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Chlorhexidine and cetrimide are often used as antiseptics and disinfectants. While their individual activities are well-documented, their synergism has rarely been evaluated. Here, we attempted to evaluate the antimicrobial and antibiofilm effects of the combination of these two antimicrobial agents against two environment isolates, viz., P. aeruginosa and S. aureus. The synergism was assayed by determining the fractional inhibitory concentrations, while the antibiofilm effects were determined using crystal violet staining and the resazurin assay. Further, the effects on the biofilms were visualized using brightfield and confocal laser scanning microscopy. Our results show that the combination of these antimicrobials resulted in synergistic inhibition of P. aeruginosa growth. When tested at concentrations below the individual MICs (one-quarter of the MICs), the combination was able to significantly reduce the adherence of S. aureus biofilms to a polystyrene surface, while no effect was observed for P. aeruginosa. The combination was also able to significantly reduce the viability of pre-formed biofilms of both bacteria, thereby showing its antibiofilm potential. Next, we evaluated the performance of this combination against a wide array of micro-organisms. This fixed-dose combination formulation exhibited a significant reduction in the viability of an array of clinically relevant micro-organisms, including ESKAPE pathogens, Mycobacterium sp., MRSA, Leptospira, Candida sp., norovirus and adenovirus. Overall, it can be inferred that the combination of chlorhexidine and cetrimide is a potential biocide that continues to be relevant for use in antisepsis and disinfection against infection-causing pathogens.

Class A serine β-lactamases (SBLs) have a conserved non-active site structural domain called the omega loop (Ω-loop), in which a glutamic acid residue is believed to be directly involved in the hydrolysis of β-lactam antibiotics by providing a water molecule during catalysis. We aimed to design and characterise potential pentapeptides to mask the function of the Ω-loop of β-lactamases and reduce their efficacy, along with potentiating the β-lactam antibiotics and eventually decreasing β-lactam resistance. Considering the Ω-loop sequence as a template, a group of pentapeptide models were designed, validated through docking, and synthesised using solid-phase peptide synthesis (SPPS). To check whether the β-lactamases (BLAs) were inhibited, we expressed specific BLAs (TEM-1 and SHV-14) and evaluated the trans-expression through a broth dilution method and an agar dilution method (HT-SPOTi). To further support our claim, we conducted a kinetic analysis of BLAs with the peptides and employed molecular dynamics (MD) simulations of peptides. The individual presence of six histidine-based peptides (TSHLH, ETHIH, ESRLH, ESHIH, ESRIH, and TYHLH) reduced β-lactam resistance in the strains harbouring BLAs. Subsequently, we found that the combinational effect of these peptides and β-lactams sensitised the bacteria towards the β-lactam drugs. We hypothesize that the antimicrobial peptides obtained might be considered among the novel inhibitors that can be used specifically against the Ω-loop of the β-lactamases.

The consistently mutating bacterial genotypes appear to have accelerated the global challenge with antimicrobial resistance (AMR); it is therefore timely to investigate certain less-explored fields of targeting AMR mechanisms in bacterial pathogens. One of such areas is beta-lactamase (BLA) induction that can provide us with a collection of prospective therapeutic targets. The key genes (ampD, ampE and ampG) to which the AmpC induction mechanism is linked are also involved in regulating the production of fragmented muropeptides generated during cell-wall peptidoglycan recycling. Although the involvement of these genes in inducing class C BLAs is apparent, their effect on serine beta-lactamase (serine-BLA) induction is little known. Here, by using ∆ampD and ∆ampE mutants of E. coli, we attempted to elucidate the effects of ampD and ampE on the expression of serine-BLAs originating from Enterobacteriaceae, viz., CTX-M-15, TEM-1 and OXA-2. Results show that cefotaxime is the preferred inducer for CTX-M-15 and amoxicillin for TEM-1, whereas oxacillin for OXA-2. Surprisingly, exogenous BLA expressions are elevated in ∆ampD and ∆ampE mutants but do not always alter their beta-lactam susceptibility. Moreover, the beta-lactam resistance is increased upon in trans expression of ampD, whereas the same is decreased upon ampE expression, indicating a differential effect of ampD and ampE overexpression. In a nutshell, depending on the BLA, AmpD amidase moderately facilitates a varying level of serine-BLA expression whereas AmpE transporter acts likely as a negative regulator of serine-BLA.

