis (ICAS) are closely related; however, few studies have compared the strength of the relationship between strictly measured office and out-of-office blood pressure (BP) measurements. The relationship of day-by-day or short-term variability in BP to asymptomatic ICAS also remains unclear.

METHODS

In apparently healthy 677 men (mean age, 70 years) from a population-based cohort, we examined the association of strictly measured office BP and 7-day home BP with ICAS on magnetic resonance angiography. We conducted 24-h ambulatory BP monitoring in 468 of the men. Variability indices included day-by-day, daytime, and night-time variability, nocturnal decline, and morning pressor surge. Any ICAS was defined as either mild (1-49%) or severe (≥50%) stenosis.

RESULTS

We observed mild and severe ICAS in 153 (22.6%) and 36 (5.3%) participants, respectively. In multivariable-adjusted Poisson regression with robust error variance, higher SBP in office, home, or ambulatory BP monitoring was associated with the presence of any or severe ICAS. The associations with ICAS were comparable between office, home, and ambulatory SBP (all heterogeneity P values >0.1). Independent of mean SBP, greater nocturnal decline or morning pressor surge, but not day-by-day, daytime, or night-time variability, in SBP was associated with higher burden of any or severe ICAS.

CONCLUSION

The magnitude of association of strictly measured office BP for asymptomatic ICAS was comparable with that of BP measured at home or in ambulatory BP monitoring. Circadian BP variation based on ambulatory BP monitoring was positively associated with asymptomatic ICAS burden.

Association Between Morning Surge in Systolic Blood Pressure and SYNTAX Score I in Patients With Stable Coronary Artery Disease

A high morning surge in systolic blood pressure poses a risk in people who have cardiovascular disease. We investigated the relationship between this phenomenon and the SYNTAX score I in patients who had stable coronary artery disease. Our single-center study included 125 consecutive patients (109 men and 16 women; mean age, 54.3 ± 9 yr) in whom coronary angiography revealed stable coronary artery disease. We calculated each patient's sleep-trough morning surge in systolic blood pressure, then calculated the SYNTAX score I. The morning surge was significantly higher in patients whose score was >22 (mean, 22.7 ± 13.2) than in those whose score was ≤22 (mean, 12.4 ± 7.5) (P <0.001). Forward stepwise logistic regression analysis revealed that morning surge in systolic blood pressure was the only independent predictor of an intermediate-to-high score (odds ratio=1.183; 95% CI, 1.025-1.364; P=0.021). To our knowledge, this is the first study to show an association between morning surge in systolic blood pressure and the SYNTAX score I in patients who have stable coronary artery disease.

The Association of Morning Surge and Night-Time Dipping Blood Pressure with Significant and Complex Coronary Artery Lesions

INTRODUCTION

Hypertension responsible for more than 10 million deaths annually worldwide and abnormal diurnal blood pressure (BP) variation is associated with cardiovascular events.

AIM

This study aimed to investigate the association between the 24-h ambulatory night BP dipping and morning BP surge (MS) with characteristic of coronary artery lesions that may contribute cardiovascular events and mortality burden.

METHODS

A cross sectional study over 1-year, collected 263 cases of hypertensive (80%) and non-hypertensive patients, aged 61 ± 10 years, who undergoing invasive coronary angiography (CAG) and 24-h ambulatory BP monitoring admitted to cardiology department complain of chest pain. The night-time/day-time dip and sleep-trough MS were calculated. Non-dipper status was considered when night-time/day-time dip < 10%, and significant coronary lesion (SCL) when ≥ 50 % stenosis in 1.5 mm vessels. The SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score was used to quantify the complexity of SCL.

RESULT

The mean morning systolic BP (SBP) surge was higher in the high SYNTAX Score subgroup than low and intermediate subgroups (25 ± 11 vs 17 ± 13 and 10 ± 10 mmHg, p < 0.010). Non-dipper SBP status was more frequently in patients with SCL than non-SCL (p < 0.019). In ordinal regression, hypertension was independent predictor of SCL (odd ratio: 0.40, p < 0.003), the night-time/day-time BP dip was independent predictor of being in a higher SYNTAX score subgroup (systolic odd ratio: 0.88, diastolic odd ratio: 1.14 p < 0.05).

CONCLUSION

Hypertension is associated with SCL and the night-time/day-time BP dip as a continuous variable is associated with complex coronary lesion. Non-dipping as categorical variable and morning BP surge were not independent predictors of significant or complex coronary lesions.

