苅尾 七臣

The home blood pressure monitoring (HBPM) method that measures blood pressure during sleep hours was reported to be comparable to ambulatory blood pressure monitoring (ABPM) in measuring nighttime blood pressure and detecting nocturnal hypertension. The aim of this study was to directly compare the prognostic power of nocturnal hypertension detected by HBPM versus ABPM for predicting future cardiovascular events. We analyzed nighttime blood pressure (measured by HBPM and ABPM) data of 1005 participants who were included in the J-HOP study (Japan Morning Surge-Home Blood Pressure). During a follow-up period of 7.6±3.4 years, 80 cardiovascular disease events occurred. The majority (91.8%) of our study population were hypertensive, and 80.7% of participants were using antihypertensive medication. Nighttime home systolic blood pressure (SBP) was higher compared to nighttime ambulatory SBP (123.0±14.6 versus 120.3±14.4 mm Hg, P&lt 0.001). Nocturnal hypertension was defined as nighttime home or ambulatory SBP of ≥120 mm Hg. The number of participants with nocturnal hypertension defined by HBPM and ABPM was 564 (56.1%) and 469 (46.7%), respectively. Nocturnal hypertension defined by HBPM was associated with increased risk of future cardiovascular events: total cardiovascular events (coronary artery disease and stroke events 1.78 [1.00-3.15]) and stroke (2.65 [1.14-6.20]), independent of office SBP. These results were absent with nocturnal hypertension defined by ABPM. This is the first comparison prospective study illustrating that uncontrolled nocturnal hypertension defined by HBPM (independent of office SBP) is a predictor of future cardiovascular events.

＜Point＞1 家庭血圧は診察室血圧よりも優れた心血管イベント予測能をもつことが報告されており,高血圧診療において非常に有用である。2 家庭血圧を有効に活用しJSH2019でも推奨されている治療目標125/75mmHgを達成することは心血管イベント抑制に有用と考えられる。3 家庭血圧測定を正しく行うには患者の協力が不可欠であり,測定することの意義や測定法を正しく説明することが重要である。(著者抄録)

This study investigated the association between salt intake and risk of disaster hypertension. We analyzed the data of surveys evaluating the health condition of evacuees in shelters after the Great East Japan Earthquake on April 30 and May 5, 2011. Among 272 subjects who completed the basic health condition questionnaire and underwent a medical examination, 158 (58%) had disaster hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg). Average estimated sodium intake assessed by spot urine was significantly associated with disaster hypertension (odds ratio per 1 g/d, 1.16 95% CI, 1.05-1.30). When we defined the high risk factors for salt-sensitive hypertension as older age (≥65 years), obesity (body mass index, ≥25 kg/m2), chronic kidney disease, and diabetes mellitus, estimated sodium intake was found to be a risk factor for disaster hypertension in the total group (odds ratio per 1 g/d, 1.27 95% CI, 1.12-1.43) and even in the group without prevalent hypertension before disaster (n=146 odds ratio per 1 g/d, 1.46 95% CI, 1.19-1.79). There was an interaction between estimated sodium intake and disaster hypertension according to the presence or absence of high risk of salt-sensitive hypertension in the group without prevalent hypertension (P=0.03). Disaster hypertension conferred a risk of microalbuminuria (odds ratio, 3.00 95% CI, 1.71-5.26 P&lt 0.001). We conclude that increased estimated sodium intake was associated with disaster hypertension in evacuees after disaster. This association was noted in the population with high risk of salt-sensitive hypertension and without prevalent hypertension before natural disaster. Additionally, disaster hypertension was associated with subclinical organ damage.