Choroidal neovascular membrane in the macular area is one of the leading causes of severe visual loss. Usually a manifestation in elderly population, it is often associated with age-related macular degeneration. The current mainstay of management is early diagnosis, usually by fundus examination, aided by angiography and photocoagulation in selected cases. Various other modalities of treatment including surgery are being considered as alternate options, but with limited success. The purpose of this review is to briefly outline the current concepts and the management strategy from a clinician′s viewpoint.

Abstract Background Research into the relation of literacy to health status has not included measures of nutritional literacy. This may be a critical area in the study of chronic conditions such as hypertension and diabetes, which can both relate to obesity and nutrition. This paper details the development and psychometric characteristics of the Nutritional Literacy Scale (NLS), offered as a measure of adults' ability to comprehend nutritional information. Methods In order to assess the internal consistency and construct validity of the NLS, demographic data, readability statistics, NLS scores and scores on the Reading Comprehension Section of the Short Test of Functional Health Literacy in Adults (S-TOFHLA) were collected in a cross-sectional study of 341 patients from two primary care practices. Results The NLS score showed acceptable internal consistency of 0.84 by Cronbach's alpha coefficient. The Pearson correlation between the NLS and the S-TOFHLA was 0.61, supporting evidence for construct validity. Conclusion Given the importance of proper weight and nutrition in the health of the public, as well as the absence of research on literacy skills as related to nutritional concepts, the NLS has the potential to add to the national research agenda in these areas.

Introduction: Depression and anxiety are common leading causes of disability and are associated with systemic effects including cardiovascular comorbidities. Low-income populations may experience higher frequencies of depressive or anxiety-related symptoms, and be at greater risk for developing hypertension., Aim: We performed a cross-sectional study of low-income participants who completed hypertension and disability questionnaires as part of the 2017-2018 cycle of the National Health and Nutrition Examination Survey (NHANES) to identify associations between depressive/anxiety-related symptoms and hypertension status., Methods: Multivariable logistic regressions were performed to identify whether (1) frequency of depressive symptoms, (2) frequency of anxiety-related symptoms, (3) self-reported depression medication use, or (4) self-reported anxiety medication use predicted previous hypertension diagnosis., Results: A total of 74,285,160 individuals were represented in our cohort. Participants that reported taking depression (OR 2.72; 95% CI 1.41-5.24; P = 0.009) and anxiety (OR 2.50; 95% CI 1.42-4.41; P = 0.006) medications had greater odds of hypertension. Individuals with depressive feelings daily, monthly, and few times per year were more likely to have hypertension. Respondents with daily (OR 2.28; 95% CI 1.22-4.24; P = 0.021) and weekly (OR 1.88; 95% CI 1.05-3.38; P = 0.040) anxiety symptoms were more likely to have hypertension., Conclusions: Low-income adults in the United States with symptoms of anxiety or depression have higher likelihood of hypertension than those with no symptoms. Respondents who indicated taking medication for anxiety disorders or depression were more likely to have been diagnosed with hypertension., (© 2023. Italian Society of Hypertension.)

Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disorder that was first described in the late 1800s as a variant of multiple sclerosis (MS). However, it has recently been categorized, as a disease, especially with the discovery of aquaporin-4 (AQP4-Ab) and myelin oligodendrocyte glycoprotein antibodies (MOG-Ab). Unfortunately, patient presentation is not always clear, and NMOSD may initially be diagnosed as an alternative neurological disease. We present a 58-year-old woman who was hospitalized several times for what was initially perceived as a pontine stroke. However, given worsening symptoms, serologic testing confirmed AQP4-Ab positivity and, subsequently, the NMOSD diagnosis. In addition to the case report, a systematic literature review was performed to identify NMOSD cases initially misdiagnosed as stroke. Publications were selected and curated in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Six NMOSD patients were initially thought to have had acute strokes. However, steady progression and/or the recurrence of symptoms suggested that further investigations with neuroimaging studies and serological immune assays were necessary to exclude alternative etiologies. Notably, the age at onset in all cases was significantly more advanced than patients with typical NMOSD presentations (median age 32-41). In conclusion, the NMOSD diagnosis should be considered in cases with atypical stroke-like presentations, particularly those of later onset (defined as equal to or greater than 50 years of age). This is important as early recognition and treatment with immune therapies can improve functional outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Huang et al.)

