Native Aortic Valve Endocarditis Secondary to Gastric Antral Vascular Ectasia Manipulation During Endoscopic Argon Plasma Coagulation

Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal (GI) bleeds. Due to the high vascularity of the region, transient bacteremia due to manipulation of the GI tract can very rarely cause the translocation of bacteria. We present a rare case in which endoscopic manipulation to treat GAVE led to native valve infective endocarditis (IE). Our patient had a prior history of GAVE and presented with worsening dizziness and shortness of breath (SOB). After an esophagogastroduodenoscopy (EGD) and subsequent argon plasma coagulation (APC) for active preantral bleeding, the patient was noted to have repeated fevers, a new cardiac murmur, and positive blood cultures for Staphylococcus epidermidis, leading to a diagnosis of native infective endocarditis. With high clinical suspicion and early recognition of a new cardiac murmur, a transesophageal echocardiogram (TEE) was key in identifying vegetation. This case highlights the importance of combining history, a physical exam, and diagnostic lab tests and imaging to identify endocarditis. Management included two months of intravenous (IV) vancomycin and repeat TEE for close monitoring of vegetation improvement.

Characterization of Myocardial Injury in Patients With COVID-19

BACKGROUND

Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial injury remain unclear and prior studies have not reported cardiovascular imaging data.

OBJECTIVES

This study sought to characterize the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19.

METHODS

We conducted an international, multicenter cohort study including 7 hospitals in New York City and Milan of hospitalized patients with laboratory-confirmed COVID-19 who had undergone transthoracic echocardiographic (TTE) and electrocardiographic evaluation during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin at the time of clinical presentation or during the hospitalization.

RESULTS

A total of 305 patients were included. Mean age was 63 years and 205 patients (67.2%) were male. Overall, myocardial injury was observed in 190 patients (62.3%). Compared with patients without myocardial injury, those with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities that included left ventricular wall motion abnormalities, global left ventricular dysfunction, left ventricular diastolic dysfunction grade II or III, right ventricular dysfunction and pericardial effusions. Rates of in-hospital mortality were 5.2%, 18.6%, and 31.7% in patients without myocardial injury, with myocardial injury without TTE abnormalities, and with myocardial injury and TTE abnormalities. Following multivariable adjustment, myocardial injury with TTE abnormalities was associated with higher risk of death but not myocardial injury without TTE abnormalities.

CONCLUSIONS

Among patients with COVID-19 who underwent TTE, cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Myocardial injury was associated with increased in-hospital mortality particularly if echocardiographic abnormalities were present.

Right Atrial Vacuum-Assisted Thrombectomy: Single-Center Experience

BACKGROUND

Right heart thrombus in the absence of structural heart disease, atrial fibrillation, or intracardiac catheter is rare. It typically represents a thrombus migrating from the venous system to the lung, known as thrombi-in-transit, and can lead to a life-threatening pulmonary embolism. The optimal therapy for thrombi-in-transit remains controversial. We report our experience using percutaneous removal of right heart thrombus using vacuum aspiration.

METHODS

Patients with right atrial mass who were hemodynamically stable and underwent vacuum thombectomy using the AngioVac system (AngioDynamics) at our institution were included in this analysis. Between December 2012 and August 2014, a total of 7 patients (2 men, 5 women) with a mean age of 51.5 years (range, 20-83 years) underwent right atrial thrombectomy. Data during the procedure and follow-up period were collected and analyzed.

RESULTS

All patients were hemodynamically stable before the procedure. The procedure was considered successful in 6 patients. All patients survived through hospitalization. No periprocedural bleeding, stroke, or myocardial infarction occurred. One patient developed cardiogenic shock after the procedure that required extracorporeal membrane oxygenation support for <24 hours. There was no recurrent venous thromboembolism at a mean follow-up of 9 months.

CONCLUSION

Vacuum-assisted thrombectomy can be a potential treatment option for hemodynamically stable patients with large right-sided intracardiac thrombus who are not surgical candidates.

Successful first-in-man percutaneous transapical-transseptal Melody mitral valve-in-ring implantation after complicated closure of a para-annular ring leak

AIMS

Transcatheter techniques can theoretically be applied to the treatment of para-annular ring (PAR) leaks. Little is known about their potential application and resultant complications in such cases. We describe the first-in-man percutaneous transapical-transseptal Melody valve-in-ring (ViR) implantation after a complication from percutaneous PAR leak closure.