We evaluated the diagnostic value of atrial fibrillation (AF) measured by a wrist-type pulse wave monitor in this case-control study. Six serial pulse wave values (three in the left and three in the right wrist) were measured using a wrist-type monitor in 29 AF patients and 30 subjects with sinus rhythm. We defined “monitor AF in irregular pulse peak (IPP) 15/20/25” as follows: (a) IPP: |interval of pulse peak − the average of the interval of the pulse peak| ≥ the average of the interval of the pulse peak × 15/20/25% (b) irregular heartbeat (IHB): beats of IPP ≥ total pulse × 20% and (c) monitor AF: ≥4 IHBs of the six pulse wave measurements. In IPP 15, the sensitivity and specificity were 0.97 and 1.00, respectively. Pulse wave analysis by a wrist-type monitor was shown to have high sensitivity and specificity for the diagnosis of AF.

There are no known methods to easily evaluate the dietary salt intake of children. We hypothesized that the salt check sheet, for which validity has been confirmed in both hypertensive outpatients and in the general population, can be used to assess dietary salt intake in children. We enrolled 188 healthy schoolchildren (mean age 11.2 ± 1.1 years, 53.2% boys) and asked them to answer both the salt check sheet and a brief self-administered dietary history questionnaire for Japanese schoolchildren aged 6-18 years (BDHQ15y). The mean total salt check-sheet score was 12.7 ± 4.0 points (range: 4-24 points), and the estimated daily salt intake from the BDHQ15y was 12.1 ± 3.7 g (range: 4.7-27.2 g). The total check-sheet score was significantly positively correlated with the estimated daily salt intake from the BDHQ15y (r = 0.408, P &lt  0.001). Thirty-one study participants were assigned to the “low” salt group (total score on the salt check sheet was 0-8 points), 78 participants to the “medium” salt group (9-13 points), and 79 participants to the “high and very high” salt group (≥14 points), and a comparison estimating daily salt intake from the BDHQ15y among the three groups was performed. Daily salt-intake levels tended to increase as the group of total check-sheet scores increased: “low” vs “medium” vs “high and very high” salt group levels were 9.5 ± 3.1 vs 11.6 vs 13.5 ± 3.9, respectively (P &lt  0.001). This demonstrates that the salt check sheet is a useful tool to easily assess dietary salt intake in children.

The correlations between organ damage and hourly ambulatory blood pressure (BP) have not been established. The patients were 1464 participants of the Japan Morning Surge-Home Blood Pressure (J-HOP) study participants who underwent ambulatory BP monitoring. The hourly systolic BP (SBP) at x o'clock was defined as the average of SBP values measured at times x − 30 minutes, x, and x + 30 minutes. The mean age was 64.8 ± 11.6 years. The percentage of male participants was 47.8%. The left ventricular mass index (LVMI) was significantly associated with SBP at 6 o'clock (r = 0.166, P &lt  0.001). The carotid intima-media thickness was significantly associated with SBP at 5 o'clock (r = 0.196, P &lt  0.001). After adjustment for age, sex, smoking, hyperlipidemia, diabetes mellitus, antihypertensive drug use, clinic SBP, and 24-hour ambulatory SBP, the correlations of the LVMI and hourly SBP at 6 o'clock remained significant (beta coefficient = 0.125, P &lt  0.01). In conclusion, morning ambulatory systolic BP especially at 5 and 6 o'clock was independently associated with organ damage.

A 68-year-old Japanese man was admitted to our hospital with right eye pain, a sudden worsening of his eyesight, and a fever. He was diagnosed with endogenous bacterial endophthalmitis due to infectious endocarditis (IE) of Group B Streptococcus (GBS) on the day of admission. He recovered systemically, but his right eye became phthisical only with the administration of antibiotics. We conducted a review of the reported cases of IE caused by GBS complicated with endogenous bacterial endophthalmitis. IE should be considered when an undetermined etiology of endogenous endophthalmitis is encountered. The prompt diagnosis and treatment of IE will improve patients' outcomes.

Constipation is associated with cardiovascular events. Changes to the intestinal microbiota by constipation can induce atherosclerosis, blood pressure rise, and cardiovascular events. Constipation increases with age and often coexists with cardiovascular risk factors. In addition, strain at stool causes blood pressure rise, which can trigger cardiovascular events such as congestive heart failure, arrhythmia, acute coronary disease, and aortic dissection. However, because cardiovascular medical research often focuses on more dramatic interventions, the risk from constipation can be overlooked. Physicians caring for patients with cardiovascular disease should acknowledge constipation and straining with it as important cardiovascular risk, and prematurely intervene to prevent it. The authors review and discuss the relationship between constipation and cardiovascular disease.