Cannabis is among the most used recreational and medicinal drugs in the United States. The effects of chronic use on hypertension remain poorly understood. Our study retrospectively evaluated data collected by the National Health and Nutrition Examination Survey from 2017 to 2018. Cannabis use was measured with five metrics: (1) sustained use at any point in the past, (2) sustained use within the past year, (3) frequency of use, (4) age of first cannabis use, and (5) current use. Hypertension status was determined by individuals reporting having been diagnosed in the past. Multivariable logistic regressions were performed, controlling for age, race, and gender. A total of 4565 respondents were identified, of which 867 (19.0%) reported sustained cannabis use in the past. Participants who reported past sustained cannabis use did not have statistically different odds of having hypertension (OR: 1.12; 95% CI: .66-1.91; p = .6). Moderate (OR: 1.08; 95% CI: .36-3.25; p = .8) and highly-frequent users (OR: 1.30; 95% CI: .56-3.03; p = .4) did not have different odds of having hypertension than infrequent users. No relationship between the age of first cannabis use and hypertension was observed. The recency of sustained cannabis use was not associated with hypertension status. Current cannabis users had similar odds of hypertension as past users (OR: 1.03; 95% CI: .59-1.79; p = .9). The findings of this study indicate that neither past nor current cannabis use is associated with clinical hypertension., (© 2022 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC.)

