Faculty Bibliography

The current study examined the degree of blood pressure (BP) control and incidence of myocardial ischemia in hypertensive patients (n=2039) referred for cardiac stress test. Patients were categorized into well-controlled (<140/90 mm Hg), poorly controlled (140-160/90-100 mm Hg), and very poorly controlled (>160/100 mm Hg) groups according to their resting BP. The mean age[±standard error of the mean] of the patients was 68±13 years, and 885 (43.4%) were men. The prevalence of well-controlled hypertension (HTN) was 47.2%, poorly controlled HTN was 29.5%, and very poorly controlled HTN was 23.3%. Evidence of ischemia was seen in 19.8% and 19.3% of the well-controlled and poorly controlled groups, respectively. The very poorly controlled group had the lowest incidence of ischemia (14.3%) (P<.05) compared with the other two groups. Symptoms that mimic ischemic heart disease in hypertensive patients may be partly explained by poorly controlled BP. Quality of care might be improved by optimally controlling BP in patients with angina symptoms prior to ordering diagnostic testing associated with radiation exposure and cost.

BACKGROUND Association of persistent left superior vena cava (PLSVC) and sinus venosus-type atrial septal defect (SVASD) is rare. We describe a patient with dilated coronary sinus (CS) found to have PLSVC and SVASD. CASE REPORT The patient is a 60-year-old man with history of stroke who underwent a transthoracic echocardiogram (TTE) for evaluation of shortness of breath. TTE demonstrated a markedly dilated CS. Agitated saline was injected into the left antecubital vein to further assess CS. The parasternal long axis view demonstrated immediate filling of the CS and confirmed the presence of a PLSVC. Apical 4-chamber view with injection of agitated saline into the right antecubital vein demonstrated immediate contrast opacification of both atria, consistent with a right to left cardiac shunt. Cardiac magnetic resonance (CMR) was performed, which confirmed the TTE findings of PLSVC and defined the cardiac shunt as SVASD. CONCLUSIONS PLSVC should be suspected in a patient with an abnormally dilated CS. In this case we identified a rare association of PLSVC with a SVASD. TTE with agitated saline contrast injection and CMR are useful diagnostic tools for PLSVC and associated cardiac congenital anomalies, respectively.

Introduction. The purpose of this observational cross-sectional study was to assess left ventricular mass (LVM) in prehypertensive individuals in comparison to normotensives and to determine if central blood pressure (BP) correlates better with LVM index (LVMI) than brachial BP. Methods and Result. Brachial and central BP measurements were completed at first visit and at 4 weeks in 65 healthy volunteers who were at least 40 years old and not on medication. Subjects were divided into two groups of normotensives and prehypertensives based on JNC-7 criteria and LVM was obtained using cardiac magnetic resonance imaging. Prehypertensives had significantly higher LVMI compared to normotensives (P < 0.01). Brachial and central BP also both positively correlate with LVMI (r = 0.460, P < 0.01; r = 0.318, P = 0.012, resp.) in both groups and neither method was superior to the other. After multivariate regression analysis and adjusting for cardiovascular risk factors, prehypertension remained an independent determinant of LVM. Conclusion. Prehypertension is associated with cardiovascular target organ damage, and central BP was not superior to brachial BP or vice versa for association with LVMI.

Angiotensin II (Ang II) is well known to participate in the abnormal autonomic cardiovascular control that occurs during the development of chronic heart failure (CHF). Disrupted cardiovascular circadian rhythm in CHF is also well accepted; however, the mechanisms underlying and the role of central Ang II type 1 receptors (AT1R) and oxidative stress in mediating such changes are not clear. In a post myocardial infarction (MI) CHF mouse model we investigated the circadian rhythm for mean arterial pressure (MAP), heart rate (HR), and baroreflex sensitivity (BRS) following MI. The cardiovascular parameters represent the middle 6-h averages during daytime (6:00-18:00) and nighttime (18:00-6:00). HR increased with the severity of CHF reaching its maximum by 12 weeks post-MI; loss of circadian HR and BRS rhythms were observed as early as 4 weeks post-MI in conjunction with a significant blunting of the BRS and an upregulation in the AT1R and gp91(phox) proteins in the brainstem. Loss of MAP circadian rhythm was observed 8 weeks post-MI. Circadian AT1R expression was demonstrated in sham animals but was lost 8 weeks following MI. Losartan reduced AT1R expression in daytime (1.18 ± 0.1 vs. 0.85 ± 0.1; P < 0.05) with a trend toward a reduction in the AT1R mRNA expression in the nighttime (1.2 ± 0.1 vs. 1.0 ± 0.1; P > 0.05) but failed to restore circadian variability. The disruption of circadian rhythm for HR, MAP and BRS along with the upregulation of AT1 and gp91(phox) suggests a possible role for central oxidative stress as a mediator of circadian cardiovascular parameters in the post-MI state.

