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International Guidelines recommend ambulatory blood pressure monitoring (ABPM) for the management of hypertension. ABPM phenotypes predict outcomes independent of office blood pressure (BP). The authors explored the prevalence and clinical correlates of ABPM phenotypes and relationship with office BP in Saudi patients (n = 428, mean age 53.5 ± 14.6, 55% male) referred to a Specialist Hypertension clinic in Riyadh, Saudi Arabia. ABPM phenotypes included sustained normotension (27%), masked hypertension, MHT(32%), sustained hypertension, SHT(52%), and white coat hypertension(2.6%). MHT was more prevalent using asleep than 24‐hours (26.4% vs 12.9%, P

Background: In the early stages of atrial remodeling, increased aortic stiffness might indicate atrial fibrosis. Objective: This study aimed to investigate the association between left atrial (LA) mechanical function, assessed by two-dimensional speckle tracking echocardiography and aortic stiffness and whether this association is medicated by circulating biomarkers in early hypertension. Methods: We studied 34 patients, mean age 47.5 ± 11.6 years, 56% females. All parameters for arterial stiffness including 24 hour central systolic pressure, augmentation index and pulse wave velocity were measured non–invasively using Mobil-O-graph PWA. All patients underwent standard two-dimensional echocardiography with Spackle tracking analysis for left atrium (LA). Circulating biomarkers including renin, aldosterone and morning cortisol were measured using ELISA. Results: LA strain showed a significant relationship with central aortic systolic pressure; 24-hr (r = –0.46, p < 0.05), daytime (r = –50, p < 0.05) and nighttime (r = –55, p < 0.01) with no relationship with central diastolic or brachial pressures. There was a significant positive association between LA strain and aldosterone (r = 0.49, p < 0.05), aldosterone-renin ratio (r = 0.30, p < 0.05) and cortisol (r = 0.66, p < 0.01) with no relationship observed with plasma renin activity. In a stepwise regression model, central systolic pressure, aldosterone and cortisol emerged as predictors of LA strain independent of age, gender, brachial pressure and LAVi. Conclusions: In mild hypertension, central but not brachial systolic pressure determines LA remodeling which in turn may be mediated by circulating aldosterone and cortisol. This study highlights the important role of circulating biomarkers in mediating aortic stiffness and LA fibrosis in early hypertension.

Background Age-related changes in arterial stiffness are ascribed to collagen and elastin content in the aorta (Ao) which is modulated by the matrix metalloprotienases (MMPs). However, no study has directly compared arterial stiffness and arterial structure in man. Methods Aortic and internal mammary artery (IMA) tissue were obtained from 10 patients (62±1 years, 2 female) undergoing coronary artery bypass grafting (CABG). Aortic pulse wave velocity (PWV) was measured prior to CABG. Collagen content was assessed in tissue sections using Sirius Red staining and elastin by ACCUSTAIN. Elastin fragmentation in the Ao media was graded; increasing in severity from 1 to 4. MMP-2 and MMP-9 activity was quantified in the Ao using gelatine zymography. Results are expressed as mean±SEM, p Results The collagen concentration was 50% (intima), 42% (media)and 76% (adventitia) in the Ao but was lower in the IMA. PWV was significantly associated with Ao medial (r=0.79, p=0.03) but not intimal or adventitial collagen concentrations. Aortic intimal thickness was related significantly with age (r=0.70, p Conclusions Our proof-of-concept study is the first one to show that elastin fragmentation in the aorta may underlie arterial stiffening in man. In contrast, the internal mammary artery does not age, unlike the aorta, which makes it the reassuring choice for coronary artery bypass grafting. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Health Research Board, Ireland

Hypertension guidelines recommend that blood pressure (BP) should be measured using a monitor that has passed validation testing for accuracy. BP monitors that have not undergone rigorous validation testing can still be cleared by regulatory authorities for marketing and sale. This is the situation for most BP monitors worldwide. Thus, consumers (patients, health professionals, procurement officers, and general public) may unwittingly purchase BP monitors that are non-validated and more likely to be inaccurate. Without prior knowledge of these issues, it is extremely difficult for consumers to distinguish validated from non-validated BP monitors. For the above reasons, the aim of this paper is to provide consumers guidance on how to check whether a BP monitor has been properly validated for accuracy. The process involves making an online search of listings of BP monitors that have been assessed for validation status. Only those monitors that have been properly validated are recommended for BP measurement. There are numerous different online listings of BP monitors, several are country-specific and two are general (international) listings. Because monitors can be marketed using alternative model names in different countries, if a monitor is not found on one listing, it may be worthwhile cross-checking with a different listing. This information is widely relevant to anyone seeking to purchase a home, clinic, or ambulatory BP monitor, including individual consumers for use personally or policy makers and those procuring monitors for use in healthcare systems, and retailers looking to stock only validated BP monitors.