Obstructive sleep apnea (OSA) presents as repetitive interruptions of ventilation >10 seconds during sleep as a result of upper airway obstruction resulting in increased respiratory effort. Intermittent hypoxia causes physiologic changes resulting in increased catecholamine production, increased total peripheral resistance, tachycardia, and increased venous return, leading to increased cardiac output, hypertension, tachyarrhythmias, left ventricular hypertrophy, and heart failure. OSA causes an abnormal dip on 24-hour ambulatory blood pressure monitoring. Definitive diagnosis is made by polysomnography. Continuous positive airway pressure (CPAP) remains the first-line treatment. Effective treatment using CPAP reduces blood pressure and is indispensable for proper management of atrial fibrillation., Competing Interests: Disclosure The authors have nothing to disclose, (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Elderly patients awaiting moderate to high-risk surgery may undergo nuclear stress testing (NST) in order to evaluate their cardiovascular risk. The prognostic utility of such testing in the very elderly (≥ 85 years) has yet to be fully evaluated. Octogenarians and nonogenarians frequently have a number of concurrent conditions including a high rate of coronary disease, and therefore the prognostic value of NST for their preoperative risk assessment has been questioned. Our evaluation assesses the ability of nuclear stress testing to predict peri-operative cardiac outcomes in this patient population., Aim: To investigate the ability of NST to predict peri-operative cardiac outcomes in elderly patients awaiting moderate to high-risk surgery., Methods: Patients ≥ 85 years undergoing pre-operative NST were retrospectively evaluated. Patients undergoing low-risk surgery were excluded. Major adverse cardiac events (MACE) were considered any adverse event that occurred prior to discharge and included acute heart failure, arrhythmia, acute myocardial infarction, unstable angina, or death. Associations between patient risk factors, MACE, and the obtained results of the pre-operative stress testing, ejection fraction (< 40% or ≥ 40%), summed stress score (≤ 8, ≥ 9), and the summed difference score (≤ 0, > 0) were analyzed., Results: A total of 69 patients (mean age 88 ± 2.6 years, 31 males) underwent nuclear stress testing prior to surgery. There were 41 (60%) patients found to have an abnormal NST. Sixteen (23%) patients were noted to experience post-operative MACE. No significant associations between risk factors and MACE were noted. Patients with an abnormal NST and/or a summed stress score ≥ 9 were significantly ( P < 0.01) more likely to develop peri-operative MACE., Conclusion: Indicated preoperative NST is useful to assess pre-operative risk in elderly patients ≥ 85 years undergoing moderate to high-risk surgery., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to declare., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: The lower rate of primary outcome events in the intensive treatment group in SPRINT (Systolic Pressure Intervention Trial) was associated with increased clinically significant serious adverse events (SAEs). In 2017, the American College of Cardiology/American Heart Association issued risk-based blood pressure treatment guidelines. The authors hypothesized that stratification of the SPRINT population by degree of future cardiovascular disease (CVD) risk might identify a group which could benefit the most from intensive treatment., Objectives: This study investigated the effect of baseline 10-year CVD risk on primary outcome events and all-cause SAEs in SPRINT., Methods: Stratifying by quartiles of baseline 10-year CVD risk, Cox proportional hazards models were used to examine the associations of treatment group with the primary outcome events and SAEs. Using multiplicative Poisson regression, a predictive model was developed to determine the benefit-to-harm ratio as a function of CVD risk., Results: Within each quartile, there was a lower rate of primary outcome events in the intensive treatment group, with no differences in all-cause SAEs. From the first to fourth quartiles, the number needed to treat to prevent primary outcomes decreased from 91 to 38. The number needed to harm for all-cause SAEs increased from 62 to 250. The predictive model demonstrated significantly increasing benefit-to-harm ratios (± SE) of 0.50 ± 0.15, 0.78 ± 0.26, 2.13 ± 0.73, and 4.80 ± 1.86, for the first, second, third, and fourth quartile, respectively (p for trend <0.001). All possible pairwise comparisons of between-quartile mean values of benefit-to-harm ratios were significantly different (p < 0.001)., Conclusions: In SPRINT, those with lower baseline CVD risk had more harm than benefit from intensive treatment, whereas those with higher risk had more benefit. With the 2017 American College of Cardiology/American Heart Association blood pressure treatment guidelines, this analysis may help providers and patients make decisions regarding the intensity of blood pressure treatment., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Despite the high prevalence of insomnia in veterans with epilepsy, it remains understudied. Our aim was to identify the associations of insomnia with epilepsy, comorbidities, and treatment-related variables in South Florida veterans., Methods: We performed a cross-sectional analysis of veterans attending an epilepsy clinic over 18 months. Participants completed standardized assessments of seizure and sleep. Insomnia was defined as 1) difficulty with sleep onset, maintenance, or premature awakenings with daytime consequences or 2) sedative-hypnotic use on most nights of the previous month., Results: One hundred sixty-five veterans (87% male, age 56 ± 15 years) were included: 66 reporting insomnia (40%). In logistic regression analysis, insomnia was significantly associated with post-traumatic seizure etiology, lamotrigine prescription, and mood and psychotic disorders. Female gender and levetiracetam treatment were associated with lower odds for insomnia., Conclusion: Insomnia was associated with post-traumatic epilepsy, mood/psychotic comorbidities, and antiepileptic regimen. Insomnia represents an under-recognized opportunity to improve comprehensive epilepsy care., (Published by Elsevier Inc.)

Follicular helper T cells (T(FH) cells) constitute the CD4(+) T cell subset that is specialized to provide help to germinal center (GC) B cells and, consequently, mediate the development of long-lived humoral immunity. T(FH) cell differentiation is driven by the transcription factor Bcl6, and recent studies have identified cytokine and cell-cell signals that drive Bcl6 expression. However, although T(FH) dysregulation is associated with several major autoimmune diseases, the mechanisms underlying the negative regulation of T(FH) cell differentiation are poorly understood. In this study, we show that STAT5 inhibits T(FH) cell differentiation and function. Constitutive STAT5 signaling in activated CD4(+) T cells selectively blocked T(FH) cell differentiation and GCs, and IL-2 signaling was a primary inducer of this pathway. Conversely, STAT5-deficient CD4(+) T cells (mature STAT5(fl/fl) CD4(+) T cells transduced with a Cre-expressing vector) rapidly up-regulated Bcl6 expression and preferentially differentiated into T(FH) cells during T cell priming in vivo. STAT5 signaling failed to inhibit T(FH) cell differentiation in the absence of the transcription factor Blimp-1, a direct repressor of Bcl6 expression and T(FH) cell differentiation. These results demonstrate that IL-2, STAT5, and Blimp-1 collaborate to negatively regulate T(FH) cell differentiation.

