[Telemedical-Supported Screening of Retinal Vessels ("Talking Eyes").]

[Article in German]

Michelson G, Groh M, Groh MJ, Baleanu D, Harazny J, Horstmann R, Kolominsky-Rabas P.

Augenklinik mit Poliklinik, Universitat Erlangen-Nurnberg. georg.michelson rzmail.uni-erlangen.de.

BACKGROUND: Cerebral and retinal vessels behave similarly under the influence of vascular risk factors. Several groups have shown that retinal microvascular abnormalities represent an independent risk factor with regard to strokes and heart attacks. AIM OF THE STUDY: The aim of this study was to perform a prospective screening examination with regard to retinal microvascular abnormalities as well as an extended vessel diagnosis in a subgroup of patients with lower arteriovenous risk values. Methods: In the course of a prospective cross-sectional study ("Talking Eyes") between 1.9.2001 and 1.8.2002 a telemedical-supported screening of the retina (study I) was carried out in 7,163 subjects. The patients were selected without any inclusion or exclusion criteria. The mean age was 48.2 +/- 8 years (18 - 83 years) with a sex distribution of 39.2 % females to 60.8 % males. Digital fundus photos of the right and left eyes were taken for all patients. The pictures were taken without pupil dilation using a CANON-NM camera. The pictures and case histories were stored in a central server using web-based software (MedStage, Siemens). In a central reading centre, the arteriovenous ratio of both eyes was determined telemedically using the Parr-Hubbard formula and the retinas subjected to a standardised examination by an ophthalmologist. The retinal risk factor was calculated on the basis of the arteriovenous ration, the presence of microvascular abnormalities and the case history. The reproducibility of measurement of the arteriovenous ratio (Kronbach alpha coefficient) was evaluated by double measurements on 1,332 images. In a subgroup of study I with arteriovenous ratio values < 0.76 (N = 107), an extended vessel diagnosis with measurement of 24-h blood pressure and vessel-relevant blood values (homocysteine, cholesterol, LDL, HDL, CRP, TG, HbA1c) was carried out (study II). RESULTS: Study I: The Kronbach alpha coefficient as a measure of reproducibility amounted to 0.77. The mean arteriovenous ratio of the retinal vessels was 0.83 +/- 0.09 and showed a pronounced age dependence (R = 0.9, p < 0.0001). On multivariate testing the arteriovenous ratio correlated significantly (R = 0.33, p < 0.001) with the factors age, systolic blood pressure, diastolic blood pressure and body mass index. Diastolic blood pressure followed by age had the largest influence. The prevalence of microvascular abnormalities in the right (RE) and left (LE) eyes, respectively were: cotton wool foci RE 0.0015 %, LE 0.003 %, retinal haemorrhage RE 0.1 %, LE 0.1 %, focal stenoses RE 3.4 %, LE 3.4 %, tortuositas vasorum RE 4.1 %, LE 4.0 %, arteriovenous crossing signs RE 11.2 %, LE 11.2 %. On multivariate testing the occurrence of microvascular abnormalities correlated significantly (R = 0.38, p < 0.001) with the factors high blood pressure known from case history, body mass index, and gender. Arterial hypertension had the strongest influence followed by diastolic blood pressure. The calculated retinal risk factor correlated with the prevalence of angina pectoris. Study II: 2/3 of the subjects with arteriovenous risk factor values < 0.76 exhibited pathologically high 24-h blood pressure values. For these patients there were significant correlations between the arteriovenous ratio and the low-density lipoprotein concentration as well as the Framingham risk score. CONCLUSION: In the course of a prospective, telemedical-supported screening examination of the retinal vessels of more than 7,000 subjects the arteriovenous ratio exhibited a strong dependence on age and blood pressure. Among the subjects with lowered arteriovenous ratio values, 2/3 exhibited arterial hypertension in the 24-h blood pressure determination.

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A Comparison of the Vasotrac with Invasive Arterial Blood Pressure Monitoring in Children After Pediatric Cardiac Surgery.

Cua CL, Thomas K, Zurakowski D, Laussen PC.

Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115. peter.laussen cardio.chboston.or.

