Decline in blood pressure over time and risk of dementia: a longitudinal study from the Kungsholmen project.

Qiu C, von Strauss E, Winblad B, Fratiglioni L.

Aging Research Center, Division of Geriatric Epidemiology and Medicine, Department of Neurotec, Karolinska Institutet, Stockholm, Sweden. chengxuan.qiu neurotec.ki.se

BACKGROUND AND PURPOSE: Low blood pressure has been related to an increased risk of dementia. We sought to verify blood pressure variations before and after a dementia diagnosis and to relate blood pressure decline to subsequent Alzheimer disease and dementia. METHODS: A community dementia-free cohort aged > or =75 years (n=947) underwent follow-up examinations twice over a period of 6 years to detect dementia cases (Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised [DSM-III-R] criteria, n=304). Blood pressure variation before and after dementia diagnosis was verified with linear mixed-effects models. Using the dementia-free cohort identified at first follow-up (n=719), the association between blood pressure decline from baseline to first follow-up and subsequent risk of dementia was examined. RESULTS: Blood pressure markedly decreased over 3 years before dementia diagnosis and afterward, whereas no substantial decline was present 3 to 6 years before the diagnosis. However, among subjects with baseline systolic pressure <160 mm Hg, systolic pressure decline > or =15 mm Hg occurring 3 to 6 years before diagnosis was associated with relative risks (95% CI) of 3.1 (1.3 to 7.0) for Alzheimer disease and 3.1 (1.5 to 6.3) for dementia. There was a dose-response relationship between systolic pressure decline and dementia risk in subjects with vascular disease. CONCLUSIONS: Blood pressure starts to decrease only 3 years before dementia diagnosis and continues to decline afterward. A greater decline in systolic pressure occurring 3 to 6 years before diagnosis is associated with an increased risk of dementia only in older people with already low blood pressure or affected by vascular disorders.

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[Postprandial hypotension and autonomic neuropathy in diabetic patients]

[Article in Polish]

Trofimiuk M, Huszno B, Golkowski F, Szybinski Z.

Katedra i Klinika Endokrynologii Collegium Medicum Uniwersytetu Jagiellonskiego ul. Kopernika 17, 31-501 Krakow.

Postprandial hypotension is commonly defined as the decrease in systolic blood pressure of 20 mm Hg and more, observed within 2 hours after meal ingestion. This phenomenon was described in subjects with comprised function of autonomic nervous system. However, the data on its prevalence in diabetic patients are scarce. The aim of the study was to assess the concordance of postprandial hypotension and autonomic cardiovascular neuropathy in diabetes mellitus. The study included 67 patients (26 males, 41 females, mean age: 47.5 +/- 16.2 years) with diabetes type 1 or 2 (mean disease duration: 13.3 +/- 8.8 years), treated with diet and insulin injections. Postprandial hypotension was diagnosed based on results of automatic blood pressure recordings performed within 90 minutes after test meal ingestion. Tests of Ewing's battery were used to evaluate autonomic cardiovascular neuropathy. RESULTS: Mean postprandial decrease in systolic blood pressure of 17.7 +/- 11.7 mm Hg was noted at 48.0 +/- 13.7 min after meal ingestion. The study patients were divided into 2 groups based on results of systolic blood pressure recordings. In group A of 39 subjects (58.2%) the mean fall in systolic blood pressure of 8.9 +/- 4.4 mm Hg was observed. In group B of 28 (41.8%) subjects fulfilling the criteria of postprandial hypotension systolic blood pressure decreased after the meal of 30.0 +/- 6.2 mm Hg, the difference between groups was statistically significant (p < 0.001). Autonomic cardiovascular neuropathy was recognized in 41 (61.2%) of the study patients. The more advanced neuropathy was stated in group B (neuropathy scale score: group A--1.54 +/- 1.48 points, group B--5.11 +/- 1.93 points, p < 0.001). Statistically significant correlation between the magnitude of postprandial systolic blood pressure fall and cardiovascular neuropathy scale score was noted (Spearman's correlation co-efficient R: -0.612: p < 0.01). Postprandial blood pressure fall correlated significantly with orthostatic systolic blood pressure changes (correlation co-efficient R: 0.610; p < 0.001). CONCLUSIONS: Postprandial hypotension is an important symptom of diabetic cardiovascular neuropathy. It is recommended to include postprandial blood pressure measurements in diagnostic algorithm of autonomic nervous system dysfunction in diabetic patients.

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Helicobacter pylori lipopolysaccharide: biological activities in vitro and in vivo, pathological correlation to human chronic gastritis and peptic ulcer.

Luo YH, Yan J, Mao YF.

Department of Medical Microbiology and Parasitology, College of Medical Science, Zhejiang University, 353 Yan An Road, Hangzhou 310031, Zhejiang Province, China.