Surface acting and deep acting with customers are strategies for service performance, but evidence for their effectiveness is limited and mixed. We propose that deep acting is an effective strategy for most employees, whereas surface acting's effect on performance effectiveness depends on employee extraversion. In Study 1, restaurant servers who tended to use deep acting exceeded their customers' expectations and had greater financial gains (i.e., tips) regardless of extraversion, whereas surface acting improved tips only for extraverts, not for introverts. In Study 2, a call center simulation, deep acting improved emotional performance and increased the likelihood of extrarole service behavior beyond the direct and interactive effects of extraversion and other Big Five traits. In contrast, surface acting reduced emotional performance for introverts and not extraverts, but only during the extrarole interaction. We discuss implications for incorporating traits into emotional labor research and practice., ((c) 2011 APA, all rights reserved.)

Background: Normal or near normal myocardial perfusion stress imaging (MPI) suggests the absence of life-threatening coronary artery disease (CAD). Nevertheless, there are instances where severe left main or three-vessel CAD may be present despite no significant perfusion abnormalities on MPI., Methods: Review of Tl-201 or Tc-99m sestamibi MPI over a period of 5 years to ascertain the features that may prevent misdiagnosis. Out of 9171 tests, 3992 (44%) were interpreted as normal or near normal. For clinical reasons, 98 (2%) of these patients underwent coronary angiography within 6 months., Results: A total of 3992 patients were interpreted as normal or near normal. Seventy (22 men/48 women; 58 +/- 13 years) did not have obstructive CAD. Nine (six men/three women; 64 +/- 8 years) had either left main (n = 3), three-vessel CAD with or without left main (n = 3) or severe proximal left anterior descending (n = 3) disease. Although both normal patients and patients with CAD had similar proportions of imaging artifacts, those with severe CAD had significantly more markers of CAD (increased lung Tl-201 uptake, transient ischemic cavity dilatation, stress-induced ST-segment depression, chest pain, and/or hypotension with exercise; P < 0.01; no CAD vs. severe CAD; two-tail Fisher's Exact Test). Similarly, patients with moderate CAD by coronary angiography (n = 19), and a random sample of 250 patients (82 men/168 women; 62 +/- 14 years) with normal or near normal MPI who did not undergo coronary angiography, had similar proportions of imaging artifacts but significantly fewer markers of CAD., Conclusion: When dealing with individual patients, the referring physician and the interpreter of MPI studies should consider severe CAD when there are markers of CAD despite normal or near normal perfusion images.

Intracerebral hemorrhage (ICH) is an infrequent but severe complication in pregnant women with hypertension. The authors describe a patient with chronic hypertension who developed superimposed preeclampsia and spontaneous ICH during the thirty-fifth week of pregnancy. ICH was diagnosed by computed tomographic scan. She underwent successful emergent cesarean section and neurosurgical decompression of the ICH. Both intraoperative surveillance and postoperative magnetic resonance angiographic examination of the cerebral vessels failed to identify an aneurysm or arteriovenous malformation. The authors discuss the diagnosis and management in this case and review the literature regarding this challenging complication of pregnancy and preeclampsia. Controversies regarding treatment of hypertension during pregnancy are discussed in light of the impact on the management of this patient.

Stress myocardial perfusion imaging (MPI) plays an important role in the diagnostic and prognostic assessment of coronary artery disease (CAD) in patients of all age groups who are undergoing assessment prior to non-cardiac surgery. MPI may utilise exercise treadmill or pharmacological stress testing. While MPI has been evaluated in a wide variety of patient subpopulations, there are very limited data on its prognostic value in the elderly population, particularly those >75 years of age, who are making up an ever increasing proportion of the patient population. Because of the higher prevalence and greater severity of CAD in older patients, the sensitivity of noninvasive MPI increases with age, whereas specificity tends to decline. In addition, maximal aerobic exercise capacity tends to decrease with age, making it common practice for elderly patients being assessed for CAD to undergo pharmacological MPI to evaluate their cardiovascular risk. In this article, we review the literature with respect to cardiac risk estimation in elderly patients undergoing MPI, particularly with respect to making prognostic assessments prior to undergoing surgery. Current data allow for the proper application of stress MPI in the elderly population. Use of MPI facilitates identification of the severity and extent of ischaemia as well as left ventricular dilatation and systolic function in elderly patients undergoing non-cardiac surgery.