Morning blood pressure surge is associated with the severity of stable coronary artery disease in hypertensive patients

Background: We aimed to investigate the association between morning surge (MS) of blood pressure (BP) and SYNTAX score (SS) which gives information regarding the complexity and extent of coronary artery disease (CAD) in hypertensive patients. Methods: We included 187 hypertensive patients (134 males, 53 females; mean age: 62.5 ± 10.9 years) who underwent elective coronary angiography. Patients with the acute coronary syndrome and a history of coronary intervention were excluded from the study. The MBPS was calculated as the difference between the average BP during the 2 hours after awakening (four BP readings) and the lowest nighttime BP. The severity of coronary lesions was evaluated based on the SS assessed by coronary angiography. Patients were classified into two groups according to SS: low SS (SS ≤ 22) and intermediate-to-high SS (>22).Results: Patients in the intermediate-to-high SS group were found to be older, have higher uric acid levels, average daytime systolic BP (SBP), nighttime SBP, morning SBP, MS of BP and have higher rates of diabetes (DM) and female gender. There was no significant difference in terms of hypertensive treatment. In multivariate analysis, MS of BP (OR: 2.151, p: 0.005) and DM (OR: 0.014, p: 0.015) were independent parameters for predicting intermediate-to-high SS. The cutoff value of MS of BP obtained by ROC curve analysis was 18,5 mmHg for prediction of intermediate-high SS (sensitivity: 76.5%, specificity: 71.2%). The area under the curve was 0.762 (p < .001).Conclusion: MS of BP significantly correlates with the severity of coronary stenosis in hypertensive patients, suggesting that it could be a potential predictive marker of CAD.

Morning blood pressure surge is associated with autonomic neuropathy and peripheral vascular disease in patients with diabetes

Although vascular and autonomic nervous system have been involved in the regulation of morning surge in blood pressure (MBPS), data on clinical correlates of MBPS in diabetic population are scarce, in particular with regard to diabetic complications. This study was aimed at investigating predictors and correlates of MBPS in diabetes. In a cross-sectional study including 167 patients with diabetes (age 58.5 ± 11.1 years, duration 15.9 ± 12.1 years), clinical variables, diabetic and neuropathic complications, and MBPS (using 24-h ambulatory blood pressure monitoring) were measured. The upper quartile of MBPS (>30.5 mmHg) was associated with higher values of waist circumference (P = 0.027), triglycerides (P = 0.021), and Michigan Diabetic Neuropathy Score (P = 0.042), with lower HDL cholesterol (P = 0.030), and with the presence of cardiovascular autonomic neuropathy (CAN) (P = 0.016) and peripheral vascular disease (PVD) (P < 0.0001). In a logistic regression analysis, PVD (odds ratio: 10.2, P = 0.001), CAN (odds ratio: 6.09, P = 0.016), and diastolic blood pressure (BP) (odds ratio: 1.06, P = 0.022) predicted MBPS upper quartile (r² = 0.20, P = 0.0005). In a multiple regression analysis, PVD (P = 0.002) and diastolic BP (P = 0.003) were the only determinants of MBPS (r² = 0.20). MBPS upper quartile was associated with BP dipping (systolic BP day-night reduction > 10%) (P = 0.012), and MBPS was positively related to systolic (rho = 0.41, P < 0.0001) and diastolic BP day-night reduction. In conclusion, metabolic syndrome stigmata, diastolic BP, CAN and PVD are the main predictors of MBPS in the diabetic population. Excessive MBPS and nondipping are not concurrent 24-h BP alterations. Autonomic dysfunction might exert an exacerbating effect on MBPS phenomenon.

Preoperative hypertension is associated with atherosclerotic intraplaque hemorrhage in patients undergoing carotid endarterectomy

BACKGROUND AND AIMS

Both hypertension and atherosclerotic plaque characteristics such as intraplaque hemorrhage (IPH) are associated with cardiovascular events (CVE). It is unknown if hypertension is associated with IPH. Therefore, we studied if hypertension is associated with unstable atherosclerotic plaque characteristics in patients undergoing carotid endarterectomy (CEA).

METHODS

Prospectively collected data of CEA-patients (2002-2014) were retrospectively analyzed. Blood pressure (BP) was the mean of 3 preoperative measurements. Preoperative hypertension was defined as systolic BP ≥ 160 mmHg. Post-CEA, carotid atherosclerotic plaques were analyzed for the presence of calcifications, collagen, smooth muscle cells, macrophages, lipid core, IPH and microvessel density. Associations between BP (systolic and diastolic), patient characteristics and carotid plaque characteristics were assessed with univariate and multivariate analyses with correction for potential confounders. Results were replicated in a cohort of patients that underwent iliofemoral endarterectomy.