METHODS AND RESULTS

A 49-year-old woman, at high operative risk, presented with congestive heart failure secondary to severe para-ring/extravalvular regurgitation two months after bypass surgery and mitral ring annuloplasty. Successful percutaneous closure of the leak was performed using an AMPLATZER Vascular Plug IV. One month later, she developed haemolysis with severe PAR regurgitation, through and around the device. After device retrieval and placement of an AMPLATZER Muscular VSD occluder, the patient developed severe intravalvular regurgitation. Completely percutaneous, transseptal delivery of a Melody ViR was performed over a transapical-transseptal, arteriovenous rail. Echocardiography revealed trivial residual regurgitation through the implanted valve with mild transvalvular gradients.

CONCLUSIONS

Percutaneous closure of mitral PAR leaks after ring annuloplasty in the high-risk patient is feasible (proof-of-concept), particularly when the leak is para-ring/extravalvular. Potential complications include severe intravalvular mitral regurgitation caused by disruption of the mitral apparatus and/or ring deformation during device deployment, which can be successfully treated via percutaneous transapical-transseptal ViR implantation.

Guidance of post myocardial infarction ventricular septal defect and pseudoaneurysm closure

Left ventricular pseudoaneurysm and ventricular septal defect are rare but devastating complications of myocardial infarction. With medical treatment alone, the majority of patients will die from these complications. Until recently, the recommended treatment was surgical closure. These surgeries carried extreme risk due to abnormal hemodynamics, necrotic substrates and the comorbidities of these patients. Recently, trans-catheter closure was shown to be an acceptable alternative to open surgical intervention. 3D echocardiography identifies the location, size, and shape of the defect and can assess, guide, and follow up the closure procedure.

CT angiography-fluoroscopy fusion imaging for percutaneous transapical access

OBJECTIVES

The aim of this proof-of-principle study is to validate the accuracy of fusion imaging for percutaneous transapical access (TA).

BACKGROUND

Structural heart disease interventions, including TA, are commonly obtained under fluoroscopic guidance, which lacks important spatial information. Computed tomographic angiography (CTA)-fluoroscopy fusion imaging can provide the 3-dimensional information necessary for improved accuracy in planning and guidance of these interventions.

METHODS

Twenty consecutive patients scheduled for percutaneous left ventricular puncture and device closure using CTA-fluoroscopy fusion guidance were prospectively recruited. The HeartNavigator software (Philips Healthcare, Best, the Netherlands) was used to landmark the left ventricular epicardium for TA (planned puncture site [PPS]). The PPS landmark was compared with the position of the TA closure device on post-procedure CTA (actual puncture site). The distance between the PPS and actual puncture site was calculated from 2 fixed reference points (left main ostium and mitral prosthesis center) in 3 planes (x, y, and z). The distance from the left anterior descending artery at the same z-plane was also assessed. TA-related complications associated with fusion imaging were recorded.

RESULTS

The median (interquartile range [IQR]) TA distance difference between the PPS and actual puncture site from the referenced left main ostium and mitral prosthesis center was 5.00 mm (IQR: 1.98 to 12.64 mm) and 3.27 mm (IQR: 1.88 to 11.24 mm) in the x-plane, 4.48 mm (IQR: 1.98 to 13.08 mm) and 4.00 mm (IQR: 1.62 to 11.86 mm) in the y-plane, and 5.57 mm (IQR: 3.89 to 13.62 mm) and 4.96 mm (IQR: 1.92 to 11.76 mm) in the z-plane. The mean TA distance to the left anterior descending artery was 15.5 ± 7.8 mm and 22.7 ± 13.7 mm in the x- and y-planes. No TA-related complications were identified, including evidence of coronary artery laceration.

CONCLUSIONS

With the use of CTA-fluoroscopy fusion imaging to guide TA, the actual puncture site can be approximated near the PPS. Moreover, fusion imaging can help maintain an adequate access distance from the left anterior descending artery, thereby, potentially reducing TA-related complications.

Review of surgical prosthetic paravalvular leaks: diagnosis and catheter-based closure

Paravalvular leak (PVL) is an uncommon yet serious complication associated with surgical prosthetic valve implantation. Paravalvular leak can have significant clinical consequence such as congestive heart failure, haemolytic anaemia, and infective endocarditis. Recently, transcatheter therapy has been applied to the treatment of this disorder with reasonable procedural and clinical success. This review discusses the current state of PVLs, the utilization of multi-modality imaging in their diagnosis and treatment, and the available therapeutic options. Further aim of this review is to examine transcatheter therapy of PVLs including the principles, outcomes, and procedural-related complications.