To investigate the blood pressure (BP)–lowering effects of statins by conducting a systematic review and meta-analysis of placebo-randomized controlled trials (RCTs). We conducted a meta-analysis of placebo RCTs reporting antihypertensive effects of statins therapy. We only included RCTs that did not allow for concomitant antihypertensive therapy, or clearly stated that antihypertensive therapy was fixed throughout the study period. Our meta-analysis included 46 placebo RCTs, including 53 group comparisons and a total of 49,087 participants (24,589 participants in the statin groups and 24,498 participants in the placebo group). Subgroup analysis, based on use of concomitant antihypertensive, was performed. The meta-analysis showed that statin reduced systolic BP by − 1.6 mmHg (95% CI: − 2.50 to − 0.60), and diastolic BP by − 0.96 mmHg (95% CI: − 1.36 to − 0.56). Although the presence of concomitant antihypertensive therapy diluted the BP lowering effect of statins, it remained statistically significant and independent of the lipid-lowering activity. Furthermore, the BP –lowering effect of the statins was independent of the dose or type of statin (p > 0.05). Our results strengthen the evidence for pleiotropic effects of statins on BP that are independent of their lipid-lowering activity, supporting their beneficial role in hypertensive patients with dyslipidemia.

Background Patients with mechanical heart valves require life-long anticoagulation with warfarin. Variability of anticoagulation is a major concern in such patients. Previously, we found that mechanical heart valve patients spent only 66% of their time within the therapeutic range (TTR). However, there is currently little data relating quality of anticoagulation to bleeding risk in patients with mechanical heart valve prostheses. Methods This was a cross-sectional study of patients attending a Nurse-Led Heart Valve Anticoagulation Clinic. Data analyzed included patient demographics, comorbidities, and concurrent drug therapy to calculate HAS-BLED and ATRIA scores. International normalized ratio (INR) values were used to calculate time spent in the therapeutic range (TTR) by the Rosendaal Method. The relationship between variables was analyzed using linear correlation (Spearman Rho) and logistic regression as deemed appropriate. Data were analyzed using SPSS (SPSS for Windows), with p Results The study cohort consisted of 260 patients with a mean age of 54±15 years. The mean TTR was 66+16%. 27 (10%) patients had HAS-BLED scores of more than 3 (high risk). Bleeding (cerebral, gastrointestinal, or hemoglobin Conclusion Similar to previous reports of patients with atrial fibrillation, ATRIA and HAS-BLED scores were the best predictors of bleeding in our cohort of patients with mechanical heart valves, with no independent contribution of TTR to estimation of bleeding risk.

Objective: Since the Coronavirus Disease 2019 (COVID-19) pandemic began, conflicting reports have emerged regarding its association with hypertension (HTN) in various populations worldwide. However, there is paucity of data regarding the association between the severity of COVID-19 and HTN phenotypes and HTN mediated organ damage (HMOD). Design and method: In a cohort of patients (n=501, mean age 53.5±14.6) attending a specialist hypertension clinic at King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia, we identified patients diagnosed with COVID-19 between January and November, 2020. We compared HTN phenotypes and HMOD in patients admitted with severe COVID-19 infection to those with mild disease and without disease. Data were analysed using JMP version 13 Pro(SAS for Windows). Results: Twenty-seven patients developed COVID-19 (5.38%), 8 of whom were admitted (29.6%), with one fatality (3.8%). Patients admitted with COVID-19 were more likely to have refractory HTN (43% vs. 15% vs. 8.9%, p 30 (85.7% vs. 46% vs. 47%, p