BACKGROUND Although many studies have reported that the presence of minor or major ST-T change of electrocardiography (ECG) was associated with a risk of cardiovascular events, it is not clear whether there is a difference in the prognostic power depending on the summation of ST-T area (ST-T area ) assessed by a quantitative method. METHODS Electrocardiograms were performed in 834 clinical patients with one or more cardiovascular risks. ST-T area was assessed as the area enclosed by the baseline from the end of the QRS complex to the end of the ST-T segment using a computerized quantitative method. We used the lower magnitude of ST-T area in the V5 or V6 lead for the analysis. RESULTS After a mean follow-up 8.4 ± 2.9 years (7,001 person-years), there were 92 cardiovascular events. With adjustment for covariates, the results from Cox proportional hazards models (Model 1) suggested that the lowest quartile of ST-T area was associated with a higher risk for cardiovascular outcome compared with the remaining quartile groups (hazard ratio, 2.08 95% confidence interval, 1.36-3.16, P &lt 0.01). Even when adding the ECG left ventricular hypertrophy by Cornell voltage (Model 2) and Cornell product (Model 3) to Model 1, the significance remained (both P &lt 0.01). When we used ST-T area as a continuous variable substitute for the lowest quartile of ST-T area , these associations were similar in all models (all P &lt 0.01). CONCLUSION The lower summations of ST-T area assessed by a computerized quantitative method were associated with increased risk of cardiovascular disease incidence in a clinical population.

PURPOSE: Low-dose adenosine triphosphate (LD-ATP) is useful for diagnosing ATP-sensitive atrial tachycardia. However, the clinical implications of the sensitivity of LD-ATP in atrioventricular nodal reentrant tachycardia (AVNRT) still remain unknown. This study aimed to evaluate the mechanism of LD-ATP sensitivity in slow-fast AVNRT. METHODS: We estimated the sensitivity of LD-ATP in slow-fast AVNRT by a 2-4-mg ATP intravenous injection during the tachycardia. We evaluated the atrial-His (A-H) interval, tachycardia termination mode, prevalence of a lower common pathway (LCP), and successful ablation site in slow-fast AVNRT with LD-ATP sensitivity. LCPs were defined as His-atrial interval differences of at least 5 ms between that during ventricular pacing at the tachycardia cycle length and that during the tachycardia. RESULTS: Twenty-eight patients (mean age = 58 ± 11 years old, 18 females) with slow-fast AVNRT, who underwent catheter ablation of the antegrade slow pathway, were enrolled. Seventeen of 28 (61%) patients had LD-ATP sensitivity defined as termination of the tachycardia and/or a prolongation of the A-H interval of over 30 ms after an LD-ATP injection. The patients with LD-ATP sensitivity had a significantly higher prevalence of an LCP than those without (15/17 vs0/11, P < 0.0001). The successful ablation site in the LD-ATP sensitive group was significantly closer to the His bundle area than that in the LD-ATP nonsensitive group (13.3 ± 3.8 vs 20.5 ± 5.4 mm; distance to His bundle area in the left anterior oblique fluoroscopic view, P < 0.0001). CONCLUSIONS: LD-ATP sensitivity in slow-fast AVNRT may suggest the existence of an LCP. The successful ablation site in patients with LD-ATP sensitivity could be closer to the His bundle region.