Catheter-based left atrial appendage occlusion procedure: role of echocardiography

Atrial fibrillation is a common, clinically significant arrhythmic disorder that results in increased risk of morbidity and mortality in affected patients. Atrial fibrillation is more prevalent among men compared with women and the risk for developing atrial fibrillation increases with advancing age. Ischaemic stroke is the most common clinical manifestation of embolic events from atrial fibrillation. While anticoagulation treatment is the preferred treatment, unfortunately, many patients have contraindications for anticoagulation treatment making this option unavailable to them. Previous data have shown that most thrombi that form in association with non-valvular atrial fibrillation occur in the left atrial appendage (LAA). It has been suggested that isolating the LAA from the body of the left atrium might reduce the risk of embolic events and that LAA obliteration may be a treatment option for patients with atrial fibrillation who are not candidates for anticoagulation treatment. Several procedures have been developed for isolation of the LAA, including surgical procedures as well as catheter-based ones. In this paper, we will review the currently available techniques, emphasizing the catheter-based ones. We will examine the increasing role of real-time three-dimensional transoesophageal echocardiography for appropriate screening and patient selection for these procedures, intra-procedural guidance, and follow-up care.

Evaluation of a posterior mitral valve leaflet aneurysm by real time three-dimensional transesophageal echocardiography

Posterior mitral valve (MV) leaflet aneurysms are extremely rare complications of infective endocarditis (IE). When MV aneurysms occur, they usually involve the anterior leaflet. Real time three-dimensional transesophageal echocardiography (RT3D TEE) has been recently developed and provides views of unparalleled quality by optimizing visualization of spatial relationships. We present a rare case of a posterior MV leaflet aneurysm due to IE in a 64-year-old woman, best visualized by RT3D TEE.

Use of real time three-dimensional transesophageal echocardiography in intracardiac catheter based interventions

BACKGROUND

Real-time three-dimensional (RT3D) echocardiography is a recently developed technique that is being increasingly used in echocardiography laboratories. Over the past several years, improvements in transducer technologies have allowed development of a full matrix-array transducer that allows acquisition of pyramidal-shaped data sets. These data sets can be processed online and offline to allow accurate evaluation of cardiac structures, volumes, and mass. More recently, a transesophageal transducer with RT3D capabilities has been developed. This allows acquisition of high-quality RT3D images on transesophageal echocardiography (TEE). Percutaneous catheter-based procedures have gained growing acceptance in the cardiac procedural armamentarium. Advances in technology and technical skills allow increasingly complex procedures to be performed using a catheter-based approach, thus obviating the need for open-heart surgery.

METHODS

The authors used RT3D TEE to guide 72 catheter-based cardiac interventions. The procedures included the occlusion of atrial septal defects or patent foramen ovales (n=25), percutaneous mitral valve repair (e-valve clipping; n=3), mitral balloon valvuloplasty for mitral stenosis (n=10), left atrial appendage obliteration (n=11), left atrial or pulmonary vein ablation for atrial fibrillation (n=5), percutaneous closures of prosthetic valve dehiscence (n=10), percutaneous aortic valve replacement (n=6), and percutaneous closures of ventricular septal defects (n=2). In this review, the authors describe their experience with this technique, the added value over multiplanar two-dimensional TEE, and the pitfalls that were encountered.

RESULTS

The main advantages found for the use RT3D TEE during catheter-based interventions were (1) the ability to visualize the entire lengths of intracardiac catheters, including the tips of all catheters and the balloons or devices they carry, along with a clear depiction of their positions in relation to other cardiac structures, and (2) the ability to ability to demonstrate certain structures in an "en face" view, which is not offered by any other currently available real-time imaging technique, enabling appreciation of the exact nature of the lesion that is undergoing intervention.

CONCLUSION

RT3D TEE is a powerful new imaging tool that may become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based procedures.

Non-Doppler two dimensional strain imaging for evaluation of coronary artery disease

Over the recent years, strain echocardiography has emerged as a quantitative technique for the evaluation of global and segmental cardiac function. Strain is a measure of deformation, expressed as a percent change in a segment's length compared to its predeformation length. Strain rate (SR) is the local rate of deformation or strain per unit time. Recently non-Doppler two dimensional strain imaging has been developed. This technique is based on tracking ultrasonic speckles from the two dimensional echocardiographic images. These speckles are followed over a number of successive frames, and myocardial velocity is calculated by measuring frame-to-frame changes. This technique is independent of the Doppler angle of incidence and allows measurement of several vectors of strain within myocardial tissue. Non-Doppler strain is a powerful tool, enabling detection of subtle abnormalities in myocardial function. Current evidence shows that non-Doppler strain imaging may allow identification of the early changes that occur with ischemic insult to the myocardium. It may also provide a tool for identification of scarred, non-viable myocardium, with similar accuracy to that of cardiac MRI. Non-Doppler strain imaging is likely to become a standard tool in the evaluation of patients with ischemic heart disease.