ObjectivesTo assess the effect of the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) hypertension guideline on the prevalence of elevated blood pressure (BP) and hypertension and the initiation of antihypertensive treatment, as well as the level of adherence to the BP target in the Saudi population.DesignA cross-sectional study.ParticipantsA total of 10 799 adults (≥18 years old), with three BP readings during 2017–2020 from the Saudi Biobank was used.Primary outcomeHypertension was defined using three sources: the Joint National Committee 7 Blood Pressure Guideline (JNC-7) guideline (systolic BP (SBP)≥140 or diastolic BP (DBP)≥90 mm Hg), the 2017 ACC/AHA guideline (SBP≥130 or DBP≥80 mm Hg) and a self-reported hypertension diagnosis.ResultsThe prevalence of hypertension, according to the JNC-7 guideline, was 14.49% (95% CI 14.37 to 14.61), and the 2017 ACC/AHA, 40.77% (95% CI 40.60 to 40.94), a difference of 26.28%. Antihypertensive medication was recommended for 24.84% (95% CI 24.69 to 24.98) based on the JNC-7 guideline and 27.67% (95% CI 27.52 to 27.82) using the 2017 ACC/AHA guideline. Lifestyle modification was recommended for 13.10% (95% CI 12.47 to 13.74) of patients with hypertension who were not eligible for a pharmacological intervention, based on the 2017 ACA/AHA guideline. For patients with prescribed antihypertensive medication, 49.56% (95% CI 45.50 to 53.64) and 27.81% (95% CI 24.31 to 31.59) presented with a BP reading above the treatment goal, based on the 2017 ACA/AHA and JNC-7 guidelines, respectively. Using the two definitions, the risk factors were older age, male gender, diabetes diagnosis, increased body mass index, waist circumference and waist-to-hip ratio.ConclusionsAccording to the 2017 ACC/AHA guideline, the prevalence of hypertension has increased significantly, but there was only a small increase in the proportion of patients recommended for antihypertensive treatment. A large proportion of patients with prescribed antihypertensive medication, had a BP above the target. Unless public health prevention efforts are adopted, the increased prevalence of elevated BP and hypertension will increase cardiovascular disease.

Background: Hemodynamic monitoring is an integral part of a cardiac catheterization procedure; however it is prone to many distortions, including damping and resonance [1]. Objectives: We sought to compare damping ratio, ascending aortic pressure waveform and invasive blood pressure between Manifold and ACIST CVi® devices in subjects undergoing cardiac catheterization. Methods: This prospective randomised, single-blind, cross-over study was conducted in 81 adults subjects (mean age 59.2 ± 12, 24% females) undergoing cardiac catheterization. The fast-flush test [2] was performed at the beginning of the procedure with both Manifold and ACIST. The square wave was analysed to calculate the damping coefficient. Data analyzed by JMP Pro (SAS for Windows, Version 13) p < 0.05 considered significant. Results: The mean damping ratio was 0.63 ± 0.11 (range 0.34–0.95) with Manifold vs. 0.94 ± 0.25 (range 0.53–2.1) with ACIST, mean difference 0.30, p < 0.0001. The pressures were significantly different between the two devices; systolic −2.85 (p < 0.05); diastolic −5.2 (p < 0.0001) and mean pressure 3.5 (p < 0.01), mmHg. The inter-device BP difference showed a wide scatter; systolic, −24 to +67; diastolic, −44 to +25 and mean pressure, −24 to +54 mmHg. Conclusions: To the best of our knowledge, this is the first study comparing a manual haemdynamic monitoring system to an automated one commonly used in the cardiac cath lab. The Manifold meets the international recommendations for accurate haemodynamic monitoring, compared with an overdamped ACIST which also underestimated pressures in our study. Manifold may be the preferred device for haemodynamic monitoring, particularly patients haemodynamically unstable, with cardiomyopathies and valvular heart disease.

