苅尾 七臣

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.

The appropriate target blood pressure (BP) in elderly patients with hypertension remains uncertain. We investigated the relationship between morning home systolic blood pressure (MHSBP) during follow-up and cardiovascular (CV) risk in outpatients receiving olmesartan-based treatment aged <75 years (n = 16799) and ≥75 years (n = 4792) in the HONEST study. In the follow-up period (mean 2.02 years), the risk for major CV events was significantly higher in patients with MHSBP ≥155 mmHg compared with <125 mmHg in both age groups in Cox proportional hazards model adjusted for other risk factors and there was no significant difference in trend between the two groups (interaction P = 0.9917 for MHSBP). Hazard ratios for CV events for 1-mmHg increase in MHSBP were similar in patients aged <75 years and in patients aged ≥75 years. The incidence of adverse drug reactions related to excessive BP lowering was lower in patients <75 years than in patients ≥75 years (0.73 vs 1.02%, P = 0.0461). In conclusion, the study suggests even in patients ≥75 years antihypertensive treatment targeting the same MHSBP levels in patients <75 years may be beneficial in reducing CV risk when treatment is tolerated.

The authors sought to determine the association between the blunted morning blood pressure (BP) surge and nocturnal BP dipping of the riser pattern in 501 patients with hypertension enrolled in the ACHIEVE-ONE (Ambulatory Blood Pressure Control and Home Blood Pressure [Morning and Evening] Lowering by the N-Channel Blocker Cilnidipine) trial. The patients' sleep-trough morning BP surge and prewaking surge were calculated and then classified according to their nocturnal systolic BP reduction pattern as extreme dippers, dippers, nondippers, and risers. The prevalence of the riser pattern was significantly higher in both the lowest sleep-trough morning BP surge decile and the prewaking surge decile (blunted surge group) compared with the remaining deciles (56.0% vs 10.4% [P&lt;.0001] and 59.2% vs 10.2% [P&lt;.0001], respectively). The riser pattern was a significant determinant of both blunted sleep-trough morning BP surge (odds ratio, 73.3; P&lt;.0001) and blunted prewaking surge (odds ratio, 14.8; P&lt;.0001). The high prevalence of the riser pattern in patients with blunted morning BP surges may account for the cardiovascular risk previously reported in such patients.

The authors evaluated a new algorithm for detecting atrial fibrillation (AF) using a home blood pressure monitor. Three serial blood pressure values were measured by the monitor in 16 patients with AF and 20 patients with sinus rhythm. The authors defined monitor AF in irregular pulse peak (IPP) 25 as follows: (1) IPP: |interval of pulse peak-the average of the interval of the pulse peak| the average of the interval of the pulse peak x25%; (2) irregular heart beat: beats of IPP total pulse x20%; and (3) monitor AF: two or more irregular heart beats of the three blood pressure measurements. Cutoff IPP values were set at 20% (IPP20) and 15% (IPP15). The monitor's AF specificity was 1.0 in IPP25, IPP20, and IPP15, and its sensitivity was 0.88 in IPP25, 0.94 in IPP20, and 1.0 in IPP15. The new algorithm had high diagnostic accuracy for detecting AF and a low false-positive rate.

Background: Nocturnal blood pressure (BP) is an independent risk factor of cardiovascular events. The NOCTURNE study, a multicenter, randomized controlled trial (RCT) using our recently developed information and communication technology (ICT) nocturnal home BP monitoring (HBPM) device, was performed to compare the nocturnal HBP-lowering effects of differential ARBbased combination therapies in 411 Japanese patients with nocturnal hypertension (HT). Methods and Results: Patients with nocturnal BP = 120/70 mmHg at baseline even under ARB therapy (100 mg irbesartan daily) were enrolled. The ARB/CCB combination therapy (irbesartan 100 mg+amlodipine 5 mg) achieved a significantly greater reduction in nocturnal home systolic BP (primary endpoint) than the ARB/diuretic combination (daily irbesartan 100 mg+trichlormethiazide 1 mg) (-14.4 vs. -10.5 mmHg, P&lt;0.0001), independently of urinary sodium excretion and/or nocturnal BP dipping status. However, the change in nocturnal home systolic BP was comparable among the post-hoc subgroups with higher salt sensitivity (diabetes, chronic kidney disease, and elderly patients). Conclusions: This is the first RCT demonstrating the feasibility of clinical assessment of nocturnal BP by ICT-nocturnal HBPM. The ARB/CCB combination was shown to be superior to ARB/diuretic in patients with uncontrolled nocturnal HT independently of sodium intake, despite the similar impact of the 2 combinations in patients with higher salt sensitivity.