RESULTS

Within CEA-patients (n = 1684), 708 (42%) had preoperative hypertension. Increased systolic BP was associated with the presence of plaque calcifications (adjusted OR1.11 [95% CI 1.01-1.22], p = 0.03), macrophages (adjusted OR1.12 [1.04-1.21], p < 0.01), lipid core >10% of plaque area (adjusted OR1.15 [1.05-1.25], p < 0.01), IPH (adjusted OR1.12 [1.03-1.21], p = 0.01) and microvessels (adjusted beta 0.04 [0.00-0.08], p = 0.03). Increased diastolic BP was associated with macrophages (adjusted OR1.36 [1.17-1.58], p < 0.01), lipid core (adjusted OR1.29 [1.10-1.53], p < 0.01) and IPH (adjusted OR1.25 [1.07-1.46], p < 0.01) but not with microvessels nor plaque calcifications. Replication in an iliofemoral-cohort (n = 657) showed that increased diastolic BP was associated with the presence of macrophages (adjusted OR1.78 [1.13-2.91], p = 0.01), lipid core (adjusted OR1.45 [1.06-1.98], p = 0.02) and IPH (adjusted OR1.48 [1.14-1.93], p < 0.01).

CONCLUSIONS

Preoperative hypertension in severely atherosclerotic patients is associated with the presence of carotid plaque macrophages, lipid core and IPH. IPH, as a plaque marker for CVE, is associated with increased systolic and diastolic BP in both the CEA and iliofemoral population.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.

Effect of morning blood pressure peak on early progressive ischemic stroke: a prospective clinical study

OBJECTIVE

To prospectively evaluate the effect of morning blood pressure peak (MBPP) on early progressive ischemic stroke (EPIS).

PATIENTS AND METHODS

A total of 135 patients with acute ischemic stroke were enrolled and completed all assessments. The patients were divided into EPIS group and non-EPIS group, with 22 and 113 cases in each group, respectively, according to the assessment of Scandinavian stroke scale within three days after onset. All cases received conventional treatment for stroke and its risk factors. 24 -h dynamic blood pressure monitoring was performed within 24 h after admission. Based on the 24 -h mean blood pressure, MBPP, morning blood pressure, and other risk factors for EPIS, we conducted a logistic regression analysis to evaluate whether MBPP was an independent risk factor for EPIS.

RESULTS

Mean systolic blood pressure, systolic and diastolic MBPP, morning systolic and diastolic blood pressure were all significantly higher in EPIS group than in non-EPIS group (p = 0.037, p = 0.001, p = 0.035, p = 0.003, p = 0.042, respectively). Logistic regression analysis showed that MBPP was an independent risk factor for EPIS (OR = 1.057, 95% CI 1.014-1.102, p = 0.009). Further stratified analysis showed that incidences of EPIS in patients with elevated MBPP combined with large artery atherosclerosis or small artery occlusion were comparable (41.2% vs. 25.0%, p = 0.367), and the systolic MBPP was significantly higher in morning EPIS group than in non-morning EPIS group (p = 0.041).

CONCLUSION

Elevated systolic MBPP might be an independent risk factor for EPIS, and play a more obvious effect on EPIS manifesting in the morning especially.

Morning surge in blood pressure and blood pressure variability in Asia: Evidence and statement from the HOPE Asia Network

Hypertension is a major risk factor for cardiovascular and cerebrovascular diseases. To effectively prevent end-organ damage, maintain vascular integrity and reduce morbidity and mortality, it is essential to decrease and adequately control blood pressure (BP) throughout each 24-hour period. Exaggerated early morning BP surge (EMBS) is one component of BP variability (BPV), and has been associated with an increased risk of stroke and cardiovascular events, independently of 24-hour average BP. BPV includes circadian, short-term and long-term components, and can best be documented using out-of-office techniques such as ambulatory and/or home BP monitoring. There is a large body of evidence linking both BPV and EMBS with increased rates of adverse cardio- and cerebrovascular events, and end-organ damage. Differences in hypertension and related cardiovascular disease rates have been reported between Western and Asian populations, including a higher rate of stroke, higher prevalence of metabolic syndrome, greater salt sensitivity and more common high morning and nocturnal BP readings in Asians. This highlights a need for BP management strategies that take into account ethnic differences. In general, long-acting antihypertensives that control BP throughout the 24-hour period are preferred; amlodipine and telmisartan have been shown to control EMBS more effectively than valsartan. Home and ambulatory BP monitoring should form an essential part of hypertension management, with individualized pharmacotherapy to achieve optimal 24-hour BP control particularly the EMBS and provide the best cardio- and cerebrovascular protection. Future research should facilitate better understanding of BPV, allowing optimization of strategies for the detection and treatment of hypertension to reduce adverse outcomes.