Introduction: Left Main Coronary Artery (LMCA) disease is prognostically the most important coronary lesion. LMCA differs from the other coronaries in having high elastin content. Aortic Pulsatility (AP) is an independent predictor of cardiovascular events in CAD. We hypothesized that pulsatile stress may be an independent determinant of disease in the LMCA. Methods: This was a prospective cohort study in patients undergoing coronary angiography between the years 2011 and 2016 (n = 4633, 25% female) at King Abdul Aziz Cardiac Center, Riyadh, Saudi Arabia. We excluded patients with acute myocardial infarction, cardiogenic shock and significant valvular disease. Aortic systolic and diastolic blood pressures (BP) were measured in the ascending aorta. Mean Arterial Pressure (MAP) by direct integration of the BP curve and Pulse pressure (PP) as difference between systolic and diastolic BP. AP was calculated as PP/MAP. CAD was defined as > 50% stenosis in any major vessel. Results: Six percent of the population had LMCA disease (mean age 60 ± 11 years, 25% female). LMCA disease was associated with higher PP (69 ± 22 vs. 58 ± 18, p < 0.0001) despite similar MAP (94 ± 16 vs. 94.5 ± 14, p = 0.92) compared with non-LMCA disease. AP was significantly higher (0.72 ± 0.30) in LMCA disease compared with; 3-vd (0.63 ± 0.32); 2-vd (0.61 ± 0.28), 1-vd (0.58 ± 0.31) and non-obstructive CAD (0.52 ± 0.26) (p < 0.0001). In a stepwise regression model, AP was an independent predictor of LMCA disease (R2=0.68, P < 0.0001) even when adjusted for potential confounders, including MAP, age and gender. Conclusions: LMCA disease is independently associated with high AP. Considering aortic pulsatile stress to be an independent cardiovascular prognosticator, stiffness of the LMCA may play an important role in plaque formation, hitherto ignored.

Introduction: Invasive intra-aortic pressures are the gold standard for accurate Blood Pressure (BP) measurement. Hypertension management is guided by brachial cuff BP although its accuracy has been questioned. Hypothesis: We hypothesized that there may be a discrepancy between brachial and invasive intra-aortic BPs. Methods: Invasive intra-aortic and brachial cuff pressures were recorded in some 3000 patients undergoing coronary angiography (mean age 58.6 ± 28, 23% female) between 2010 and 2016, at King Abdul AzizCardiac Centre, Riyadh, Saudi Arabia. Clinical and angiographic data were collected from electronic medical records (Apollo Lx®). Results: Cuff brachial BP underestimated intra-aortic systolic BP (−6.2 mm Hg;95% CI:−7.2 to −5.4 mmHg; p < 0.0001),but overestimated intra-aortic diastolic BP (2.5 mm Hg; 95% CI:1.5 to 3.8 mm Hg;p < 0.001). The discrepancy betweenintra-aortic and brachial systolic BP was significantly higher in women than men ( −15 mm Hg; 95% CI: −14 to −17 mm Hg vs. −3.9 mm Hg;95% CI: −2.8 to −4.1 mm Hg, p < 0.0001). Intra-aortic diastolic BP was overestimated by cuff BP in men (0.9 mm Hg; 95% CI;0.74 to 1.26, p < 0.0.001) but underestimated in women ( −3.6 mm Hg;95% CI:−3 to −4 mm Hg, p < 0.0001). While brachial BP correctly estimated intra-aortic systolic BP in subjects 50 yr-olds ( −8.6 mm Hg; 95% CI: −8.1 to −9.5 mm Hg, p < 0.0001). Conclusions: Brachial BP underestimates intra-aortic systolic BP, particularly in women, older subjects and at higher BPs with implications for HTN mangagement.

Background:Physical activity has beneficial effects on arterial stiffness among healthy adults. There is a lack of data on this relationship in adults with hypertension. The majority of studies which have examined physical activity and arterial stiffness have used subjective measures of activity. The aim of this study was to investigate the relationship between objectively measured habitual physical activity and arterial stiffness in individuals with newly diagnosed essential hypertension.Methods:Adults attending an outpatient hypertension clinic were recruited into this cross sectional study. Physical activity was measured using a triaxial accelerometer. Pulse wave velocity (PWV) and augmentation index (AIx) were measured using applanation tonometry. Participant’s full lipid profile and glucose were determined through the collection of a fasting blood sample.Results:Fifty-three adults [51(14) years, 26 male] participated, 16 of whom had the metabolic syndrome. Inactivity was positively correlated with PWV (r = .53, P < .001) and AIx (r = .48, P < .001). There were significant inverse associations between habitual physical activity of all intensities and both AIx and PWV. In stepwise regression, after adjusting for potential confounders, physical activity was a significant predictor of AIx and PWV.Conclusion:Habitual physical activity of all intensities is associated with reduced arterial stiffness among adults with hypertension.