Real-time 3-dimensional transesophageal echocardiography in the evaluation of post-operative mitral annuloplasty ring and prosthetic valve dehiscence

OBJECTIVES

This study sought to assess the use of real-time (RT) 3-dimensional (3D) transthoracic and transesophageal echocardiography (TEE) in the evaluation of post-operative mitral valve dehiscence.

BACKGROUND

Mitral valve replacement or repair may be complicated by post-operative dehiscence of the valve or annuloplasty ring resulting in clinically significant mitral regurgitation or hemolysis. Diagnosis is generally performed using 2-dimensional transthoracic echocardiography and TEE. Recently, an RT 3D TEE probe has been developed to produce high-quality real-time images.

METHODS

We used RT 3D TEE to evaluate mitral regurgitation after mitral valve repair or replacement as a result of mitral ring dehiscence. We studied the additional information and diagnostic utility provided by RT 3D TEE.

RESULTS

Eighteen patients were studied (8 patients after repair and 10 after replacement). Real-time 3D TEE allowed accurate evaluation of the pathology, including definition of the type of ring or prosthesis used; description of the site, size, shape, and area of the dehisced segment; and clear definition of the origin of the mitral regurgitation.

CONCLUSIONS

In mitral valve dehiscence, RT 3D TEE provides additional information about the exact anatomic characteristics of the dehiscence that can be used to help in planning the most appropriate corrective intervention.

Three-dimensional transthoracic echocardiographic evaluation of cor triatriatum

We present an adult patient with cor triatriatum (CTT) due to a left atrial (LA) membrane. Two-dimensional and real-time three-dimensional transthoracic echocardiography (3DE) were performed as well as echocardiographic examination after exercise. These non-invasive modalities provided a comprehensive anatomic and hemodynamic evaluation of the anomaly.

Fibrinous material in a pericardial effusion mimicking intraatrial thrombus

A 74-year-old woman presented with an acute cerebrovascular infarct involving multiple vascular territories, suggestive of an embolic event. The initial transesophageal images create the impression of an echogenic mass in the left atrial appendage. A small pericardial effusion was also seen surrounding the left atrial appendage. After further views were obtained, the echogenic mass appeared to be in this fluid-filled space rather than in the appendage itself. To confirm this finding, echo contrast (Definity) was administered. After contrast injection, the left atrial appendage was opacified, while the effusion around the appendage and the echodensity within this space were not opacified. Our case highlights the utility of contrast-enhanced echocardiography in clearly delineating the boundaries of the endocardium in cases, when a pericardial effusion surrounds the left atrial appendage.

Systolic and diastolic pulsus alternans in severe heart failure

Pulsus alternans is usually a systolic phenomenon. We present a case of a patient with severe heart failure, and systolic and diastolic pulsus alternans. This case may help clarify the mechanism of pulsus alternans.

Non-Doppler two-dimensional strain imaging by echocardiography--from technical considerations to clinical applications

During the past several years, strain and strain rate imaging have emerged as a quantitative technique to accurately estimate myocardial function and contractility. Non-Doppler, 2-dimensional (2D) strain imaging is a new echocardiographic technique for obtaining strain and strain rate measurements. It analyzes motion by tracking speckles in the ultrasonic image in two dimensions. Current available software allows spatial and temporal image processing with recognition and selection of such elements on ultrasound image. The geometric shift of each speckle represents local tissue movement. By tracking theses speckles, 2D tissue velocity, strain, and strain rate can be calculated. Non-Doppler 2D strain imaging is simple to perform. It requires only one cardiac cycle to be acquired; further processing and interpretation can be done after image data acquisition. Because it is not based on tissue Doppler measurements, it is angle independent. Data regarding accuracy, validity, and clinical application of non-Doppler 2D strain imaging are rapidly accumulating. This technique may prove to be of significant clinical value, enabling rapid and accurate assessment of global and segmental myocardial function.