Lipid and Non-lipid Factors Affecting Macrophage Dysfunction and Inflammation in Atherosclerosis

Atherosclerosis is a chronic inflammatory disease and a leading cause of human mortality. The lesional microenvironment contains a complex accumulation of variably oxidized lipids and cytokines. Infiltrating monocytes become polarized in response to these stimuli, resulting in a broad spectrum of macrophage phenotypes. The extent of lipid loading in macrophages influences their phenotype and consequently their inflammatory status. In response to excess atherogenic ligands, many normal cell processes become aberrant following a loss of homeostasis. This can have a direct impact upon the inflammatory response, and conversely inflammation can lead to cell dysfunction. Clear evidence for this exists in the lysosomes, endoplasmic reticulum and mitochondria of atherosclerotic macrophages, the principal lesional cell type. Furthermore, several intrinsic cell processes become dysregulated under lipidotic conditions. Therapeutic strategies aimed at restoring cell function under disease conditions are an ongoing coveted aim. Macrophages play a central role in promoting lesional inflammation, with plaque progression and stability being directly proportional to macrophage abundance. Understanding how mixtures or individual lipid species regulate macrophage biology is therefore a major area of atherosclerosis research. In this review, we will discuss how the myriad of lipid and lipoprotein classes and products used to model atherogenic, proinflammatory immune responses has facilitated a greater understanding of some of the intricacies of chronic inflammation and cell function. Despite this, lipid oxidation produces a complex mixture of products and with no single or standard method of derivatization, there exists some variation in the reported effects of certain oxidized lipids. Likewise, differences in the methods used to generate macrophages in vitro may also lead to variable responses when apparently identical lipid ligands are used. Consequently, the complexity of reported macrophage phenotypes has implications for our understanding of the metabolic pathways, processes and shifts underpinning their activation and inflammatory status. Using oxidized low density lipoproteins and its oxidized cholesteryl esters and phospholipid constituents to stimulate macrophage has been hugely valuable, however there is now an argument that only working with low complexity lipid species can deliver the most useful information to guide therapies aimed at controlling atherosclerosis and cardiovascular complications.

Morning blood pressure surge: pathophysiology, clinical relevance and therapeutic aspects

Morning hours are the period of the day characterized by the highest incidence of major cardiovascular events including myocardial infarction, sudden death or stroke. They are also characterized by important neurohormonal changes, in particular, the activation of sympathetic nervous system which usually leads to a rapid increase in blood pressure (BP), known as morning blood pressure surge (MBPS). It was hypothesized that excessive MBPS may be causally involved in the pathogenesis of cardiovascular events occurring in the morning by inducing hemodynamic stress. A number of studies support an independent relationship of MBPS with organ damage, cerebrovascular complications and mortality, although some heterogeneity exists in the available evidence. This may be due to ethnic differences, methodological issues and the confounding relationship of MBPS with other features of 24-hour BP profile, such as nocturnal dipping or BP variability. Several studies are also available dealing with treatment effects on MBPS and indicating the importance of long-acting antihypertensive drugs in this regard. This paper provides an overview of pathophysiologic, methodological, prognostic and therapeutic aspects related to MBPS.

Coordination of cardiac rhythmic output and circadian metabolic regulation in the heart

Over the course of a 24-h day, demand on the heart rises and falls with the sleep/wake cycles of the organism. Cardiac metabolism oscillates appropriately, with the relative contributions of major energy sources changing in a circadian fashion. The cardiac peripheral clock is hypothesized to drive many of these changes, yet the precise mechanisms linking the cardiac clock to metabolism remain a source of intense investigation. Here we summarize the current understanding of circadian alterations in cardiac metabolism and physiology, with an emphasis on novel findings from unbiased transcriptomic studies. Additionally, we describe progress in elucidating the links between the cardiac peripheral clock outputs and cardiac metabolism, as well as their implications for cardiac physiology.

High morning blood pressure surge is associated with oxidative stress and paraoxonase 1 activity in newly diagnosed hypertensive patients

BACKGROUND

Both oxidative stress and morning surge (MS) of blood pressure (BP) were found to be closely related with cardiovascular and cerebrovascular diseases. We investigated the association between MS of BP and oxidative stress in newly diagnosed hypertensive patients.

METHODS

We prospectively included 237 newly diagnosed hypertensive patients in the present study (mean age: 51.6 ± 11.7 years). The patients were classified according to the extent of the sleep-through surge as follows: the top decile of sleep-through surge (>47.2 mmHg, n = 27; EMShigh group), versus all others (n = 210, EMSlow group). Total antioxidant capacity (TAC) and total oxidant status (TOS) levels were determined by using an automated measurement method. The oxidative stress index (OSI) was calculated as the ratio of TOS to TAC. Serum paraoxonase 1 (PON-1) activity was measured spectrophotometrically.

RESULTS

Patients in EMShigh group were found to have higher hs-CRP, TOS, and OSI values and lower TAC and PON-1 values (p < 0.01, for all). MS of BP was associated with hs-CRP, PON-1, TOS, TAC, and OSI levels in bivariate analysis. Multivariate linear regression analysis showed that MS of BP was significantly associated with PON-1(β = -0.206, p < 0.001), OSI (β = 0.602, p < 0.001) and hs-CRP (β = 0.210, p < 0.001).