Aldosterone influences independently the vascular environment in humans, acting through structural and functional modifications of the arterial wall as derived from mineralocorticoid receptors. In rats, aldosterone infusion increases arterial stiffness in the presence of high-sodium intake, together with development of extracellular matrix and inflammatory factors. A selective increase in systolic and pulse pressure ensues, causing predominant organ damage on the heart, kidney and large arteries. In humans at rest, but independently of mean arterial pressure, arterial stiffness and wave reflections are associated with a steeper increase in these parameters with age. This finding is observed mainly with the CC genotype and not the TT or the TC genotype of the aldosterone synthase gene polymorphism. Early identification of individuals presenting this genotype could be important to detect hypertension.

Drugs acting on cardiovascular (CV) prevention are, by definition, interconnected with age-induced arterial changes. However, this question has been poorly investigated along long-term treatment. This goal requires a major prerequisite: to determine statistical links associating age-induced changes in arterial stiffness and wave reflections with drug classes acting on CV prevention. We studied 347 subjects where CV prevention involved hypertension, diabetes mellitus and hypercholesterolaemia; and included six drug classes: diuretics, β-blocking agents, angiotensin II (ANGII) and calcium-channel (CCB) blockers, insulin therapy and statins. For each class, the total population was divided into two subgroups according to the presence or absence of the corresponding class. Statistical comparisons between subgroups involved brachial and central blood pressure measurements, aortic pulse wave velocity (PWV), augmentation index (AIx), used as a marker of wave reflections. Non-invasive measurements included tonometry and pulse wave analysis. Appropriate adjustments indicated among results the respective role of age, sex, mean blood pressure (MBP), standard risk factors and other confounding variables. CCB and statins did not exhibit statistical association with PWV or AIx. β-Blocking agents were significantly linked with heart rate reduction and resulting increase in AIx and central pulse pressure (PP). Increased PWV independent of age, MBP, CV risk factors were noticed under diuretics, ANGII blockers and insulin, pointing to intrinsic modifications of the arterial wall. Treatment of CV prevention involves alterations of the arterial wall depending on drug class. β-Blocking agents and insulin are associated with the higher increases of central PP.

Introduction: Arterial stiffness and wave reflection are independent prognosticators of cardiovascular morbidity and mortality. There are two types off arteries in the body; elastic and muscular. The elastic arteries receive the blood directly from the heart while the muscular arteries distribute the blood to various organs of the body. The elasticity of the major arteries decreases with age and therefore may play a key role in the development and control of hypertension and subsequently the choice of drug therapy. The aim of the study is to evaluate the effects of the amlodipine, on arterial stiffness in essential hypertension, compared to hydrochlorothiazide. Methodology: We randomised 24 hypertensive patients hypertension (clinic blood pressure (BP) > 140/90 mmHg and ambulatory >135/85 mmHg) to amlodipine 5 mg or hydrochlorothiazide 12.5 mgs in a single blind parallel group study for one month and measured aortic pulse wave velocity (PWV) and augmentation index (AIx) at baseline and one month after treatment. The patients were studied fasting, having abstained from smoking, caffeinated beverages and alcohol 12 h prior to the measurements. Brachial BP and heart rate (Omron), pulse wave velocity (PWV, Complior) and augmentation index (AIx, SphymoCor), a measure of wave reflection, were measured in the supine position after a rest of 15 min. Results were analysed with JMP (SAS for Windows) using Wilcoxon-Rank Sums test and ANOVA. Results are expressed as mean ± SEM, p

Introduction: Invasive physiologic variables such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are used in clinical practice to assess the functional significance of epicardial coronary stenosis and guide the management. However, these two variables may show discrepancies when binary cut-offs are used to decide for revascularization strategy. We investigated the clinical characteristics of lesions with discordance between iFR and FFR. Methodology: 256 vessels (220 patients mean age 61 ± 12, 77% males) with available pre-intervention FFR and iFR values were included in the study. The vessels were classified according to FFR and iFR into concordant normal (Group 1 [n = 112]; FFR > 0.8 and iFR > 0.89); discordant with abnormal FFR and normal iFR (Group 2 [n = 12); FFR 0.89); discordant with normal FFR and abnormal iFR (Group 3 [n = 43], FFR > 0.8 and iFR