Objective The aim of this study was to validate the TM-2441 ambulatory blood pressure monitoring (ABPM) device using the ISO 81060-2:2013 standard. Participants and methods Participants were healthy individuals aged more than 12 years who were recruited from among the outpatients and volunteers of Jichi Medical University (Tochigi, Japan). The same-arm sequence protocol (clinical validation) and the opposite-limb simultaneous method (ambulatory validation) from the ISO 81060-2:2013 standard were used. Results One hundred and seven participants were enrolled 85 participated in the clinical validation and 35 participated in the ambulatory validation (13 participants were included in both validation protocols). The TM-2441 device performed well against the standard in both the clinical and ambulatory validations the mean and SD values for the differences between device and observed systolic and diastolic blood pressure values in both tests fulfilled criterion 1 and criterion 2 of the standard. The Bland-Altman plots did not show any systematic variation in the error. Conclusion The TM-2441 ABPM device was accurate and fulfilled all ISO 81060-2:2013 standard requirements for ABPM determination in adults. It is therefore suitable for use for ABPM in adults with hypertension.

This study investigated the association between winter morning surge in systolic blood pressure (SBP) as measured by ambulatory BP monitoring and the housing conditions of subjects in an area damaged by the Great East Japan Earthquake. In 2013, 2 years after disaster, hypertensives who lived in homes that they had purchased before the disaster (n = 299, 74.6 ± 8.1 years) showed significant winter morning surge in SBP (+5.0 ± 20.8 mmHg, P &lt  0.001), while those who lived in temporary housing (n = 113, 76.2 ± 7.6 years) did not. When we divided the winter morning surge in SBP into quintiles, the factors of age ≥75 years and occupant-owned housing were significant determinants for the highest quintile (≥20 mmHg) after adjustment for covariates. The hypertensives aged ≥75 years who lived in their own homes showed a significant risk for the highest quintile (odds ratio 5.21, 95% confidence interval 1.49-18.22, P = 0.010). It is thus crucial to prepare suitable housing conditions for elderly hypertensives following a disaster.

Idiopathic ventricular tachycardias (VTs) originating from the non-coronary cusp (NCC) are very rare. The previous reports suggested NCC-VTs were characterized by a narrower QRS duration and smaller III/II ratio than VTs originating from other coronary-cusps. We present a rare case of an NCC-VT with a local fragmented potential recorded at the NCC inconsistent with the known ECG characteristics of NCC-VTs.

Background: Maximum home systolic blood pressure (maximum SBP) has been reported as a parameter of blood pressure (BP) variability. We tested the hypothesis that maximum SBP is one of the risk factors of hypertensive target organ damage (TOD).Methods: We conducted a cross-sectional study of 4,310 subjects with>1 cardiovascular risk factor. The subjects measured their home BP for 14 consecutive days. Mean and maximum SBPs were used as independent variables. As dependent variables, we used left ventricular mass index (LVMI), brachial-ankle pulse wave velocity (baPWV), maximum carotid intima-media thickness (CIMT), and urine albumin creatinine ratio (UACR).Results: In a multiple regression analysis, the subjects' mean and maximum SBPs were significantly associated with the above TOD markers. Compared to mean SBP, maximum SBP demonstrated a significantly stronger association with CIMT (p<0.001).Conclusion: Based on its clinical significance herein, measurement of maximum home SBP is warranted in addition to measurement of mean home SBP.

OBJECTIVE: This study investigated the changes of ambulatory blood pressure (ABP) profiles on the same participants over a 19-year follow-up. PARTICIPANTS AND METHODS: This is a longitudinal study. We conducted 24-h ABP monitoring at baseline in November 1997 and at follow-up in November 2016 for the same participants who were outpatients in a solitary island clinic. To estimate ambulatory blood pressure variability (ABPV), SD, coefficient of variation, and average real variability of ABP were calculated. ABP levels and ABPV at baseline and follow-up were compared using paired t-test. RESULTS: A total of 35 participants were recruited at follow-up (79.3±6.7 years at follow-up). Mean systolic blood pressure levels in 24-h, daytime, and night-time did not change significantly. However, ABPV of systolic/diastolic blood pressure in 24-h and daytime increased at follow-up compared with baseline (P<0.01 in all variables: SD, coefficient of variation, and average real variability), whereas ABPV in night-time did not change significantly. CONCLUSION: Our observations suggested that 24-h and daytime ABPV increase with aging in community-dwelling elderly people.

