Search

BackgroundSystemic hypoperfusion plays a pivotal role in the pathogenesis of primary open-angle glaucoma (POAG). Extreme dips in mean arterial pressure (MAP) due to high 24-h variability are associated with POAG, however, whether this is driven by diurnal or nocturnal dips remains undocumented. We aimed this study to investigate the association of POAG damage with variability and dips in the diurnal and nocturnal MAP.MethodsWe conducted a retrospective longitudinal study that included 110 POAG patients who underwent 24-h ambulatory blood pressure monitoring. Our outcomes included (i) functional [visual field defects expressed as mean deviation (MD)] and (ii) structural (optic disc cupping obtained from cup-to-disc ratio) glaucoma damage. MAP variability independent of the mean (VIMmap) was computed for diurnal and nocturnal MAP. Dips were the five diurnal and three nocturnal lowest drops in MAP. We also calculated the night-to-day ratio. We applied mixed models to evaluate the progression of visual field defects and optic disc cupping in relation to diurnal and nocturnal MAP measures.ResultsThe mean age was 64.0 y (53% women). The median follow-up was 9 years. In adjusted mixed models, functional progression of glaucoma damage was associated with VIMmap (−2.57 dB change in MD per every 3 mmHg increase in VIMmap; P < 0.001) and diurnal MAP dips (changes in the MD ranged from −2.56 to −3.19 dB; P < 0.001). Every 5 mmHg decrease in the nocturnal MAP level was associated with −1.14 dB changes in MD [95% confidence interval (CI), −1.90 to −0.40] and 0.01 larger optic disc cupping (95% CI, 0.01–0.02). Lower night-to-day ratio was also related to both outcomes (P ≤ 0.012). Functional glaucoma damage worsened if nocturnal hypotension was combined with high variability or extreme dips in the diurnal MAP (P ≤ 0.022).ConclusionProgression of glaucoma damage in POAG associates with high variability and extreme dips in the diurnal MAP. Structural glaucoma damage seems more vulnerable to nocturnal hypotension. Ambulatory blood pressure monitoring allows the assessment of sporadic diurnal and persistent nocturnal hypotension episodes. These phenotypes might offer an opportunity to improve the risk-stratification of open-angle glaucoma (OAG).

AIM: To investigate the relationship among sleep apnea hypopnea syndrome(SAHS), nocturnal hypotension(NHP)and nonarteritic anterior ischmic optic neuropathy(NAION). METHODS:The retrospective study participants included 31 patients with NAION and 31 age- and sex-matched controls. Twenty-four hour ambulatory blood pressure monitoring was used to evaluate the presence of NHP in NAION group and in control group. Berlin questionnaire was involved to evaluate the risk of SAHS. All participants underwent full-night respiratory polysomnography for monitoring apnea-hypopnea index(AHI), minimum oxygen saturation(MOS). RESULTS: Totally 23 NAION patients(74%)presented with NHP, which was found in 14 control subjects(45%). The incidence of NHP was significantly higher among NAION patients compared to the controls(P=0.020). Of the 31 NAION patients, 22 patients(71%)had SAHS, compared to 13(42%)control subjects. Logistic regression analysis showed that NHP(OR=2.762, 95% CI: 1.275-3.746), AHI(OR=2.959, 95% CI: 1.478-6.432)and MOS(OR=3.058, 95% CI: 1.734-7.743)were risk factors for NAION.CONCLUSION: SAHS and NHP were related with NAION. Taking precautions against SAHS and NHP may be crucial to the prevention and cure of NAION.

AIM Although nocturnal hypotension is considered the key factor responsible for the increased cardiovascular risk associated with the extreme dipping (ED) pattern, no information is available on its prevalence in this setting. Therefore, we have assessed this topic in a cohort of patients referred to a single out-patient hypertension center. METHODS A large database of individual 24-hour ambulatory BP recordings from untreated individuals with a history of hypertension and treated individuals with hypertension was analyzed. RESULTS A total of 339 of 7,074 patients (4.5%) exhibited an ED pattern (207 had a nighttime reduction in both systolic and diastolic BP ≥ 20% compared to daytime values and 132 a nighttime reduction in diastolic BP ≥ 20%). Among patients with ED, the prevalence of nocturnal hypotension varied from 9.1% to 45.0% depending on the criteria used (i.e. mean nighttime BP < 90/50 mm Hg or < 100/60 mm Hg), and the prevalence of nocturnal hypertension (i.e. mean nighttime BP ≥ 120/70 mm Hg) was 19.5%. Compared with untreated patients, those taking antihypertensive drugs were more likely to have nocturnal hypotension and less likely to have nocturnal hypertension. CONCLUSIONS Our findings support the view that ED pattern is a condition not always associated with nocturnal hypotension because a large fraction of ED patients has normal or elevated mean BP nocturnal values. [ABSTRACT FROM AUTHOR]