BACKGROUND A standard 12-lead electrocardiogram (ECG) is performed in all hypertensive patients, primarily to detect left ventricular hypertrophy. Echocardiographic assessment of hypertensive subjects reveals that abnormalities in diastolic function occur more commonly and earlier than increased left ventricular mass. However, ECG changes associated with diastolic dysfunction (DD) remain poorly defined; we assessed the ventricular activation time (VAT) (i.e., the time for the ventricle to depolarize) as a potential marker for DD in early hypertension. METHODS Ninety subjects (aged 46 +/- 1.3 years; 43 men) with newly diagnosed, untreated hypertension underwent ECG and comprehensive two-dimensional echocardiography. Left ventricular DD was echocardiographically assessed using Canadian Consensus Guidelines. We compared VAT, which corresponds to the QR interval in the 12-lead ECG, with echocardiographic parameters of DD. RESULTS VAT was prolonged in subjects with DD (46.3 +/- 0.4 vs. 39.6 +/- 0.3 ms, P < 0.01). There was a significant correlation between VAT and tissue Doppler imaging (TDI) (early diastolic velocity) e' (r = -0.53, P < 0.0001), (ratio of early and late diastolic velocities) e'/a' (r = -0.53, P < 0.0001), transmitral Doppler (TMD) (early peak filling rate, and early deceleration peak) E/A (r = -0.32, P = 0.001), and (ratio of early diastolic mitral inflow and early diastolic velocities) E/e' (r = 0.44, P < 0.0001). CONCLUSION Prolongation of the VAT is associated with DD in patients with newly diagnosed untreated hypertension.

Invasive physiological indices such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are used in clinical practice to identify ischemia-causing epicardial stenosis. While FFR requires maximal hyperaemic response to agents like adenosine, iFR does not. Increased aortic

Cigarette smoking is the commonest modifiable risk factor for coronary artery disease (CAD) and vascular inflammation may play an important role in the pathogenesis. However, the presence of confounding factors, particularly age and gender, makes it difficult to interpret vascular effects of smoking

To test the hypothesis that the cardiac structural and functional abnormalities of the metabolic syndrome (MS) are independent of body mass index (BMI), 160 untreated patients (aged 47+/-1 years [mean +/- SEM], 53% male) underwent 2-dimensional echocardiography and tissue Doppler imaging and evaluation for MS. Participants with MS and controls were similar in age, BMI, and ejection fraction, but those with MS had greater left ventricular relative wall thickness (RWT) (0.43+/-0.008 vs 0.39+/-0.005, P.001), reduced midwall fractional shortening (MFS) (13%+/-0.3% vs 14.2%+/-0.3%, P.05), and reduced peak mitral annular velocity (Em) (9.9+/-0.5 vs 12.3+/-0.5 cm/sec, P.01) than controls. There was a linear relationship between the number of features of MS and Em velocity (P.001), RWT (P.001), and MFS (P.05). In a stepwise multiple regression analysis adjusting for likely determinants, MS was an independent predictor of Em in addition to age and nonindexed left ventricular mass. MS is associated with left ventricular concentric remodeling and reduced systolic and diastolic function independent of BMI.

The ambulatory arterial stiffness index (AASI) has been proposed as a novel measure of arterial stiffness and has been prospectively shown to predict stroke and cardiovascular death, but not cardiac death. This index has prompted considerable controversy as to whether it is a true measure of arterial stiffness.The present study aimed to examine three different measures of arterial stiffness - pulse wave velocity (PWV; Complior), wave reflection [augmentation index (AIx)] and AASI - in a large hypertensive population, comparing their determinants and intercorrelations, both unadjusted and adjusted for confounders, and using Bland-Altman analysis to determine 95% confidence intervals for the ability of the AASI to predict PWV, the proposed gold standard of arterial stiffness.The AASI correlated univariately with both PWV and the AIx in individuals overall (r = 0.28 for PWV and r = 0.24 for AIx; both P0.001) and in those with untreated or treated hypertension. Adjustment for age in the current study negated entirely the positive correlation between the AASI, PWV and AIx. Additional adjustment for confounders did not significantly alter these nonsignificant relationships. Furthermore, the 95% prediction limits for the AASI to predict PWV were +/- 4.18 m/s and for the AASI to predict AIx were +/- 25.4%, suggesting that the methods would not be interchangeable in a clinical setting. Direct comparative studies would be required to establish the relative predictive strength of each measure and whether combining measures can provide additional risk prediction. Until such data become available, we propose that the measures should not be considered interchangeable.