The main goal of current antihypertensive therapy is to achieve a lowering of intra-arterial pressure by various mechanisms. A plethora of data suggests that this reduces cardiovascular morbidity and mortality due to stroke, heart failure and to a lesser extent, ischemic heart disease. Early cardiac manifestations of chronic hypertension, left ventricular hypertrophy (LVH) and diastolic dysfunction (CHF-D) confer additional risk of cardiovascular morbidity and mortality in patients with hypertension. Regression of left ventricular (LV) mass with antihypertensive therapy is associated with improved diastolic function and overall reduction in cardiovascular events, and this benefit may be independent of actual lowering of arterial pressure. Antihypertensive therapy should therefore be geared to both lower arterial blood pressure and specifically reverse pathophysiologic processes that promote LVH and CHF-D. Emerging therapies accomplish this without specifically affecting blood pressure. Therefore, future treatments for hypertension may require a combination of drugs performing complimentary tasks in lowering arterial pressure and reversing maladaptive physiologic and genetic processes causing hypertensive heart disease. This review summarizes the current and emerging approaches to the treatment of individuals with hypertensive heart disease.

Aim: The authors wished to compare the strength of association of several anthropometric measures of body size and fat distribution among themselves and in comparison with other known risk factors for prevalent coronary heart disease (CHD)., Methods: Prevalent CHD was assessed in 466 middle-aged, male, multiracial Triborough Bridge and Tunnel Authority officers in New York City by verified history, electrocardiogram or exercise stress test. Anthropometric measures included body mass index, waist, hip and thigh circumferences, waist-hip ratio, waist-thigh ratio, sagittal abdominal diameter and abdominal diameter index (sagittal abdominal diameter/thigh circumference). Results were compared with other CHD risk factors measured simultaneously (history of diabetes, smoking, blood pressure, lipid profile, apolipoproteins A and B, lipoprotein (a), homocysteine, fibrinogen, urinary microalbumin, serum vitamin E and ferritin) and a calculated 10-year CHD risk using a Framingham algorithm (10-year Framingham CHD risk)., Results: CHD was found in 29 individuals. Of the six anthropometric measures, abdominal diameter index gave the largest and most significant standardized odds ratio (OR) for CHD [1.80, 95% confidence interval (CI) 1.20, 2.71], equivalent to 10-year Framingham CHD risk. Men in the highest compared with the lowest tertile of abdominal diameter index had a univariate OR of 5.47 (95% CI 1.55, 19.28) which was the only anthropometric measure that remained significant after adjusting for 10-year Framingham CHD risk., Conclusions: For middle-aged American men, abdominal diameter index may be the most powerful anthropometric measure of risk for prevalent CHD.

Left ventricular hypertrophy (LVH) and diastolic dysfunction (CHF-D) are the early manifestations of cardiovascular target organ damage in patients with arterial hypertension and signify hypertensive heart disease. Identification of hypertensive heart disease is critical, as these individuals are more prone to congestive heart failure, arrhythmias, myocardial infarction and sudden cardiac death. Regression of left ventricular (LV) mass with antihypertensive therapy decreases the risk of future cardiovascular events. The goal of antihypertensive therapy is to both lower blood pressure (BP) and interrupt BP-independent pathophysiologic processes that promote LVH and CHF-D. The purpose of this review is to summarize current and emerging approaches to the pathophysiology and treatment of hypertensive heart disease.

Left ventricular hypertrophy (LVH) and diastolic dysfunction (CHF-D) are early signs of cardiac end-organ damage (hypertensive heart disease) in patients with arterial hypertension. The presence of LVH or CHF-D confers increased risk of cardiovascular morbidity and mortality in patients with hypertension. Regression of left ventricular mass with antihypertensive therapy is associated with reduction in cardiovascular events. Antihypertensive therapy should be geared to both lower blood pressure and specifically reverse the pathophysiologic processes that may be independent of actual blood pressure. This review summarizes current and emerging approaches to the treatment of individuals with hypertensive heart disease.