Neurohumoral disturbances characterize chronic heart failure (CHF) and are reflected, in part, as impairment of baroreflex sensitivity (BRS) and sympathetic function. However, the mechanisms that trigger these neurohumoral abnormalities in CHF are not clear. We hypothesized that the BRS is blunted early in CHF and that the humoral effects occur later and contribute to progressive loss of cardiovascular control in CHF. We assessed the BRS (beats/min per mmHg) and recorded renal sympathetic nerve activity (RSNA) in four groups of conscious rabbits at varying time intervals: control, 1-week CHF, 2-week CHF, and 3-week CHF. Chronic heart failure was induced by ventricular pacing at 360 beats/min and was assessed by echocardiography. Arterial blood pressure and heart rate were recorded by an implanted telemetric device and RSNA through an implanted electrode. A significant fall in the ejection fraction, fractional shortening, and an increase in left ventricular end-systolic diameter and left ventricular end-diastolic diameter were observed in all CHF groups. The BRS was significantly reduced in all the CHF groups with no significant change in the basal RSNA (% of maximum) after 1 week of pacing; a small but insignificant rise in RSNA was seen at 2 weeks, and a significant rise in RSNA was observed at 3 weeks. Angiotensin II type 1 (AT-1) receptor protein (Western Blot) and mRNA (reverse transcriptase-polymerase chain reaction) expression in the rostral ventrolateral medulla exhibited a progressive increase with the duration of CHF, reaching significance after 3 weeks, the same time point in which RSNA was significantly elevated. These data are the first to examine early changes in central AT-1 receptors in CHF and suggest that the fall in BRS and hemodynamic changes occur early in the development of CHF followed by sympathoexcitation and overexpression of AT-1 receptors with the progression of CHF, causing further impairment of cardiovascular control.

Exercise training (EX) has become an important modality capable of enhancing the quality of life and survival of patients with chronic heart failure (CHF). Although 4 wk of EX in animals with CHF evoked a reduction in renal sympathetic nerve activity and ANG II plasma levels and an enhancement in baroreflex sensitivity at rest (Liu JL, Irvine S, Reid IA, Patel KP, Zucker IH, Circulation 102: 1854-1862, 2000; Liu JL, Kulakofsky J, Zucker IH, J Appl Physiol 92: 2403-2408, 2002), it is unclear whether these phenomena are causally related. CHF was induced in rabbits by ventricular pacing (360-380 beats/min) for 3 wk. CHF rabbits were EX for 4 wk at 15-18 m/min, 6 days/wk, 30-40 min/day. Three groups of rabbits were studied: CHF (with no EX), CHF-EX, and CHF-EX + ANG II infusion [in which ANG II levels were kept at or near levels observed in CHF (non-EX) rabbits by subcutaneous osmotic minipump infusion]. EX prevented the increase in plasma ANG II levels shown in CHF rabbits. CHF and CHF-EX + ANG II infusion rabbits had significantly depressed baroreflex sensitivity slopes (P < 0.01 for sodium nitroprusside and P < 0.001 for phenylephrine) and higher baseline renal sympathetic nerve activities than CHF-EX animals. EX downregulated mRNA and protein expression of ANG II type 1 receptors in the rostral ventrolateral medulla in CHF rabbits. This was prevented by ANG II infusion. These data are consistent with the view that the reduction in sympathetic nerve activity and the improvement in baroreflex function in CHF after EX are due to the concomitant reduction in ANG II and angiotensin receptors in the central nervous system.

Angiotensin II (ANG II) is known to activate central sympathetic neurons. In this study we determined the effects of ANG II on the autonomic components of the cardiovascular responses to stimulation of nasopharyngeal receptors with cigarette smoke. Experiments were carried out in conscious New Zealand White rabbits instrumented to record arterial pressure and heart rate. Rabbits were exposed to 50 ml of cigarette smoke before and after subcutaneous osmotic minipump delivery of ANG II at a dose of 50 ng.kg(-1).min(-1) for 1 wk in one group and intracerebroventricular (icv) infusion at a dose of 100 pmol/min for 1 h in a second group. The responses were compared before and after heart rate was controlled by pacing. Autonomic components were evaluated by intravenous administration of atropine methyl bromide (0.2 mg/kg) and prazosin (0.5 mg/kg). ANG II given either systemically or icv significantly blunted the pressor response to smoke (P < 0.05) when the bradycardic response was prevented. This blunted response was not due to an absolute increase in baseline blood pressure after ANG II infusion (71.64 +/- 11.6 vs. 92.1 +/- 19.8 mmHg; P < 0.05) because normalization of blood pressure with sodium nitroprusside to pre-ANG II levels also resulted in a significantly blunted pressor response to smoke. The effect of smoke was alpha(1)-adrenergic receptor-mediated because it was essentially abolished by prazosin in both the pre- and the post-ANG II states (P < 0.05). These results suggest that elevations in central ANG II reduce the sympathetic response to smoke in conscious rabbits. This effect may be due to an augmentation of baseline sympathetic outflow and a reduction in reflex sensitivity similar to the effect of ANG II on baroreflex function.

BACKGROUND:The aim of this work was to study the association between blunted nighttime dipping of blood pressure (BP) and coronary artery stenosis in men. METHODS:Sixty-eight men (aged 52 +/- 11 years) with coronary artery disease (CAD) defined as >/=70% diameter stenosis, and a control group of 68 men, matched for age and risk factors without angiographic CAD were studied by ambulatory blood pressure monitoring. Patients were defined as nondippers when the nighttime systolic and diastolic BP decrease was <10%. Medications included beta-blockers in 20 (15%), calcium antagonists in 39 (29%), angiotensin-converting enzyme inhibitors in 44 (32%), angiotensin receptor blockers in 21 (15%), and diuretics in 37 (27%) patients. A logistic regression model was used to define independent predictors of angiographic CAD. Covariates were symptoms, total cholesterol, daytime BP, and nondipping. RESULTS:A larger proportion of patients with CAD were nondippers as compared to control subjects (49 [72%] v 31 [46%], P < .005). In a logistic regression model, nondipping was associated with coronary artery stenosis independent of other clinical parameters (odds ratio 3.6, 95% confidence interval 1.6-8.8). CONCLUSIONS:Blunted nighttime dipping of BP is independently associated with angiographic coronary artery stenosis in men.