"Blindness upon awakening" occurs in a significant proportion of patients with non-arteritic anterior ischemic optic neuropathy (NAION). This observation has led to a notion that nocturnal hypotension is a significant contributor and, perhaps, the final insult in a multifactorial process leading to the development of NAION, as has been proposed in other ischemic events like strokes, myocardial infarction, and ischemic rest pain. An extension of this concept has led to the recommendation that patients who have experienced NAION avoid taking blood pressure medications at bedtime. However, mounting evidence in the cardiology literature suggests that nocturnal hyper tension is associated with increased risk of cardiovascular morbidity. In two prospective blood pressure monitoring studies in 1994 and 1999, Hayreh observed an extreme dipping pattern in nocturnal systolic blood pressure in NAION patients compared to reported normal values. Yet, two subsequent ambulatory blood pressure studies found either normal or non-dipping patterns in NAION patients. The majority of clinical trials published since 1976 that have studied nocturnal administration of antihypertensives have reported enhanced blood pressure control and reduced cardiovascular risk. Most notably, the large, prospective 2020 Hygia Chronotherapy Trial reported a statistically-significant beneficial effect of nocturnal antihypertensive dosing on cardiovascular outcomes and mortality. The controversy regarding nocturnal hypotension and NAION is of increasing relevance as there is new evidence to suggest a beneficial effect of nocturnal antihypertensive dosing in cardiovascular risk. This new information should prompt a re-evaluation of the relevant risk-to-benefit of reducing the risk of NAION on one hand, and the potential increase of cardiovascular risk on the other. Definitive resolution of this question would require a prospective, randomized control study with input from both cardiology and ophthalmology.

Ocular blood flow is thought to play an important role in the development of primary open-angle glaucoma (POAG). Whereas there is a large body of evidence evaluating the role of static blood flow in POAG, a growing amount of research focuses on dynamic blood flow and glaucoma, specifically, the autoregulation of blood flow to ocular tissues and its dysfunction in POAG. Autoregulation is defined here as the maintenance of tissue perfusion in light of changes in vascular hemodynamics. This article reviews the clinical evidence of autoregulatory dysfunction in POAG patients and further focuses on the vascular anatomy, physiology and animal and human studies pertinent to the study of autoregulation and POAG. [ABSTRACT FROM AUTHOR]

Background: Systemic hypoperfusion plays a pivotal role in the pathogenesis of primary open-angle glaucoma (POAG). Extreme dips in mean arterial pressure (MAP) due to high 24-h variability are associated with POAG, however, whether this is driven by diurnal or nocturnal dips remains undocumented. We aimed this study to investigate the association of POAG damage with variability and dips in the diurnal and nocturnal MAP., Methods: We conducted a retrospective longitudinal study that included 110 POAG patients who underwent 24-h ambulatory blood pressure monitoring. Our outcomes included (i) functional [visual field defects expressed as mean deviation (MD)] and (ii) structural (optic disc cupping obtained from cup-to-disc ratio) glaucoma damage. MAP variability independent of the mean (VIMmap) was computed for diurnal and nocturnal MAP. Dips were the five diurnal and three nocturnal lowest drops in MAP. We also calculated the night-to-day ratio. We applied mixed models to evaluate the progression of visual field defects and optic disc cupping in relation to diurnal and nocturnal MAP measures., Results: The mean age was 64.0 y (53% women). The median follow-up was 9 years. In adjusted mixed models, functional progression of glaucoma damage was associated with VIMmap (-2.57 dB change in MD per every 3 mmHg increase in VIMmap; P < 0.001) and diurnal MAP dips (changes in the MD ranged from -2.56 to -3.19 dB; P < 0.001). Every 5 mmHg decrease in the nocturnal MAP level was associated with -1.14 dB changes in MD [95% confidence interval (CI), -1.90 to -0.40] and 0.01 larger optic disc cupping (95% CI, 0.01-0.02). Lower night-to-day ratio was also related to both outcomes ( P ≤ 0.012). Functional glaucoma damage worsened if nocturnal hypotension was combined with high variability or extreme dips in the diurnal MAP ( P ≤ 0.022)., Conclusion: Progression of glaucoma damage in POAG associates with high variability and extreme dips in the diurnal MAP. Structural glaucoma damage seems more vulnerable to nocturnal hypotension. Ambulatory blood pressure monitoring allows the assessment of sporadic diurnal and persistent nocturnal hypotension episodes. These phenotypes might offer an opportunity to improve the risk-stratification of open-angle glaucoma (OAG)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Melgarejo, Eijgen, Wei, Maestre, Al-Aswad, Liao, Mena, Vanassche, Janssens, Verhamme, Keer, Stalmans and Zhang.)