Randomized controlled trials and meta-analyses have established the benefits of blood pressure (BP) lowering. The 2017 American Heart Association/American College of Cardiology (AHA/ACC) guidelines for the management of hypertension established 130/80 mmHg as the threshold for the diagnosis- and treatment-target BP level. Area covered: The global trends are thought to be heading toward intensive BP-lowering management. In this paper, authors summarize the evidence on lowering the BP target in hypertensive patients with a focus on the 2017 AHA/ACC guidelines. Expert commentary: According to the results of clinical research, meta-analyses and the 2017 AHA/ACC guidelines, the target systolic BP may change from less than 140/80 mmHg to 130/80 mmHg in any other international hypertension guidelines. However, this direction of intensive BP control is still controversial.

The objective of this study was to test our hypothesis that nocturnal home blood pressure (BP) measurement adapted to the chosen bedtime of participants (measurement at 2, 3, and 4 hour after the chosen bedtime) would be more reliable than measurement at fixed time points (2:00, 3:00, and 4:00 am). Forty-eight hypertensives were randomized to two groups undergoing two seven-night measurement phases in a crossover manner and were asked to measure nocturnal home BP for 14 consecutive nights using a validated automatic information/communication technology-based device. The intraclass correlation coefficients (ICCs) of systolic BP (SBP) obtained by a single measurement per night over two nights showed lower agreement than those of systolic BP obtained by multiple measurements based on a participant-specified bedtime (0.539-0.625 vs 0.675-0.768) and multiple measurements at fixed times (0.468-0.505 vs 0.661-0.790). The ICCs obtained using specific bedtime-based time points and those obtained using fixed time points showed major agreement when SBP was obtained by multiple measurements. The standard errors of measurement for SBP were similar between the bedtime-based measurement phase (1.4-1.7 mm Hg) and the fixed-time measurement phase (1.2-1.6 mm Hg). Neither a fixed bias nor a proportional bias was observed between the SBP values measured by the specific bedtime-based time points and those measured by the fixed-time measurement phase. In conclusion, the reliability of nocturnal home BP measurement appeared to be similar between nocturnal home BP adapted to the chosen bedtime of participants and that measured at fixed time points.

Background: The association between the vectorcardiographic QRS area, bundle branch pattern and clinical long-term prognosis in patients who have undergone cardiac resynchronization therapy (CRT) has been unclear. Methods: We enrolled 50 consecutive patients who underwent CRT. Vectorcardiograms were constructed from preprocedural digital 12-lead electrocardiograms using the inverse Dower method. The vectorcardiographic QRS area was defined as the root of the sum of the square in the integral between the ventricular deflection curve and the baseline from QRS beginning to end in leads X, Y, and Z. The primary endpoints were total mortality and admission due to heart failure. Results: The vectorcardiographic QRS area in left bundle branch block (N = 13), right bundle branch block (N = 13), interventricular conduction delay (N = 11) and pacemaker rhythm (N = 13) were 218 ± 99, 97 ± 44, 90 ± 40, and 131 ± 58 μVs, respectively (ANOVA p &lt 0.001). During the mean follow-up period of 28 (2–86) months, 13 primary endpoints occurred. We divided patients into two groups: a large QRS area group (QRS area ≥114 μVs, N = 25) and a small QRS area group (QRS area &lt 114 μVs, N = 25) by the median. The large QRS area group had a significantly lower rate of the primary endpoint compared with that of the small QRS area group (log rank 4.35, p = 0.037). The Cox regression analysis revealed that a QRS area &lt 114 μVs was a significant predictor of the primary endpoint (HR 3.98, 95% CI 1.01–15.63, p = 0.048). Conclusions: A larger preprocedural vectorcardiographic QRS area was associated with left bundle branch block and good prognosis in patients who underwent CRT.