Left ventricular (LV) diastolic dysfunction identifies patients at risk of developing heart failure and may be common in patients with hypertension. The prevalence of LV diastolic dysfunction in patients with newly diagnosed hypertension was compared using criteria provided by the Canadian Consensus, European Study Group, and American Medical Association guidelines. One hundred twenty patients with newly diagnosed untreated hypertension (mean age 46.9 +/- 2.1 years; 62 men, 58 women) with increased blood pressure (clinic >140/90 mm Hg, daytime ambulatory >135/85 mm Hg) underwent comprehensive 2-dimensional echocardiography. Transmitral inflow velocities were measured using pulse-wave Doppler with and without Valsalva's maneuver, and a comprehensive assessment of tissue Doppler velocities was performed. The prevalence of LV diastolic dysfunction varied according to criteria used. There was a high prevalence of LV diastolic dysfunction (59%; n = 71) using Canadian Consensus guidelines; 27% of patients (n = 32) had a pseudonormal pattern unmasked using Valsalva's maneuver and 32% (n = 39) had impaired relaxation at rest. Significantly fewer patients (10%; n = 12) had this diagnosis using European or American Medical Association guidelines (23%; n = 27). Using tissue Doppler imaging (early-late diastolic velocity ratio

What is already known about this subject • Underuse of antithrombotic therapy in atrial fibrillation has been identified in hospital base and community surveys. • Whether this applies nationally and whether underuse is age or gender related is not established. What this study adds • Using a pharmacoepidemiological database with digoxin as a surrogate for atrial fibrillation, its prevalence and the concomitant use of antithrombotic therapy nationally mirrors that seen in smaller studies. • In addition, both prescribers' views and practice show that, based on age, those at highest risk and women are least likely to receive warfarin, which is predominantly used in the low-risk population. • Such databases may be used nationally to examine adherence to guidelines. Aims To examine if appropriate antithrombotic therapy in atrial fibrillation is implemented nationally. Methods Using prescriptions for digoxin as a surrogate for atrial fibrillation, we identified its coprescription with antithrombotic therapy, aspirin or warfarin in a national prescribing database in 27 571 patients over 45 years old. Results Proportionately significantly more men were on warfarin, and use in those >75 years old was three times less than in those 75 years old least likely to receive warfarin.

Arterial stiffness is an independent predictor of cardiovascular events in a hypertensive population. Serum levels of matrix metalloproteinase (MMP)-9 are associated with arterial stiffness and predict cardiovascular risk. We investigated the role of MMP-9 polymorphism -1562CT on blood pressure (BP) and arterial stiffness in a newly diagnosed hypertensive population. Untreated hypertensive patients (n=215, mean age 46+/-13 years) were studied. Supine BP, carotid-femoral pulse wave velocity (PWV) and augmentation index were assessed. Serum biochemistry and plasma MMP-9 concentrations were measured and genotyping performed following extraction of genomic DNA. BP, aortic PWV and serum MMP-9 levels were significantly higher in T-allele carriers of the -1562CT polymorphism with a significant gene-dose effect (P0.0001). In a stepwise regression model adjusting for known or likely determinants, the 1562CT polymorphism emerged as an independent predictor of systolic BP (R(2)=0.25, P0.0001), diastolic BP (R(2)=0.16, P0.0001) and PWV (R(2)=0.47,P0.0001). This is the first study to show the effect of MMP-9 polymorphism on BP and aortic stiffness in a hypertensive population. These results suggest that hypertensive patients carrying the T allele may be at increased risk of cardiovascular events.

Cigarette smoking is an important modifiable cardiovascular risk factor and pathophysiological mechanisms may include a stiff vascular tree. Although smokers have stiffer arteries, whether smoking cessation is associated with reduced arterial stiffness is not known. We compared never-treated patients with essential hypertension (n=554) aged 18 to 80 years (56% females) classified as current smokers (n=150), ex-smokers (n=136), and nonsmokers (n=268). Ex-smokers were categorized into 1 and 10 years of smoking cessation. Measurements included aortic stiffness, assessed as pulse wave velocity (Complior), wave reflection (augmentation index [AIx]), and transit time (T R ) (Sphygmocor). Current and ex-smokers had significantly higher pulse wave velocity and AIx compared with nonsmokers (pulse wave velocity for current smokers: 10.7±0.2; ex-smokers: 10.6±0.2; nonsmokers: 9.9±0.1 m/s; P P R was lower in current and ex-smokers compared with nonsmokers (T R for current smokers: 131±1.0; ex-smokers: 135±1; nonsmokers: 137±0.8 m/s; P P P R ( P P P R ( P