The Vasotrac is a device that provides near-continuous and noninvasive arterial blood pressure monitoring and may be an alternative to direct intraarterial measurement. It has been evaluated in adult patients, but minimal information is available for pediatric patients. We evaluated agreement between measurements of arterial blood pressure and heart rate obtained from the Vasotrac versus an arterial catheter in a pediatric population. Children undergoing corrective cardiac surgery were enrolled. Simultaneous arterial blood pressure measurements were obtained postoperatively from the Vasotrac unit and an arterial catheter. Bland-Altman plots were constructed to assess agreement. Paired correlation analysis, bias, and precision calculations were performed. Sixteen patients, mean age 10.1 +/- 2.3 yr and weight 34.6 +/- 11.9 kg, were enrolled. Four-thousand-one- hundred- two paired measurements were obtained. Arterial blood pressures measured noninvasively correlated with catheter measurements with Pearson r values of 0.90, 0.80, and 0.91 for systolic, diastolic, and mean arterial blood pressures, respectively (all P < 0.001). There was excellent agreement between arterial blood pressure measurement methods. Absolute mean differences based on mixed-model regression with 95% confidence intervals were 4.0 mm Hg (3.0-5.0 mm Hg), 4.3 mm Hg (3.1-5.5 mm Hg), and 3.5 mm Hg (2.5-4.0 mm Hg) for systolic blood pressure, diastolic blood pressure, and mean blood pressure, respectively. Arterial blood pressure measurements obtained from the Vasotrac agreed well with invasive arterial monitoring in pediatric patients.

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Control of Hypertension in Elderly Patients Receiving Primary Care in Spain.

[Article in English, Spanish]

Rodriguez Roca GC, Artigao Rodenas LM, Llisterri Caro JL, Alonso Moreno FJ, Banegas Banegas JR, Lou Arnal S, Perez Llamas M, Raber Bejah A, Pacheco Lopez R.

Centro de Salud de La Puebla de Montalban. Toledo. Espana.

Introduction and objectives. Little information is available about the control of arterial hypertension in the elderly population. The aim of this study was to investigate hypertension control, factors associated with poor control, and general practitioners' responses to poor control in a large sample of hypertensive patients aged 65 years or older receiving primary care in Spain. Patients and method. A cross-sectional study of elderly hypertensive patients taking antihypertensives was carried out. Blood pressure was measured in the standard manner. Blood pressure control was regarded as optimum if pressure averaged less than 140/90 mm Hg or, in diabetics, less than 130/85 mm Hg. RESULTS. The study included 5970 patients (mean age, 72.4 years; 62.8% women). Both systolic and diastolic blood pressures were well controlled in 33.5% of patients, systolic blood pressure alone in 35.5%, and diastolic blood pressure alone in 76.2%. Blood pressure control was found to be good more frequently when it was assessed in the evening (39.8%; P<.001), and when patients had taken treatment on the day of assessment (35.1%; P <.001). Some 12.9% of diabetics had pressures less than 130/85 mmHg and 9.7% had pressures less than 130/80 mmHg. General practitioners modified their therapeutic approach with only 17.2% of poorly controlled patients. CONCLUSIONS. Arterial blood pressure control was optimum in only three out of 10 Spanish hypertensive patients aged 65 years or older. Blood pressure control assessment was significantly influenced by surgery hours and by the timing of antihypertensive intake. General practitioners' therapeutic responses to poor control were too conservative.

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Circadian and short-term regulation of blood pressure and heart rate in transgenic mice with cardiac overexpression of the beta1-adrenoceptor.

Witte K, Engelhardt S, Janssen BJ, Lohse M, Lemmer B.

Institute of Pharmacology and Toxicology, University of Heidelberg, Mannheim, Germany.