Research suggests that oxygen desaturation and sleep stage during obstructive sleep apnea (OSA) are related to the magnitude of high blood pressure (BP) in a laboratory setting. However, in a clinical setting, these associations have not been well studied. We used a noninvasive oscillometric BP measurement device to investigate the association between oxygen-triggered BP levels at the end of each OSA episode and the characteristics of the preceding OSA episode. In 42 newly diagnosed OSA patients (average age, 63.5±12.5 years; average apnea-hypopnea index, 32.6±18.2 per hour), 258 BP measurements were obtained at the end of OSA episodes. Hypoxia-peak systolic BP (SBP), defined as the maximum oxygen-triggered SBP value, was significantly higher in rapid eye movement sleep (144.9±19.9 mm Hg) than in non-rapid eye movement stage 1 sleep (129.5±15.1 mm Hg; P<0.001) and non-rapid eye movement stage 2 sleep (129.4±14.7 mm Hg; P<0.001). In a multivariate-linear mixed model, the lowest oxygen saturation percentage during each OSA episode was associated with increased hypoxia-peak SBP (-0.501 mm Hg; P<0.001), nocturnal SBP surge (-0.395 mm Hg; P<0.001), defined as the difference between the hypoxia-peak SBP and the mean nocturnal SBP, and maximum value of SBP surge (-0.468 mm Hg; P<0.001), defined as the difference between the hypoxia-peak SBP and the minimum nocturnal SBP independent of sleep stage. These values were not associated with the duration of each OSA episode. The contribution of rapid eye movement sleep and severe oxygen desaturation to OSA-related BP elevation measured with a noninvasive oscillometric method was determined in a clinical setting.

Background: Previous catheter-based renal denervation studies have reported variable efficacy results. We aimed to evaluate safety and blood pressure response after renal denervation or sham control in patients with uncontrolled hypertension on antihypertensive medications with drug adherence testing. Methods: In this international, randomised, single-blind, sham-control, proof-of-concept trial, patients with uncontrolled hypertension (aged 20–80 years) were enrolled at 25 centres in the USA, Germany, Japan, UK, Australia, Austria, and Greece. Eligible patients had an office systolic blood pressure of between 150 mm Hg and 180 mm Hg and a diastolic blood pressure of 90 mm Hg or higher a 24 h ambulatory systolic blood pressure of between 140 mm Hg and 170 mm Hg at second screening and were on one to three antihypertensive drugs with stable doses for at least 6 weeks. Patients underwent renal angiography and were randomly assigned to undergo renal denervation or sham control. Patients, caregivers, and those assessing blood pressure were masked to randomisation assignments. The primary efficacy endpoint was blood pressure change from baseline (measured at screening visit two), based on ambulatory blood pressure measurements assessed at 6 months, as compared between treatment groups. Drug surveillance was used to assess medication adherence. The primary analysis was done in the intention-to-treat population. Safety events were assessed through 6 months as per major adverse events. This trial is registered with ClinicalTrials.gov, number NCT02439775, and follow-up is ongoing. Findings: Between July 22, 2015, and June 14, 2017, 467 patients were screened and enrolled. This analysis presents results for the first 80 patients randomly assigned to renal denervation (n=38) and sham control (n=42). Office and 24 h ambulatory blood pressure decreased significantly from baseline to 6 months in the renal denervation group (mean baseline-adjusted treatment differences in 24 h systolic blood pressure −7·0 mm Hg, 95% CI −12·0 to −2·1 p=0·0059, 24 h diastolic blood pressure −4·3 mm Hg, −7·8 to −0·8 p=0.0174, office systolic blood pressure −6·6 mm Hg, −12·4 to −0·9 p=0·0250, and office diastolic blood pressure −4·2 mm Hg, −7·7 to −0·7 p=0·0190). The change in blood pressure was significantly greater at 6 months in the renal denervation group than the sham-control group for office systolic blood pressure (difference −6·8 mm Hg, 95% CI −12·5 to −1·1 p=0·0205), 24 h systolic blood pressure (difference −7·4 mm Hg, −12·5 to −2·3 p=0·0051), office diastolic blood pressure (difference −3·5 mm Hg, −7·0 to −0·0 p=0·0478), and 24 h diastolic blood pressure (difference −4·1 mm Hg, −7·8 to −0·4 p=0·0292). Evaluation of hourly changes in 24 h systolic blood pressure and diastolic blood pressure showed blood pressure reduction throughout 24 h for the renal denervation group. 3 month blood pressure reductions were not significantly different between groups. Medication adherence was about 60% and varied for individual patients throughout the study. No major adverse events were recorded in either group. Interpretation: Renal denervation in the main renal arteries and branches significantly reduced blood pressure compared with sham control with no major safety events. Incomplete medication adherence was common. Funding: Medtronic.