CONCLUSION

Present study shows that OSI is increased and antioxidant PON-1 activity is decreased in patients with enhanced MS of BP. There is a close association between high MS of BP and oxidative stress markers in newly diagnosed hypertensive patients.

Magnitude of Morning Surge in Blood Pressure Is Associated with Sympathetic but Not Cardiac Baroreflex Sensitivity

The ability of the arterial baroreflex to regulate blood pressure may influence the magnitude of the morning surge in blood pressure (MSBP). The aim was to investigate the relationships between sympathetic and cardiac baroreflex sensitivity (BRS) and the morning surge. Twenty-four hour ambulatory blood pressure was recorded in 14 young individuals. The morning surge was defined via the pre-awakening method, which is calculated as the difference between mean blood pressure values 2 h before and 2 h after rising from sleep. The mean systolic morning surge, diastolic morning surge, and morning surge in mean arterial pressures were 15 ± 2, 13 ± 1, and 11 ± 1 mmHg, respectively. During the laboratory protocol, continuous measurements of blood pressure, heart rate, and muscle sympathetic nerve activity (MSNA) were made over a 10-min period of rest. Sympathetic BRS was quantified by plotting MSNA burst incidence against diastolic pressure (sympathetic BRS_inc), and by plotting total MSNA against diastolic pressure (sympathetic BRS_total). Cardiac BRS was quantified using the sequence method. The mean values for sympathetic BRS_inc, sympathetic BRS_total and cardiac BRS were −1.26 ± 0.26 bursts/100 hb/mmHg, −1.60 ± 0.37 AU/beat/mmHg, and 13.1 ± 1.5 ms/mmHg respectively. Significant relationships were identified between sympathetic BRS_inc and the diastolic morning surge (r = 0.62, p = 0.02) and the morning surge in mean arterial pressure (r = 0.57, p = 0.03). Low sympathetic BRS was associated with a larger morning surge in mean arterial and diastolic blood pressure. Trends for relationships were identified between sympathetic BRS_total and the diastolic morning surge (r = 0.52, p = 0.066) and the morning surge in mean arterial pressure (r = 0.48, p = 0.095) but these did not reach significance. There were no significant relationships between cardiac BRS and the morning surge. These findings indicate that the ability of the baroreflex to buffer increases in blood pressure via reflexive changes in MSNA may play a role in determining the magnitude of the MSBP.

Association between glycemic control and morning blood surge with vascular endothelial dysfunction in type 2 diabetes mellitus patients

OBJECTIVE

Morning blood pressure surge (MBPS) is an independent predictor of cardiovascular events. However, little is known about the association between glycemic control and MBPS, and its effect on vascular injury in patients with type 2 diabetes mellitus (T2DM). The current study examined the association between glycemic control and MBPS and the involvement of MBPS in the development of vascular dysfunction in T2DM patients.

MATERIALS AND METHODS

One hundred and twenty-two consecutive T2DM outpatients from the Department of Cardiology and Endocrinology were enrolled in this study. We did MBPS in T2DM patients, 85 (male) (69.7%) patients and 37 (female) patients (30.3%); mean age 60.1 ± 9.39; (n = 122) using 24 h ambulatory blood pressure monitoring and assessed vascular function by brachial artery flow-mediated dilation (FMD) and nitroglycerin-mediated dilation (NMD).

RESULTS

The correlation between MBPS and various clinical variables were examined by single regression analysis in all subjects. MBPS showed significant and positive correlation with pulse rate (P = 0.01), fasting blood sugar (P = 0.002), and postprandial blood sugar (P = 0.05). To further confirm the association of insulin resistance (IR) with MBPS in T2DM patients, we examined the correlation between homeostasis model assessment-IR (HOMA-IR), an established marker of IR and MBPS in diabetic (DM) patients who were not taking insulin no significant association with MBPS in T2DM patients (P = 0.41), angiotensin-converting enzyme/angiotensin receptor blocker (P = 0.07). We examined the relationship between MBPS and vascular injury by measuring endothelium-dependent FMD and endothelium-independent NMD in T2DM patients. Among the various traditional risk factors for atherosclerosis such as DM duration (P = 0.04), platelet reactivity (P = 0.04) and morning surge (P = 0.002) emerged as significant factors. HOMA-IR was a negative correlation with FMD.

CONCLUSIONS

The current study demonstrated that poor glycemic control and IR have predictive value for the occurrence of MBPS in T2DM patients, which might be significantly associated with endothelial dysfunction.

Morning blood pressure surge and target organ damage in newly diagnosed type 2 diabetic patients: a cross sectional study

BACKGROUND

Type 2 diabetic patients display significantly higher incidence of cardiovascular (CV) events including stroke compared to non-diabetics. Morning blood pressure surge (MBPS) and blunted systolic night-day (SND) ratio have been associated with CV events in hypertensive patients. No studies have evaluated MBPS in newly diagnosed diabetic patients or studied the association with vascular target organ damage at this early time point of the diabetes disease.