Congestive heart failure is associated with a loss of circadian and short-term variability in blood pressure and heart rate. In order to assess the contribution of elevated cardiac sympathetic activity to the disturbed cardiovascular regulation, we monitored blood pressure and heart rate in mice with cardiac overexpression of the beta1-adrenoceptor prior to the development of overt heart failure. Telemetry transmitters for continuous monitoring of blood pressure and heart rate were implanted in 8 to 9-week-old wildtype and transgenic mice, derived from crosses of heterozygous transgenic (line beta1TG4) and wildtype mice. Cardiovascular circadian patterns were analyzed under baseline conditions and during treatment with propranolol (500mg/L in drinking water). Short-term variability was assessed by spectral analysis of beat-to-beat data sampled for 30min at four circadian times. Transgenic beta1TG4 mice showed an increase in 24h heart rate, while blood pressure was not different from wildtype controls. Circadian patterns in blood pressure and heart were preserved in beta1TG4 mice. Addition of propranolol to the animals' drinking water led to a reduction in heart rate and its 24 h variation in both strains of mice. Short-term variability in blood pressure was not different between wildtype and beta1TG4 mice, but heart rate variability in the transgenic animals showed a rightward shift of the high-frequency component in the nocturnal activity period, suggesting an increase in respiratory frequency. In conclusion, the present study shows that both the circadian and the short-term regulation of blood pressure and heart rate are largely preserved in young, nonfailing beta1-transgenic mice. This finding suggests that the loss of blood pressure and heart rate variability observed in human congestive heart failure cannot be attributed solely to sympathetic overactivity but reflects the loss of adrenergic responsiveness to changes in the activity of the autonomic nervous system.

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Understanding blood pressure variability: spectral indices as a function of gender and age.

Sollers JJ 3rd, Merritt MM, Silver RA, Evans MK, Zonderman AB, Thayer JF.

National Institute on Aging, 5600 Nathan Shock Drive, Baltimore, MD 21224, USA.

Typically, blood pressure variability has been calculated by taking the simple mathematical standard deviations of a collection of discrete blood pressure (BP) measurements. Recently, spectral analytic techniques have been employed to examine beat-to-beat blood pressure variability and the underlying autonomic adjustments associated with the performance of various tasks. In the present study, beat-to-beat blood pressure was examined in 104 older African-Americans males and females who were part of the Healthy Aging in Nationally Diverse Longitudinal Samples (HANDLS) Study. Participants evaluated faces and sentences depicting emotional content and rested before (Baseline) and after (Recovery) the tasks. There were no significant gender effects in any analyses. In addition, there were no significant task effects. However, there was a trend for both low and high frequency systolic blood pressure variability to decrease linearly from baseline, through faces and sentences to recovery. Interestingly, both systolic and diastolic high frequency blood pressure variability was greater in older as compared to younger adults. Increased blood pressure variability has been associated with greater sheer stress and greater end organ damage. These results will explicate the effects of aging on cardiovascular disease risk. Overall, these data indicate that blood pressure variability derived via spectral analytic techniques is a useful tool for understanding cardiodynamics and may provide a more in-depth analysis of blood pressure response.

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[Changes in the blood pressure and methods of blood pressure monitoring in patients with type 1 diabetes.]

[Article in Polish]

Pankowska E, Golicka D.

Both diabetes mellitus and hypertension are major risk factors for cardiovascular, renal and atherosclerothic vascular disease. Hypertension is known to be more common in patients with diabetes than in the general population. Patients with diabetes mellitus are at high risk for renal injury, which may be exacerbated by abnormalities in circadian blood pressure pattern. Ambulatory blood pressure monitoring (ABPM) permits the observation of blood pressure throughout day and night in a non - medical environment, and to quantify the circadian blood pressure variability. Recent studies with the use of ambulatory - blood pressure monitoring have shown that the physiological nocturnal fall in blood pressure is blunted or absent in some individuals with type 1 diabetes who are completely normotensive by conventional criteria. Patients with type 1 diabetes and microalbuminuria have higher nocturnal blood pressure than either patients with type 1 diabetes and normal albumin excretion or age - matched controls. Moreover, changes in the circadian pattern of blood pressure in patients with type 1 diabetes may predict the development of albuminuria.

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Control of Hypertension in Adults With Chronic Kidney Disease in the United States.

Peralta CA, Hicks LS, Chertow GM, Ayanian JZ, Vittinghoff E, Lin F, Shlipak MG.