Although arterial stiffness is an independent cardiovascular risk factor associated with both aging and hypertension, relatively little is known regarding the structural changes in the vessel wall that occur with vessel stiffening. We determined if collagen type-I metabolism is related to arterial stiffening in both hypertensive and normotensive subjects. Arterial stiffness was assessed by aortic pulse wave velocity (PWV) and augmentation index (AIx) in 46 subjects (48.7 +/- 2 years, 32 hypertensives) and related to circulating markers of collagen type-I turnover. Collagen synthesis was assessed by the measurement of carboxy-terminal peptide of procollagen type-I (PIP) and collagen degradation by the measurement of carboxy-terminal telopeptide of collagen type-I (ICTP), by quantitative immunoassay. Matrix metalloproteinase-1 (MMP-1) and the tissue inhibitor of metalloproteinase-1 (TIMP-1) were also quantified by immunoassay. The ratio of collagen type-I synthesis to degradation was negatively correlated with both PWV (P

The recognition that some 10% to 15% of the hypertensive population may have aldosterone excess has increased the frequency of measurement of the aldosterone-to-renin ratio (ARR) and the use of aldosterone antagonists. Whether this ratio will predict the blood pressure (BP) response to spironolactone is not clear.We correlated the BP response to spironolactone 50 mg/day to baseline ARR in 69 hypertensive patients (mean [+/-SD] age 57 +/- 2 years, 65% male), consisting of 39 subjects with long-standing hypertension (4.0 +/- 0.2 years) whose hypertension was uncontrolled on at least three antihypertensive medications and 30 previously untreated patients who were randomized in a cross-over design to receive either spironolactone 50 mg/day or bendroflumethiazide 2.5 mg/day for 4 weeks.After 4 weeks of spironolactone, BP in patients with never-treated hypertension was reduced by 18 +/- 3 / 11 +/- 1 mm Hg. There was a highly significant correlation between log ARR and the fall in systolic BP (r = 0.69, P.001) and diastolic BP (r = 0.45, P.05). Nine of ten patients with low renin activity (or =0.5 ng/mL/h) showed a20-mm Hg fall in systolic BP. No such correlations were seen when BP was reduced by bendroflumethazide 2.5 mg. For patients with resistant hypertension, despite a BP reduction of 28 +/- 3 / 13 +/- 2 mm Hg after 14 weeks of spironolactone, there was no relationship between the reduction in BP and the ARR; however, subjects with pretreatment potassium4.0 mmol/L had a greater response than those with levelsor =4.0 mmol/L (34 +/- 3 / 16 +/- 2 v 20 +/- 6 / 8 +/- 3 mm Hg, P.05)Based on the study results, ARR and low renin activity may predict the response to spironolactone in never-treated hypertensive patients but not in patients taking antihypertensive drugs, possibly because of the effect of these agents on ARR. In such patients a trial of spironolactone is required to assess the BP response.

Arterial stiffness has recently been recognised as an independent risk factor for cardiovascular morbidity and mortality in hypertension. Many of the complications seen with angiotensin II (Ang II) excess or hyperaldosteronism — an increased event rate, left ventricular hypertrophy, endothelial dysfunction and target organ damage — are also associated with arterial stiffness. It is possible that reduced arterial compliance may be one mechanism whereby increased activity of the renin-angiotensin-aldosterone system (RAAS) produces adverse vascular effects. Common pathophysiological processes, altered collagen turnover and increased fibrosis may underlie both arterial stiffness and RAAS-associated vascular damage. While it is recognised that patients with hyperaldosteronism have increased arterial stiffness, the role of the RAAS in modulating arterial compliance in essential hypertension and in normotensive subjects is less clear cut. There is, however, more consistent data which show that drugs that interfere with Ang II or aldosterone, namely angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and aldosterone antagonists, all reduce arterial stiffness. In many cases, this is to a greater extent than predicted from the extent of reduction in blood pressure (BP), suggesting a role for RAAS in vascular stiffness in hypertensive subjects. There is also evidence that combined ACE inhibitors (ACE-Is) and ARBs may have an additive effect in reducing stiffness. The reduction in cardiovascular mortality in end-stage renal disease patients treated with ACE-Is was preferentially seen in those who had reduced arterial stiffness. These data suggest that, in addition to regulation of vascular biology and BP, the RAAS is an important determinant of arterial stiffness in health and, more particularly, in disease.