Pulse pressure is more susceptible to the white coat effect than is systolic blood pressure: observations from real-life ambulatory blood pressure monitoring

BACKGROUND

Pulse pressure is a derivative of arterial stiffness. We have previously demonstrated ambulatory pulse pressure to be relatively independent from the blood pressure (BP) lowering during sleep, and thus of a neurogenic effect. On the other hand, white coat BP effects are thought to involve neurogenic activation. The aim of this work was to analyze white coat induced variability in pulse pressure.

METHODS

Percent clinic-awake differences in systolic BP (SBP) and pulse pressure (white coat effects) were calculated for 688 consecutive subjects (mean age 60 +/- 16 years, 58% female). Of the subjects, 23% had controlled hypertension, 45% uncontrolled hypertension, 8% normotension, and 4% isolated office hypertension; all were referred to our unit for 24 h ambulatory BP monitoring.

RESULTS

Pulse pressure highly correlated with SBP (r = 0.82, P <.00001). We found a larger white coat effect on pulse pressure than on SBP (8.3% and 5.2%, respectively, P < or =.0001). This was true in all subgroups except in normotensive subjects. Specifically, the magnitude of the white coat effect on pulse pressure was greater than on SBP in subjects with treated hypertension, untreated hypertension, and isolated office hypertension, and in young hypertensive subjects, older subjects, and those with diabetes.

CONCLUSIONS

Although pulse pressure is related to the mechanical properties of large arteries, it is also influenced by the white coat effect, a neurogenic process. Furthermore, in hypertensive but not in normotensive subjects, the white coat effect on pulse pressure is significantly more pronounced than on SBP.

Sex differences in the effect of heart rate on mortality in the elderly

OBJECTIVES

To examine the association between heart rate and mortality risk in the elderly.

DESIGN

Longitudinal cohort.

SETTING

Outpatient.

PARTICIPANTS

Four hundred twenty-two people, aged 70 upon entry, were surveyed and followed for 6 years.

MEASUREMENTS

Pulse rate was measured manually, while sitting and standing, and heart rate was measured from electrocardiogram recordings. The population was divided into quartiles of heart rate, with the top quartile comprising those with heart rate greater than 77 beats per minute (bpm) and the bottom quartile those with heart rate less than 60 bpm.

RESULTS

After controlling for possible confounders, there was a clear correlation (r) between heart rate and all-cause mortality in elderly women (r=0.25, P=.0003). The correlation in women was observed using the three different methods for measuring heart rate. Heart rate was associated with all-cause and cardiovascular mortality. There was no relationship between heart rate and level of exercise or smoking status. In multiple regression analysis, the increased risk of death in the women was independent of previous cardiovascular or cerebrovascular disease, hypertension, anemia, congestive heart failure, smoking, and level of exercise or activities of daily living (relative odds ratio (ROR)=3.37, 95% confidence interval (CI)=0.96-11.8). When women using beta-blockers were excluded, this relationship became even stronger (ROR=8.5, 95% CI=1.19-60.1).

CONCLUSION

Elevated heart rate is related to increased mortality in elderly women, thus representing a simple index of general health status in this population. Elevated heart rate did not predict mortality in elderly men.

Ambulatory pulse pressure is a relatively sleep-independent variable

OBJECTIVES

Characterization of sleep-induced pulse and mean arterial pressure (MAP) dip.

DESIGN

Prospective study of consecutive referred patients.

SETTING

Hypertension unit of community university hospital.

PARTICIPANTS

A total of 500 consecutive subjects referred to our unit for ambulatory blood pressure (BP) monitoring. There were 200 men and 300 women, the majority of which were treated hypertensives. Mean age was 59.7 +/- 16.6 years.

MAIN OUTCOME MEASURES

Effect of sleep on MAP and pulse pressure (PP).

RESULTS

Twenty-four hour MAP was 98 +/- 10 mmHg. Awake and asleep MAPs were 101 +/- 11 and 87 +/- 11 mmHg, respectively. Twenty-four hour, awake and asleep pulse pressures were 60 +/- 13, 61 +/- 13 and 58 +/- 13 mmHg, respectively. MAP dip was 14%, 95% confidence interval (CI) 13.4-14.6, whereas PP dip was 5%, 95% CI 4.1-5.8. Thus, the MAP dip was almost three times the PP dip (P < 0.0001). This held true for normotensives, hypertensives (treated and untreated), men, women and diabetic subjects.

CONCLUSIONS

Although pulse pressure is derived from BP, it is more stable during a 24-h period, with a lesser effect of sleep compared with MAP. This more rigid nature of the PP could explain its better prognostic value, compared to that of MAP.