The presence of left ventricular hypertrophy (LVH) confers markedly increased risk of cardiovascular morbidity and mortality in patients with hypertension. Regression of left ventricular (LV) mass with antihypertensive therapy is associated with reduction in cardiovascular events. In studies based on monotherapy, among the classes of antihypertensive drugs that have been adequately tested, diuretics and angiotensin-converting enzyme inhibitors appear to be the most effective agents for reducing LV mass. New avenues of research, based on combination antihypertensive therapy and on a more sophisticated understanding of the molecular mechanisms of LVH, may yield new pharmacologic approaches to regressing LV mass.

While essential hypertension is very prevalent, secondary hypertension does occur in clinical practice with sufficient frequency to warrant special attention being given to those patients with severe hypertension who do not respond to standard treatments. The evaluation, diagnosis and treatment of secondary hypertension pose interesting challenges to the physician. In this article, three patients are described with different secondary causes of hypertension.

Background: Female gender and hormonal status affect electrocardiographic (ECG) response to exercise. Both are often cited as factors contributing to the decreased diagnostic accuracy of exercise stress tests in women. However, there is a paucity of data. To explore the relationship between hormonal status and exercise-induced ECG changes, we used gated single photon emission computed tomography (SPECT) technetium 99m sestamibi imaging for detection of myocardial ischemia., Methods and Results: ECG response to exercise was analyzed in all female patients who underwent symptom-limited exercise stress testing over a 12-month period with no evidence of ischemia on SPECT myocardial perfusion imaging (N = 404). Hormonal status was defined as premenopausal (n = 78), postmenopausal (n = 277), and postmenopausal on hormone replacement therapy (HRT) (n = 49). Positive ECG response for ischemia was defined as 1 mm or greater horizontal and/or downsloping ST depression during and/or after exercise. The frequency of a positive ECG response to exercise without evidence of ischemia on gated SPECT imaging was analyzed according to hormonal status. Seventeen of 78 premenopausal women (22%), 48 of 277 postmenopausal women (17%), and 19 of 49 women taking HRT (39%) had a positive ECG response. ECG positivity was significantly higher in HRT users when compared with premenopausal (P =.05) and postmenopausal women (P =.001)., Conclusions: Exogenous estrogen replacement therapy affects ST-segment response to exercise, likely through a nonischemic mechanism. Unless HRT can be discontinued for a prolonged period of time (up to 6 weeks) prior to a stress test, myocardial imaging should be used to improve diagnostic accuracy.

Diastolic dysfunction in patients with hypertension may present as asymptomatic findings on noninvasive testing, or as fulminant pulmonary edema, despite normal left ventricular systolic function. Up to 40% of hypertensive patients presenting with clinical signs of congestive heart failure have normal systolic left ventricular function. In this article we review the pathophysiologic factors affecting diastolic function in individuals with diastolic function, current and emerging tools for measuring diastolic function, and current concepts regarding the treatment of patients with diastolic congestive heart failure.

Diffusely impaired coronary blood flow reserve is difficult to measure non-invasively. We developed and tested a quantitative non-invasive method of measuring coronary blood flow reserve using thallium-201 perfusion imaging. Ten anesthetized dogs were injected simultaneously at rest with thallium-201 and either Ru-103 or Sn-113 microspheres. SPECT images were obtained followed by varying doses of intravenous adenosine, and a second thallium-201 dose was injected simultaneously with either Nb-95 or Sc-46 microspheres. SPECT images were then repeated. The heart was removed, sectioned and counted, along with arterial blood samples. Blood flow was calculated at rest and stress. Peak resting counts in four regions in each of three SPECT slices were subtracted from stress values and stress/rest thallium-201 count ratios (coronary flow reserve (CFR)) were calculated and correlated with the corresponding microsphere flow ratios. Overall correlation of the imaging and microsphere flow ratios was 0.77 (p = 0.0001). Regional correlation coefficients ranged from 0.65-0.86 (p = 0.0001). Coronary blood flow reserve ratios by the microsphere method ranged from 0.7 to 5.3, and by thallium-201 imaging from 0.33-2.45. The non-invasively measured coronary blood flow reserve with thallium-201 imaging and adenosine stress correlates well with microsphere-measured coronary blood flow reserve over a wide range of coronary flows, and should be useful in clinical studies of CFR impairment.