METHODS

Ambulatory blood pressure monitoring was performed in 100 patients with newly diagnosed type 2 diabetes and 100 age and sex matched controls. MBPS and SND-ratio were calculated. Markers of early vascular target organ damage included pulse wave velocity (PWV), white matter lesions (WML) on brain MRI, and urine albumin/creatinine ratio (UAE).

RESULTS

No significant differences in MBPS were found between diabetic patients and controls. Neither MBPS or SND-ratio were associated with PWV, UAE or WML in the diabetic group independently of age, gender and 24-h systolic blood pressure. 40.2 % of diabetic patients and 25.8 % of controls were classified as non-dippers (p = 0.03).

CONCLUSION

MBPS and SND-ratio are not associated with subclinical markers of vascular target organ damage in our study sample of newly diagnosed type 2 diabetic patients.

Ethnic Differences in the Degree of Morning Blood Pressure Surge and in Its Determinants Between Japanese and European Hypertensive Subjects

Morning blood pressure (BP) surge has been reported to be a prognostic factor for cardiovascular events. Its determinants are still poorly defined, however. In particular, it is not clear whether ethnic differences play a role in determining morning surge (MS) size. Aim of our study was to explore whether differences exist in the size of MS between Japanese and Western European hypertensive patients. We included 2887 untreated hypertensive patients (age 62.3±8.8 years) from a European ambulatory BP monitoring database and 811 hypertensive patients from a Japanese database (Jichi Medical School Ambulatory Blood Pressure Monitoring WAVE1, age 72.3±9.8 years) following the same inclusion criteria. Their 24-hour ambulatory BP monitoring recordings were analyzed focusing on MS. Sleep-trough MS was defined as the difference between mean systolic BP during the 2 hours after awakening and mean systolic BP during the 1-hour night period that included the lowest sleep BP level. The sleep-trough MS was higher in Japanese than in European hypertensive patients after adjusting for age and 24-hour mean BP levels (40.1 [95% confidence interval 39.0–41.2] versus 23.0 [22.4–23.5] mm Hg; P <0.001). This difference remained significant after accounting for differences in night-time BP dipping. Age was independently associated with MS in the Japanese database, but not in the European subjects. Our results for the first time show the occurrence of substantial ethnic differences in the degree of MS. These findings may help in understanding the role of ethnic factors in cardiovascular risk assessment and in identifying possible ethnicity-related differences in the most effective measures to be implemented for prevention of BP-related cardiovascular events.

[Low-grade systemic inflammation and the development of metabolic diseases: from the molecular evidence to the clinical practice]

BACKGROUND

Systemic inflammation is characterised by high circulating levels of inflammatory cytokines and increased macrophage infiltration in peripheral tissues. Most importantly, this inflammatory state does not involve damage or loss of function of the infiltrated tissue, which is a distinctive feature of the low-grade systemic inflammation. The term "meta-inflammation" has also been used to refer to the low-grade systemic inflammation due to its strong relationship with the development of cardio-metabolic diseases in obesity.

OBJECTIVE

A review is presented on the recent clinical and experimental evidence concerning the role of adipose tissue inflammation as a key mediator of low-grade systemic inflammation. Furthermore, the main molecular mechanisms involved in the inflammatory polarization of macrophages with the ability to infiltrate both the adipose tissue and the vascular endothelium via activation of toll-like receptors by metabolic damage-associated molecular patterns, such as advanced glycation-end products and oxidized lipoproteins, is discussed. Finally, a review is made of the pathogenic mechanisms through which the low-grade systemic inflammation contributes to develop insulin resistance, dyslipidaemia, atherogenesis, type 2 diabetes, and hypertension in obese individuals.

CONCLUSIONS

A better understanding of the molecular mechanisms of low-grade systemic inflammation in promoting cardio-metabolic diseases is necessary, in order to further design novel anti-inflammatory therapies that take into consideration clinical data, as well as the circulating levels of cytokines, immune cells, and metabolic damage-associated molecular patterns in each patient.

Blood pressure morning surge, exercise blood pressure response and autonomic nervous system

OBJECTIVE

We investigated blood pressure (BP) response to exercise with respect to BP morning surge (MS), and the association between MS, exercise treadmill test (ETT) and heart rate variability (HRV) indices.

DESIGN

Eighty-four healthy subjects without hypertension were enrolled. Ambulatory BP monitoring and 24-hour Holter recordings were obtained for sleep-trough MS and HRV indices: low-frequency (LF) component, high-frequency (HF) component and LF/HF ratio. ETT was performed, and BPs were obtained at rest, end of each stage, and recovery. Third-minute heart rate recovery (HRR) and BP recovery ratio (BPRR) were calculated.