General Internal Medicine Section, San Francisco Veterans Affairs Medical Center, California; Division of Nephrology, Department of Medicine, University of California San Francisco; Department of Epidemiology and Biostatistics, University of California San Francisco; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Mass; and Department of Health Care Policy, Harvard Medical School, Boston, Mass.

Although improved control of hypertension is known to attenuate progression of chronic kidney disease (CKD), little is known about the adequacy of hypertension treatment in adults with CKD in the United States. Using data from the Fourth National Health and Nutrition Survey, we assessed adherence to national hypertension guideline targets for patients with CKD (blood pressure <130/80 mm Hg), we assessed control of systolic (<130 mm Hg) and diastolic (<80 mm Hg) blood pressure, and we evaluated determinants of adequate blood pressure control. Presence of CKD was defined as glomerular filtration rate <60 mL/min per 1.73 m(2) or presence of albuminuria (albumin:creatinine ratio >30 microg/mg). Multivariable logistic regression with appropriate weights was used to determine predictors of inadequate hypertension control and related outcomes. Among 3213 participants with CKD, 37% had blood pressure <130/80 mm Hg (95% confidence interval [CI], 34.5% to 41.8%). Of those with inadequate blood pressure control, 59% (95% CI, 54% to 64%) had systolic >130 mm Hg, with diastolic </=80 mm Hg, whereas only 7% (95% CI, 3.9 to 9.8%) had a diastolic pressure >80 mm Hg, with systolic blood pressure </=130 mm Hg. Non-Hispanic black race (odds ratio [OR], 2.4; 95% CI, 1.5 to 3.9), age >75 years (OR, 4.7; 95% CI, 2.7 to 8.2), and albuminuria (OR, 2.4; 95% CI, 1.4 to 4.1) were independently associated with inadequate blood pressure control. We conclude that control of hypertension is poor in participants with CKD and that lack of control is primarily attributable to systolic hypertension. Future guidelines and antihypertensive therapies for patients with CKD should target isolated systolic hypertension.

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Elevated Blood Pressure and Risk of End-stage Renal Disease in Subjects Without Baseline Kidney Disease.

Hsu CY, McCulloch CE, Darbinian J, Go AS, Iribarren C.

Departments of Medicine, University of California, San Francisco.

BACKGROUND: Many cases of end-stage renal disease (ESRD) are ascribed to hypertension. However, because renal disease itself can raise blood pressure, some investigators argue that ESRD seen in patients with hypertension is due to underlying primary renal disease. Previous cohort studies of the relationship between blood pressure and ESRD did not uniformly screen out baseline kidney disease. METHODS: We conducted a historical cohort study among members of Kaiser Permanente of Northern California, a large integrated health care delivery system. The ESRD cases were ascertained by matching with the US Renal Data System registry. RESULTS: A total of 316 675 adult Kaiser members participated in the Multiphasic Health Checkups from 1964 to 1985. All subjects had estimated glomerular filtration rates of 60 mL /min per 1.73 m(2) or higher and negative dipstick urinalysis results for proteinuria or hematuria. During 8 210 431 person-years of follow-up, 1149 cases of ESRD occurred. Compared with subjects with a blood pressure less than 120/80 mm Hg, the adjusted relative risks for developing ESRD were 1.62 (95% confidence interval [CI], 1.27-2.07) for blood pressures of 120 to 129/80 to 84 mm Hg, 1.98 (95% CI, 1.55-2.52) for blood pressures of 130 to 139/85 to 89 mm Hg, 2.59 (95% CI, 2.07-3.25) for blood pressures of 140 to 159/90 to 99 mm Hg, 3.86 (95% CI, 3.00-4.96) for blood pressures of 160 to 179/100 to 109 mm Hg, 3.88 (95% CI, 2.82-5.34) for blood pressures of 180 to 209/110 to 119 mm Hg, and 4.25 (95% CI, 2.63-6.86) for blood pressures of 210/120 mm Hg or higher. Similar associations between blood pressure level and ESRD risk were seen in all subgroup analyses. CONCLUSIONS: Even relatively modest elevation in blood pressure is an independent risk factor for ESRD. The observed relationship does not appear to be due to confounding by clinically evident baseline kidney disease.

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