Obstructive sleep apnea causes blood pressure (BP) surges during sleep, which may lead to increased sleep-onset cardiovascular events. The authors recently developed an oxygen-triggered nocturnal BP monitoring system that initiates BP measurements when oxygen desaturation (SpO2) falls below a variable threshold. The association between nocturnal BP parameters obtained by nocturnal BP monitoring and simultaneously examined polysomnography-derived sleep parameters in 116 patients with obstructive sleep apnea (mean age 57.9 years, 85.3% men) was studied. In multivariable analysis with independent factors of age, body mass index, sex, and polysomnography-derived measures (apnea-hypopnea index, apnea index, arousal index, lowest SpO2, and SpO2 &lt  90%), apnea-hypopnea index (β =.26, P =.02) and lowest SpO2 (β = −.34, P &lt .001) were independent determinants of hypoxia-peak systolic BP (SBP), defined as the maximum SBP value measured by nocturnal BP monitoring. Similarly, apnea-hypopnea index (β =.21, P =.04) and lowest SpO2 (β = −.49, P &lt .001) were independent determinants of nocturnal SBP surge, defined as the difference between the hypoxia-peak SBP and the average of the SBP values within 30 minutes before and after the hypoxia-peak SBP, measured by the fixed-interval function in the manner of conventional ambulatory BP monitoring. In conclusion, in polysomnography-derived parameters, lowest SpO2, defined as the minimum SpO2 value during sleep, is the strongest independent determinant of hypoxia-peak SBP and nocturnal SBP surge measured by nocturnal BP monitoring. Our findings suggest that the severity of the decrease in SpO2 and the frequency of such decreases would be important indicators to identify high-risk patients who are likely to develop cardiovascular events specifically during sleep.

The integrated flow-mediated vasodilation (FMD) response has been associated with cardiovascular (CV) risk factors, but the association between the integrated FMD response and subsequent CV events has been unclear. We enrolled 555 patients who had at least one CV risk factor (hypertension, dyslipidemia, diabetes, or smoking). We measured the peak percentage change in diameter (ΔFMD), and integrated FMD response calculated as the area under the dilation curve over a 120-second dilation period (FMD-AUC120). Elderly patients (age ≥ 65 years, N = 270) in the lowest tertile of FMD-AUC120 (FMD-AUC120 &lt 5.6) had a higher rate of CV events compared with those in the two higher tertiles (FMD-AUC120 ≥ 5.6) (log rank 4.15, P =.041). The association remained significant after adjusting for covariates (hazard ratio 3.84, P =.007). In the 285 middle-aged patients (age &lt 65 years), the CV event rates were similar between patients in the lowest tertile and those in the two higher tertiles of FMD-AUC120 (log rank 0.39, P =.53). The CV event rates were similar between patients in the lowest tertile and those in the two higher tertiles of ΔFMD in elderly and middle-aged patient groups. In conclusion, integrated flow-mediated vasodilation response, but not ΔFMD, predicted CV events in elderly patients with CV risk factors.