RESULTS

When analysed in quartiles of MS, systolic BP at low workloads was higher in the highest than in the lowest quartile, although maximum BPs at maximum exercise were not significantly different. BPRR was highest in the highest quartile in contrast to HRR, which was lowest in the highest quartile. LF/HF was highest during both at daytime and night-time in the highest quartile. BPRR and LF/HF were positively, and HRR was inversely associated with MS.

CONCLUSIONS

Subjects with a high MS have higher BP at low workloads, at which most daily activities are performed, and impairment in some indices, which indirectly reflect the autonomic nervous system.

Effect of azilsartan versus candesartan on morning blood pressure surges in Japanese patients with essential hypertension

Morning blood pressure (BP) surge is reported as a risk factor for cardiovascular events and end-organ damage independent of the 24-h BP level. Controlling morning BP surge is therefore important to help prevent onset of cardiovascular disease. We compared the efficacy of azilsartan and candesartan in controlling morning systolic BP (SBP) surges by analyzing relevant ambulatory BP monitoring data in patients with/without baseline BP surges. As part of a 16-week randomized, double-blind study of azilsartan (20-40 mg once daily) and candesartan (8-12 mg once daily) in Japanese patients with essential hypertension, an exploratory analysis was carried out using ambulatory BP monitoring at baseline and week 14. The effects of study drugs on morning BP surges, including sleep trough surge (early morning SBP minus the lowest night-time SBP) and prewaking surge (early morning SBP minus SBP before awakening), were evaluated. Patients with sleep trough surge of at least 35 mmHg were defined by the presence of a morning BP surge (the 'surge group'). Sleep trough surge and prewaking surge data were available at both baseline and week 14 in 548 patients, 147 of whom (azilsartan 76; candesartan 71) had a baseline morning BP surge. In surge group patients, azilsartan significantly reduced both the sleep trough surge and the prewaking surge at week 14 compared with candesartan (least squares means of the between-group differences -5.8 mmHg, P=0.0395; and -5.7 mmHg, P=0.0228, respectively). Once-daily azilsartan improved sleep trough surge and prewaking surge to a greater extent than candesartan in Japanese patients with grade I-II essential hypertension.

Targeting the ubiquitin-proteasome system in atherosclerosis: status quo, challenges, and perspectives

SIGNIFICANCE

Atherosclerosis is a vascular disease of worldwide significance with fatal complications such as myocardial infarction, stroke, and peripheral artery disease. Atherosclerosis is recognized as a chronic inflammatory disease leading to arterial plaque formation and vessel narrowing in different vascular beds. Besides the strong inflammatory nature of atherosclerosis, it is also characterized by proliferation, apoptosis, and enhanced oxidative stress. The ubiquitin-proteasome system (UPS) is the major intracellular degradation system in eukaryotic cells. Besides its essential role in the degradation of dysfunctional and oxidatively damaged proteins, it is involved in many processes that influence disease progression in atherosclerosis. Hence, it is logical to ask whether targeting the proteasome is a reasonable and feasible option for the treatment of atherosclerosis.

RECENT ADVANCES

Several lines of evidence suggest stage-specific dysfunction of the UPS in atherogenesis. Regulation of key processes by the proteasome in atherosclerosis, as well as the modulation of these processes by proteasome inhibitors in vascular cells, is outlined in this review. The treatment of atherosclerotic animal models with proteasome inhibitors yielded partly opposing results, the potentially underlying reasons of which are discussed here.

CRITICAL ISSUES AND FUTURE DIRECTIONS

Targeting UPS function in atherosclerosis is a promising but challenging option. Limitations of current proteasome inhibitors, dose dependency, and the cell specificity of effects, as well as the potential of future therapeutics are discussed. A stage-specific in-depth exploration of UPS function in atherosclerosis in the future will help identify targets and windows for beneficial intervention.

Role of the ubiquitin-proteasome system in cardiac dysfunction of adipose triglyceride lipase-deficient mice

Systemic deletion of the gene encoding for adipose triglyceride lipase (ATGL) in mice leads to severe cardiac dysfunction due to massive accumulation of neutral lipids in cardiomyocytes. Recently, impaired peroxisome proliferator-activated receptor α (PPARα) signaling has been described to substantially contribute to the observed cardiac phenotype. Disturbances of the ubiquitin-proteasome system (UPS) have been implicated in numerous cardiac diseases including cardiomyopathy, ischemic heart disease, and heart failure. The objective of the present study was to investigate the potential role of UPS in cardiac ATGL deficiency. Our results demonstrate prominent accumulation of ubiquitinated proteins in hearts of ATGL-deficient mice, an effect that was abolished upon cardiomyocyte-directed overexpression of ATGL. In parallel, cardiac protein expression of the ubiquitin-activating enzyme E1a, which catalyzes the first step of the ubiquitination cascade, was significantly upregulated in ATGL-deficient hearts. Dysfunction of the UPS was accompanied by activation of NF-κB signaling. Moreover, the endoplasmic reticulum (ER)-resident chaperon protein disulfide isomerase was significantly upregulated in ATGL-deficient hearts. Chronic treatment of ATGL-deficient mice with the PPARα agonist Wy14,643 improved proteasomal function, prevented NF-κB activation and decreased oxidative stress. In summary, our data point to a hitherto unrecognized link between proteasomal function, PPARα signaling and cardiovascular disease.