The authors evaluated the differences between evening home blood pressure (HBP) readings taken before dinner and those taken at bedtime, which were documented in a European and a Japanese guideline, respectively. Forty-eight patients (mean age, 76.4years) measured their evening HBP twice each day (two measurements both before dinner and at bedtime) for 14days. The authors defined the at-bedtime (B) minus the before-dinner (D) systolic HBP as the B-D difference. The mean B-D difference was -8.7mm Hg (P&lt;.001). The depressor effect of bathing was significantly prolonged for 120minutes. The B-D difference with alcohol consumption was significantly greater than that without alcohol. In the linear mixed model analysis, time after bathing 120minutes and alcohol consumption were significantly associated with the B-D difference after adjustment with covariates. There was a marked difference between evening HBP values. When patients' evening HBP is measured according to the guidelines, their daily activities should be considered.

A 72-year-old Japanese man was admitted to our hospital for effort chest pain and bilateral claudication. He was diagnosed as having severe ischemic heart disease and chronic bilateral aorto-iliac occlusions (Leriche syndrome) by a diagnostic angiography. Manifest collaterals via bilateral internal thoracic arteries (ITA) supplied sufficient blood flow for his lower limbs. We planned a two-stage operation for both the severe coronary artery disease and peripheral artery occlusive disease. He first underwent endovascular therapy (EVT) for bilateral aorto-iliac occlusion. One month later he underwent coronary artery bypass grafting (CABG) that was carried out for three coronary arteries with bilateral ITAs, also known as the internal thoracic artery, and the gastroepiploic artery. His chest symptoms and claudication were completely relieved and he was discharged uneventfully. We hereby suggest that EVT can be a safe, effective, and minimally invasive treatment to enable the patient to undergo CABG with all arterial grafts. &lt Learning objective: Patients with polyvascular disease are at a high risk for major vascular events. The priority among the revascularizations should be considered based on the less-invasiveness and better long-term patency. Hybrid treatment of EVT and CABG could be one of the choices among such patients.&gt

背景:Brugada症候群における心室性不整脈イベントにおいて就寝中や食後などの副交感神経活性との関連性が示唆されている。しかしながら不整脈発生時の状況およびtriggerとなる生活要因に関して、いまだ不明な点も多い。われわれはBrugada症候群における不整脈イベントの発生状況を検討した。方法:当院で植込み型除細動器(ICD)植込み術を施行したBrugada症候群連続32例を対象にICD適切作動を認めた患者背景を検討した。心室性不整脈に対しての適切動作を起こした9例と作動のなかった23例を比較検討した。ICD植込み前を含め心室性不整脈のみられた11例においてイベント発生時の血清カリウム値の関連について検討した。結果:適切作動と習慣性飲酒の関連性について検討した結果、適切作動群において有意に習慣性飲酒を多く認めた(適切作動群89%vs非作動群35%、p=0.002)。適切作動イベントに関す

背景:Brugada症候群における心室性不整脈イベントにおいて就寝中や食後などの副交感神経活性との関連性が示唆されている。しかしながら不整脈発生時の状況およびtriggerとなる生活要因に関して、いまだ不明な点も多い。われわれはBrugada症候群における不整脈イベントの発生状況を検討した。方法:当院で植込み型除細動器(ICD)植込み術を施行したBrugada症候群連続32例を対象にICD適切作動を認めた患者背景を検討した。心室性不整脈に対しての適切動作を起こした9例と作動のなかった23例を比較検討した。ICD植込み前を含め心室性不整脈のみられた11例においてイベント発生時の血清カリウム値の関連について検討した。結果:適切作動と習慣性飲酒の関連性について検討した結果、適切作動群において有意に習慣性飲酒を多く認めた(適切作動群89%vs非作動群35%、p=0.002)。適切作動イベントに関す

高血圧は日本人の心血管イベントに対する最大のリスク因子であり、24時間にわたる厳格な血圧コントロールが重要である。「高血圧治療ガイドライン2014(JSH2014)」では診察室外血圧測定が重視され、家庭血圧測定や24時間自由行動下血圧測定の普及とともに、白衣高血圧や仮面高血圧という概念が広く認識されるようになった。仮面高血圧の病態のなかでも早朝高血圧と夜間高血圧は臓器障害や心血管イベント発症と密接に関連しており、積極的な治療介入が必要である。血圧変動性の増大は臓器予後と関連するが、その背後には全身血行動態アテローム血栓症候群(SHATS)の病態があり、SHATSを構成する血管障害と血行動態ストレスの2つの要素は相乗的に悪循環を加速させ、心血管イベントのトリガーとなる。SHATSの病態のなかでも、まずは早朝高血圧を治療ターゲットにすることがSHATSの悪循環を断ち切るうえで重要である。そして