Background: Although prasugrel exerts stronger antiplatelet effects compared with clopidogrel, the factors affecting platelet reactivity under prasugrel have not been fully determined. This study aimed to find the novel mechanistic differences between two thienopyridines and identify the factor that influence platelet reactivity to each drug. Methods: Forty patients with stable angina who underwent elective percutaneous coronary intervention were randomly assigned to receive either prasugrel (20 mg) or clopidogrel (300 mg) as a loading dose. Platelet function (light transmission, laser light scattering, and vasodilator-stimulated phosphoprotein phosphorylation) and plasma active metabolite levels were measured after the loading dose. Results: Prasugrel consistently inhibited adenosine diphosphate receptor P2Y12 signalling to abolish amplification of platelet aggregation. Prasugrel abolished even small platelet aggregates composed of less than 100 platelets. On the other hand, clopidogrel inhibited large aggregates but increased small and medium platelet aggregates. Diabetes was the only independent variable for determining antiplatelet effects and active metabolite concentration of prasugrel, but not clopidogrel. Sleep-disordered breathing was significantly correlated with platelet reactivity in patients who had clopidogrel. Conclusions: Prasugrel efficiently abolishes residual P2Y12 signalling that causes small platelet aggregates, but these small aggregates are not inhibited by clopidogrel. Considering the differential effect of diabetes on antiplatelet effects between these two drugs, the pharmacokinetics of prasugrel, other than cytochrome P450 metabolism, might be affected by diabetes.

The impact of a nondipping blood pressure (BP) pattern, defined as (awake systolic BP – sleep systolic BP)/awake systolic BP &lt  0.1, on cardiovascular events in populations with different degrees of carotid atherosclerosis is uncertain. The authors hypothesized that a nondipping BP pattern would show differential predictive power for cardiovascular events, including total cardiovascular death, sudden death, nonfatal cardiovascular events, and nonfatal stroke, between populations with and without carotid atherosclerosis. To test this hypothesis, the authors analyzed 493 patients (mean age 67.9 years, 47.5% men) from the J-HOP (Japan Morning Surge-Home Blood Pressure) study for whom ambulatory BP monitoring and carotid intima-media thickness data were available. Twenty-nine cardiovascular events occurred during follow-up (1867 person-years). A nondipping BP pattern was independently associated with cardiovascular events in the population without carotid atherosclerosis, defined as carotid intima-media thickness &lt  1.1 mm after adjustment for other cardiovascular risk factors including age, sex, diabetes mellitus, chronic kidney disease, and 24-hour systolic BP (hazard ratio, 8.15 95% confidence interval, 1.76–37.78 [P &lt .01]). This association was not found in the population with carotid intima-media thickness ≥ 1.1 mm. Therefore, in the hypertensive population without carotid atherosclerosis, physicians should consider ambulatory BP monitoring to determine the nocturnal BP pattern as an alternative approach to assessing cardiovascular events.

Background: Although higher blood pressure (BP) levels and BP variability have been associated with cognitive impairment, data are sparse regarding the relationship between BP variability and cognitive function in elderly patients with well BP control. Methods: We analyzed 232 ambulatory patients with one or more cardiovascular risk factors. All patients underwent ambulatory BP monitoring and the Japanese version of the Montreal Cognitive Assessment (MoCA-J). Results: The mean age was 77.7 ± 8.3 years 33.6% were male, and 85.3% were taking antihypertensive drugs. The average 24-hour BP level was 118.7 ± 10.0/68.3 ± 6.4 mm Hg. When we divided the weighted SD of systolic BP (SBP) as a measure of BP variability into quartiles, the top quartile group (≥19.6 mm Hg) had a significantly lower total MoCA-J score (15.4 [95% confidence interval 14.2-16.7] vs. 17.9 [17.2-18.6], P = 0.001) and lower scores on several domains, visuoexecutive (2.2 [1.9-2.6] vs. 2.8 [2.6-2.9], P = 0.012), abstraction (1.0 [0.7-1.2] vs. 1.3 [1.1-1.4], P = 0.015), attention (2.8 [2.4-3.1] vs. 3.6 [3.4-3.8], P = 0.001), and naming (2.1 [1.9-2.3] vs. 2.5 [2.4-2.6], P = 0.001) than quartiles 1 through 3 combined, after adjustment for age and 24-hour SBP. These associations were not found in the quartiles of 24-hour SBP. Conclusions: In elderly patients with well ambulatory BP control, higher BP variability but not average ambulatory BP level was associated with cognitive impairment.