Normotensive glaucoma is a form of primary open angle glaucoma in which intraocular pressure remains within the normal range. A normotensive glaucoma patient with extreme nocturnal blood pressure dipping is herein presented. A 75-year-old male patient who had a history of drug use for benign prostate hyperplasia admitted to our glaucoma clinic. Optic disc examination of both eyes showed peripapillary atrophy and glaucomatous cupping. Intraocular pressures were 12 mmHg in the right eye and 11 mmHg in the left eye. Bilateral nasal steps and early superior arcuate defect were observed in visual field testing. In our case the mean blood pressure fell by %24 at night. Ambulatory blood pressure monitoring exhibited excessive dips between 03:15 and 06:45 AM. This case report emphasizes the importance of determining nocturnal blood pressure dips due to systemic medication in normotensive glaucoma patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: We aimed to evaluate the presence of nocturnal hypotension (NHP) in ischemic stroke (IS) survivors using ambulatory blood pressure (BP) monitoring (ABPM). Methods: We included fifty consecutive patients presenting at our outpatient clinic for review and who had been discharged for IS in the previous six months. 24-h ABPM was performed with Spacelab 90207 monitor. NHP episodes were considered those values on which the mean arterial pressure (MAP)<70mm Hg. Patients were divided into two groups according to the presence or absence of NHP. Results: We studied 31 men and 19 women, mean age 68±11years. Episodes of NHP were observed in 21 patients (42%). There were no significant differences with regard to clinical characteristics between groups. With regard to BP, patients with NHP had significantly lower mean 24-hour BPs, mean daytime BPs and mean nighttime BPs. Dipper pattern occurred more often in patients with NHP, although differences were only statistically significant in the diastolic BP values. Mean office readings were 142±26/77±13mm Hg (149±26 versus 133±20; P=0.06; 82±12 versus 71±12; P=0.008). None of the patients showed office SBP <90mmHg and only four had office DBP <60mmHg. Conclusions: Episodes of NHP in patients with recent IS are common and difficult to detect with clinical cuff measurements. It is necessary to redefine the target BP levels in secondary stroke prevention, possibly because we are subjecting our patients to increased risk of NHP and cerebral hypoperfusion. [Copyright &y& Elsevier]

Abstract: Background: Nonarteritic ischemic optic neuropathy (NAION) is the most common acute optic neuropathy in adults over the age of 50. Patients affected notice sudden and painless loss of vision in 1 eye, often upon awaking. Studies have found that the opposite eye may be affected in approximately 15% to 20% of cases within a 5-year period. NAION vision loss results from an ischemic event often affecting the short posterior ciliary arteries. This results in optic nerve pallor, nerve fiber layer defects, and corresponding visual field defects. Case Reports: Two cases of NAION are discussed here. The first patient, a 57-year-old woman, had a 10-year history of visual symptoms, and the second, a 66-year-old man, presented in less than a week after first noticing symptoms. Both had predisposing systemic risk factors and resultant visual field loss and decreased visual acuity. Conclusions: Predisposing factors for NAION include small cup-to-disc ratios of the optic nerve, obstructive sleep apnea, nocturnal hypotension, diabetes, and other vascular diseases. The vision loss is irreversible, and there is no known effective treatment to prevent subsequent disc atrophy or recurring episodes. [ABSTRACT FROM AUTHOR]

Background: Patients diagnosed with Parkinson's disease (PD) on clinics who subsequently turn out to have normal dopamine transporter images have been referred to as scans without evidence of dopaminergic deficits (SWEDDs) patients. Cardiovascular autonomic dysfunction has frequently been reported in PD. In this study, we determined the similarities and differences in cardiac autonomic dysfunction between SWEDDs and PD patients. This study investigated whether 24-hour ambulatory blood pressure monitoring (24-hour ABPM) can help identify possible cases with SWEDDs., Methods: We enrolled 28 SWEDDs patients, 46 patients with PD, and 30 healthy controls. To evaluate cardiac autonomic function, 24-hour ABPM was performed on all subjects. Cardiac metaiodobenzylguanidine (MIBG) scintigraphy was performed on the SWEDDs and PD subjects., Results: The percentage nocturnal decline in blood pressure differed significantly among SWEDDs patients, PD patients, and controls (p<0.05). In addition to the abnormal nocturnal BP, regulation (nondipping and reverse dipping) was significantly higher in SWEDDs and PD subjects than in the control subjects (p<0.05). There was no significant correlation between the % nocturnal blood pressure reduction and parameters of cardiac MIBG uptake ratio. However, orthostatic hypotension was significant correlated with the nocturnal blood pressure dip (%), nocturnal blood pressure patterns, and the cardiac MIBG uptake ratio (early and late) in combined SWEDDs and PD subjects., Conclusions: Pathologic nocturnal blood pressure regulation and nocturnal hypertension, known characteristics of PD, are also present in SWEDDs. Moreover, cardiac sympathetic denervation should not be attributed to cardiac autonomic dysfunction in SWEDDs patients. As with PD patients, the SWEDDs patients studied here tended to have cardiac autonomic dysfunction.