Morning blood pressure surge, dipping, and risk of ischemic stroke in elderly patients treated for hypertension

BACKGROUND

The independent prognostic significance of morning surge (MS) in blood pressure (BP) is not yet clear. We investigated the association between MS in systolic BP (SBP) and risk of ischemic stroke in elderly patients treated for hypertension.

METHODS

Occurrence of ischemic stroke was evaluated in 1,191 elderly patients treated for hypertension (aged 60-90 years). Patients were divided according to tertiles of MS in SBP in the population as a whole, dipping status, and group-specific tertiles of MS in SBP in dippers and nondippers.

RESULTS

During follow-up (9.1±4.9 years, range 0.4-20 years), 139 ischemic strokes occurred. The event rate per 100 patient-years was 1.28. After adjustment for various covariates, Cox regression analysis showed that stroke risk was not significantly associated with tertiles of MS in SBP in the population as a whole. When nondippers and dippers were analyzed separately by group-specific tertiles of MS in SBP, stroke risk was not associated with MS in nondippers. Conversely, in dippers, stroke risk was significantly higher in the third tertile (>23mm Hg) of MS in SBP (hazard ratio, 2.08; 95% confidence interval, 1.03-4.23; P = 0.04). Additional analysis showed that stroke risk was significantly and similarly higher in dippers with MS >23mm Hg and in nondippers than in dippers with MS <23mm Hg.

CONCLUSIONS

In elderly patients treated for hypertension, high MS in SBP predicts stroke in dippers but not in nondippers. Nondippers are at high stroke risk with or without MS >23mm Hg.

Association between glycemic control and morning blood pressure surge with vascular endothelial dysfunction in type 2 diabetic patients

OBJECTIVE

Morning blood pressure surge (MBPS) is an independent predictor of cardiovascular events. However, little is known about the association between glycemic control and MBPS, and its effect on vascular injury in patients with type 2 diabetes mellitus (T2DM). The current study examined the association between glycemic control and MBPS, and the involvement of MBPS in the development of vascular dysfunction in T2DM patients.

RESEARCH DESIGN AND METHODS

We examined MBPS in T2DM patients (25 male patients/25 female patients; mean age, 60.1 ± 13.2 years; n = 50) using 24-h ambulatory blood pressure monitoring, and assessed vascular function by brachial artery flow-mediated dilation (FMD) and nitroglycerin-mediated dilation (NMD).

RESULTS

HbA1c (ρ = 0.373, P = 0.009) and triglyceride (TG) (ρ = 0.375, P = 0.009) levels correlated significantly and positively with MBPS. In multiple regression analysis, including TG and HbA1c levels in addition to age and 24-h systolic blood pressure (SBP) as independent variables, HbA1c (β = 0.328, P = 0.016) and TG (β = 0.358, P = 0.014) were associated significantly in a positive manner with MBPS. In a noninsulin user, when homeostasis model assessment ratio (HOMA-R) was included in place of TG, HOMA-R emerged as a significant factor. MBPS (ρ = -0.289, P = 0.043) and HbA1c (ρ = -0.301, P = 0.035) correlated significantly and negatively with FMD, whereas 24-h SBP correlated with both FMD (ρ = -0.359, P = 0.012) and NMD (ρ = -0.478, P = 0.004). In multiple regression analysis, including age, gender, 24-h SBP, MBPS, LDL cholesterol, and HbA1c, MBPS (β = -0.284, P = 0.044) alone associated significantly in a negative manner with FMD, but not with NMD.

CONCLUSIONS

The current study demonstrated that poor glycemic control and insulin resistance are independently associated with the occurrence of MBPS in T2DM patients, which might be significantly associated with endothelial dysfunction.

Circadian control of the immune system

Circadian rhythms, which have long been known to play crucial roles in physiology, are emerging as important regulators of specific immune functions. Circadian oscillations of immune mediators coincide with the activity of the immune system, possibly allowing the host to anticipate and handle microbial threats more efficiently. These oscillations may also help to promote tissue recovery and the clearance of potentially harmful cellular elements from the circulation. This Review summarizes the current knowledge of circadian rhythms in the immune system and provides an outlook on potential future implications.