慢性心不全においてはレニン-アンジオテンシン-アルドステロン系(RAAS)が過剰亢進していることが明らかになり、RAAS抑制薬は心不全治療においては欠かせない薬剤になった。1987年CONSENSUS試験による予後改善効果が明らかにされて以来、RAAS系阻害薬はβ遮断薬、抗アルドステロン拮抗薬とともに心不全治療薬の主役を担ってきたが、すでに同試験が発表されてからおよそ30年が経過しようとしている。よりよい予後改善効果を求め、懸命に薬剤の開発が行われてきたが、期待された効果が伴わず、また、望ましくない副作用によりいくつもの薬剤が開発断念となった。今回、RAAS阻害薬とネプリライシン阻害薬の組合せが、心不全治療の主役であるアンジオテンシン阻害薬の予後効果を凌駕する結果を示した。待ち望んでいたエビデンスを有する薬剤に対しヨーロッパ心臓病学会もガイドラインを改定し、その立ち位置を明確にした。(著者

【目的】心血管リスクを持つ患者での圧受容体反射(baroreflex sensitivity:BRS)と低酸素イベント、経皮的動脈血酸素飽和度(SpO2)との関連を調べること。【方法】心血管リスク(高血圧、脂質異常症、糖尿病、喫煙)のうち1つ以上を持つ200名(男性52%、平均63±11歳)を対象とした。タスクフォースモニタ(CNSystems、日本光電)を用いて、5分間心電図と非侵襲的血圧測定を行い、BRSを測定した。また、パルスオキシメーターを用いて就寝中のSpO2を測定し、睡眠中の3%酸素飽和度低下指数(ODI)を測定した。【結果】BRSは3%ODIに逆相関していた(r=-0.20、p=0.005)。しかし、平均SpO2はBRSとは関連しなかった(r=0.10、p=0.19)。女性は男性よりBRSは低く(10.4±5.1 vs.12.9±11.0ms/mmHg、p=0.045)、糖尿

国内罹患者数が数百万人とされる睡眠時無呼吸症候群は、一晩に数百回にも及ぶ無呼吸発作時に急峻で甚大な血圧サージ(スリープサージ)を起こし、夜間高血圧や治療抵抗性高血圧を形成する重大な心血管危険因子である。心血管イベントは夜間から朝方の時間帯に多発することが知られているが、この著明なスリープサージがそのトリガーとなることが想定され、より正確なリスク評価のためにはスリープサージの計測が極めて重要であると考えられる。我々は最近、無呼吸発作時の経皮的動脈血酸素飽和度の低下をトリガーにしてスリープサージを検出する夜間低酸素トリガー血圧計を開発し、臨床応用に向けた取り組みを開始した。さらに、より正確なスリープサージの検出を実現するために、トノメトリ法を用いて手首位置だけで一拍毎の血圧を計測する技術開発を進めている。(著者抄録)

海外渡航を伴う睡眠不足、時差、疲労によってサーカディアンリズムが障害され、交感神経活動性の亢進と食塩感受性が増大しやすい。旅行中の食生活の変化により食塩摂取量が増大する。気温の変化、機内の低酸素も血圧上昇のリスクになり得る。旅行に伴う周囲環境の変化や、それに伴う心血管イベントの上昇はSHATSの概念で説明することができる。海外渡航前は家庭血圧測定を徹底し、ハイリスク患者では自由行動下血圧測定(ambulatory blood pressure monitoring;ABPM)による評価が望ましい。旅行中の心血管イベントを予防するためには、十分な睡眠、減塩、適度な運動量の確保、室温管理に努め、家庭血圧測定を含めた通常通りの健康管理を可能な限り継続することが重要である。旅行中の健康管理を徹底するためには、旅行者本人、旅行業界、医療従事者が健康管理に関する共通認識のもとに連携することが不可欠であ

Background:Obstructive sleep apnea (OSA) is associated with activation of the sympathetic nervous system, and patients with this condition often experience elevated blood pressure (BP), increased BP variability, and nocturnal BP surges.Methods and Results:The SYMPLICITY HTN-3 trial was a large prospective, randomized, blinded, sham-controlled trial of renal denervation for treatment of uncontrolle