AIM: To determine the biological activity of Helicobacter pylori (H. pylori) lipopolysaccharide (H-LPS) and understand pathological correlation between H-LPS and human chronic gastritis and peptic ulcer. METHODS: H-LPS of a clinical H. pylori strain and LPS of Escherichia coli strain O55:B5 (E-LPS) were extracted by phenol-water method. Biological activities of H-LPS and E-LPS were detected by limulus lysate assay, pyrogen assay, blood pressure test and PBMC induction test in rabbits, cytotoxicity test in NIH 3T3 fibroblast cells and lethality test in NIH mice. By using self-prepared rabbit anti-H-LPS serum as the first antibody and commercial HRP-labeled sheep anti-rabbit sera as the second antibody, H-LPS in biopsy specimens from 126 patients with chronic gastritis (68 cases) or gastric ulcer (58 cases) were examined by immunohistochemistry. RESULTS: Fibroblast cytotoxicity and mouse lethality of H-LPS were weaker than those of E-LPS. But the ability of coagulating limulus lysate of the two LPSs was similar (+/0.5 ng/mL). At 0.5 h after H-LPS injection, the blood pressures of the 3 rabbits rapidly declined. At 1.0 h after H-LPS injection, the blood pressures in 2 of the 3 rabbits fell to zero causing death of the 2 animals. For the other one rabbit in the same group, its blood pressure gradually elevated. At 0.5 h after E-LPS injection, the blood pressures of the three rabbits also quickly declined and then maintained at low level for approximately 1.0 h. At 0.5 h after injection with H-LPS or E-LPS, PBMC numbers of the rabbits showed a remarkable increase. The total positivity rate of H-LPS from 126 biopsy specimens was 60.3%(76/126). H-LPS positivity rate in the biopsy specimens from chronic gastritis (50/68, 73.5%) was significantly higher than that from gastric ulcer (26/58, 44.8%) (chi(2)=10.77, P<0.01). H-LPS positivity rates in biopsy specimens from chronic superficial gastritis (38/48, 79.2%) and chronic active gastritis (9/10, 90.0%) were significantly higher than that of the patients with atrophic gastritis (3/10, 30.0%) (chi(2)=7.50-9.66, P<0.01). CONCLUSION: The biological activities of H-LPS were weaker than those of E-LPS, the activities of H-LPS of lowering rabbit blood pressure and inducing rabbit PBMC were relatively stronger. H-LPS may play a critical role in inducing inflammatory reaction in human gastritis.

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Rosiglitazone improves, while Glibenclamide worsens blood pressure control in treated hypertensive diabetic and dyslipidemic subjects via modulation of insulin resistance and sympathetic activity.

Yosefy C, Magen E, Kiselevich A, Priluk R, London D, Volchek L, Viskoper RJ Jr.

Noninvasive Cardiac Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, 02114-2696, USA. cyosefy partners.org

BACKGROUND: Type II diabetes is often associated with high blood pressure, elevated sympathetic activity, and high plasma insulin levels. Hypoglycemic agents may negatively interfere with blood pressure control, sympathetic activity, and plasma insulin level; therefore the choice of treatment in type II diabetes may be crucial. We aimed to compare the effects of two hypoglycemic drugs on blood glucose, blood pressure, sympathetic activity, and insulin levels in type II diabetic and hypertensive patients. METHODS: Forty-eight (24M, 24F) type II diabetic, hypertensive, and hyperlipidemic subjects were enrolled and treated for 4 weeks with an ACE inhibitor (Cilazapril) and a statin (Simvastatin). They were then randomized into two groups to receive a thiazolidinedione (Rosiglitazone; ROS) or a sulfonylurea (Glibenclamide; GLB) for 8 weeks. Blood biochemistry, blood pressure, plasma insulin, endothelial function, and sympathetic skin activity were measured before and after treatment. RESULTS: A significant drop in systolic and diastolic blood pressure by 6.1 +/- 4.1 mm Hg and 4.2 +/- 1.9 mm Hg respectively; a reduction in plasma insulin concentration by 4.3 +/- 1.9 mU/L and a decline in skin sympathetic activity were observed in the group receiving ROS. The GLB group showed an increase in systolic blood pressure by 3.1 +/- 2.5 mm Hg, no change in diastolic blood pressure, significant elevation in plasma insulin concentration by 2.3 +/- 1.4 mu/L, and augmentation of sympathetic activity. No significant changes in endothelial function were observed in either group. CONCLUSIONS: Rosiglitazone improved both plasma glucose and blood pressure levels, probably by attenuation of hyperinsulinemia and sympathetic activity, while Glibenclamide worsened blood pressure control possibly by elevation of insulin levels and activation of the sympathetic system.

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Characteristics of 100 consecutive patients presenting with orthostatic hypotension.

Ejaz AA, Haley WE, Wasiluk A, Meschia JF, Fitzpatrick PM.

Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Jacksonville, Fla, USA. ejazaa medicine.ufl.edu

OBJECTIVE: To elucidate the demographic and clinical characteristics of a consecutive series of patients who presented for evaluation of orthostatic hypotension. PATIENTS AND METHODS: From January 1, 1997, through September 30, 2001, we assessed retrospectively the demographic and clinical characteristics, antihypertensive medication use, and blood pressure variability in 100 consecutive patients with orthostatic hypotension who underwent 24-hour ambulatory blood pressure monitoring (OH group) and in a convenience sample of 100 age-matched patients who underwent 24-hour ambulatory blood pressure monitoring for evaluation of hypertension (HTN group). RESULTS: The OH group had a mean +/- SD age of 71.6 +/- 9.4 years, and 42% were women. The most common symptoms were light-headedness and weakness. Comorbid conditions included neurologic diseases (38%), preexisting hypertension (36%), hyperlipidemia (31%), cardiac arrhythmias and coronary artery disease (45%), and neoplasm (28%). During ambulatory blood pressure monitoring, postprandial decreases in blood pressure were noted in 83% of the OH group, supine or sleep hypertension in 84%, and noncompensatory heart rate variability in 75%. Findings on autonomic testing were abnormal in 99% of patients, serum creatinine value was increased in 30%, proteinuria was present in 27%, and left ventricular hypertrophy was present in 20%. CONCLUSIONS: Orthostatic hypotension is present in a heterogeneous group of disease states, is usually symptomatic, and is often associated with an abnormal blood pressure profile of reversal of circadian pattern, postprandial hypotension, and noncompensatory heart rate variability. Consequent target organ (kidney) damage can be as frequent as in patients who undergo 24-hour ambulatory blood pressure monitoring for evaluation of hypertension.

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Music improves dopaminergic neurotransmission: demonstration based on the effect of music on blood pressure regulation.

Sutoo D, Akiyama K.

Institute of Medical Science, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan. dsutoo md.tsukuba.ac.jp

The mechanism by which music modifies brain function is not clear. Clinical findings indicate that music reduces blood pressure in various patients. We investigated the effect of music on blood pressure in spontaneously hypertensive rats (SHR). Previous studies indicated that calcium increases brain dopamine (DA) synthesis through a calmodulin (CaM)-dependent system. Increased DA levels reduce blood pressure in SHR. In this study, we examined the effects of music on this pathway. Systolic blood pressure in SHR was reduced by exposure to Mozart's music (K.205), and the effect vanished when this pathway was inhibited. Exposure to music also significantly increased serum calcium levels and neostriatal DA levels. These results suggest that music leads to increased calcium/CaM-dependent DA synthesis in the brain, thus causing a reduction in blood pressure. Music might regulate and/or affect various brain functions through dopaminergic neurotransmission, and might therefore be effective for rectification of symptoms in various diseases that involve DA dysfunction.

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Risk factors for hypertensive crisis: importance of out-patient blood pressure control.

Tisdale JE, Huang MB, Borzak S.

Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA. jtisdale iupui.edu

OBJECTIVES: The purpose of this study was to identify independent risk factors for development of hypertensive crisis. METHODS: This was a retrospective, case-controlled study. Cases were 143 patients who presented during a 3-year period to the Emergency Department with the diagnosis of hypertensive crisis, defined as systolic pressure >/=180 mmHg and/or diastolic pressure >/=110 mmHg and symptoms of hypertensive emergency during the Emergency Department presentation. Controls were 485 patients with hypertension, matched to cases on the basis of age, sex and race, who were not admitted to the Emergency Department with an episode of hypertensive crisis during the study period. Co-morbid conditions were identified from computerized health system databases and medical records. Out-patient blood pressures were obtained from medical records from randomly selected out-patient clinic visits. RESULTS: The average blood pressure during Emergency Department presentation in patients with hypertensive crisis was 197 +/- 21/108 +/- 14 mmHg. Less successful out-patient systolic blood pressure control was an independent risk factor for hypertensive crisis [odds ratio (OR) 1.30 (1.18-1.42), per 10 mmHg, P < 0.001]. Higher out-patient diastolic blood pressures [OR 1.21 (0.99-1.43 per 10 mmHg, P = 0.07] and history of heart failure [OR 3.48 (0.94-12.94), P = 0.06] trended towards independence as risk factors. CONCLUSION: Less effective blood pressure control, based on out-patient systolic blood pressure measurements, is an independent risk factor for an Emergency Department presentation due to hypertensive crisis.

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Body size and cardiovascular risk factors in a preschool population.

Williams CL, Strobino B, Bollella M, Brotanek J.

Department of Pediatrics, Children's Cardiovascular Health Center, Columbia University, New York, NY 10032, USA. chrisw320 aol.com

Data on weight, height, blood pressure, and blood lipids were obtained for 1215 children entering New York Head Start preschools from 1995-1997. In this population, 17% were overweight and 15% were obese; the risk was greatest in Hispanic children. Overall, 13% had high blood pressure. African-American children were at increased risk of elevated blood pressure but had a more favorable lipid profile (high high-density lipoprotein cholesterol level and low triglycerides level) than white or Hispanic children. Body size was a significant predictor of elevated blood pressure, low high-density lipoprotein cholesterol, and increased triglycerides. The association between obesity and blood pressure was evident in white and Hispanic children only. Neither ethnicity nor obesity was associated with total cholesterol level. Obese preschoolers had approximately three times the risk of having high systolic blood pressure and twice the risk of low high-density lipoprotein cholesterol level compared with nonobese children, indicating that at-risk populations can be identified and primary prevention begun at a young age.

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