Non-dipping in diabetic patients: insights from the siesta

Non-dipping, ie failure to lower blood pressure during sleep, has been found to be more prevalent in diabetic than in non-diabetic subjects. However, the reasons remain to be clarified. Diabetic patients may wake up more frequently during the night (for instance, due to nocturia). This may result in inclusion of awake blood pressure measurements in the night-time average and thus erroneously raise this average, causing misclassification of patients as non-dippers. However, non-dipping in diabetes may be due to blunted effect of sleep itself on blood pressure secondary to autonomic neuropathy. We undertook this study in order to further clarify this question. We studied 23 diabetic patients, and 23 matched controls who underwent 24-h ambulatory blood pressure monitoring, and reported taking an afternoon nap. Afternoon nap, by virtue of its short duration, is devoid of interruptions, and thus can be used as a model for tiled, non-interrupted sleep. We found that, both in diabetic patients and controls, blood pressure declined during the afternoon nap in a similar magnitude to the night-time decline. However, this decline was significantly blunted in the diabetic patients (13.9 +/- 2.2% decline in diastolic blood pressure during naptime in the diabetic patients, as compared with 24 +/- 2.3% decline in diastolic blood pressure during the siesta in the control group, P < 0.02). The blunted decline of blood pressure during the nap in diabetic patients demonstrates that non-dipping is due to the blunted effect of sleep itself. This can be another facet of autonomic dysfunction seen in diabetes mellitus.

The effect of the fast of Ramadan on ambulatory blood pressure in treated hypertensives

Every year, millions of Moslems throughout the world fast from sunrise till sunset daily during the month of Ramadan, that is, experience repeated cycles of fasting-refeeding. Studies in animal models have shown that repeated cycles of fasting-refeeding may cause or exacerbate hypertension. Changes in sleeping patterns as well as changes in medication timing may also influence ambulatory blood pressure. We undertook this study in order to examine the effect of the Ramadan fast on treated hypertensive subjects. Seventeen hypertensive subjects were examined, and 24-h blood pressure monitoring was carried out twice, before and during the last week of the Ramadan. All continued their medications, which were all once-daily preparations. Twenty-four hour mean blood pressure as well as average awake and average asleep blood pressure were compared. There was no difference between mean blood pressure before and during the Ramadan (138.5 +/- 18.5/77.2 +/- 8.1 mm Hg vs 136.4 +/- 20.4/75.7 +/- 5.9 mm Hg, P-nonsignificant). Blood pressure load also did not differ before and during Ramadan (systolic load 49% vs. 44%, diastolic load 21% vs. 18%, P-nonsignificant). Weight was reduced by 1.4 +/- 1.6 kg (P < 0.002). We conclude, that according to our findings, treated, hypertensive patients may be assured that, with continuation of previous medications, traditional fasting during the month of Ramadan can be safely undertaken.

Dipping status may be determined by nocturnal urination

Nondipping, ie, failure to reduce blood pressure by >/=10% during the night, is considered an important prognostic variable of 24-hour ambulatory blood pressure monitoring. However, some people wake up at night to urinate. Usually, 24-hour ambulatory blood pressure monitoring-derived blood pressure includes these rises in the nighttime blood pressure mean. We identified 97 subjects undergoing 24-hour ambulatory blood pressure monitoring who reported waking up at night to urinate. We assessed the 24-hour ambulatory blood pressure monitoring first using total daytime and total nighttime means and then using actual daytime awake and nighttime asleep (as reported by the patient) means. Nocturnal decline in blood pressure was 14.4+/-8.5/11.8+/-6.1 mm Hg with the first method and 17.1+/-8.3/13.8+/-5.9 mm Hg with the second one (P<0.00001). Although the absolute difference between the nocturnal blood pressure declines calculated by the 2 methods was small, the effect on nocturnal dip was profound. Average systolic blood pressure dipping was 10.1% by the total day-total night method and 12.0% by the actual day awake-night asleep method (P</=0.00001), and that of diastolic blood pressure was 14.2% and 16.7%, respectively (P</=0.00001). The prevalence of systolic blood pressure nondipping decreased from 42.2% by the first method to 31.9% by the second method (P</=0.0056), and that of diastolic blood pressure nondipping decreased from 22.6% to 11.3% (P</=0.00001). Inclusion of awake blood pressure measurements during the night obscured the normal dipping pattern in people who woke up to urinate. Thus, taking into account people's actual behavior increases the accuracy of the results.