The objective of the study was to assess the relative contributions and benefits of chest radiogram and electrocardiogram in detecting left ventricular hypertrophy among adult hypertensives. Seventy consecutive, newly diagnosed hypertensive patients with forty age and sex comparable healthy controls were recruited for the study at the University of Maiduguri Teaching Hospital, Northeast, Nigeria. The echocardiographic mean Left Ventricular Mass (LVM) was 260.8 ± 72.9 g (range 109.8 to 429.8 g) and 136.9 ± 18.1 g (range 104 to 188.9 g) in patients and controls respectively (p<0.001). Echocardiographic LVM correlated fairly with Cardiothoracic Ratio (CTR) on chest X-ray (r = 0.43, p<0.01) followed by SV 2 + RV6 with a correlation of 0.39 (p<0.01). However, in terms of sensitivity, specificity and accuracy in comparison with ECHO LVM, SV2 + RV6 had …

Blood pressure, like heart rate, is a changing physiologic variable. Like ambulatory electrocardiography, ambulatory blood pressure can be recorded intermittently throughout the day. Ambulatory blood pressure is a dynamic variable influenced by multiple factors, and it correlates more strongly with target organ damage than do static office blood pressure measurements. Office (but not ambulatory) measurements are subject to the placebo and physician pressor effect. There is a great patient variability of blood pressure measurements in the office compared with ambulatory methods. Ambulatory blood pressure devices are portable rather than 'ambulatory'. The auscultatory (listens for Korotkoff sounds) and oscillometric (detects maximal arterial vibrations and calculates diastolic blood pressure) methods are used to detect blood pressure. Equipment is generally safe, although mild sleep derangements have been reported. The 24-h blood pressure and diurnal change are usually assessed. A 24-h ambulatory blood pressure mean of 140/90 mm Hg or above is clearly abnormal, though recent data suggest that the 95th centile is 134/84 mm Hg. Correlation of individual blood pressure readings with diary entries may be instructive. New American and British validation criteria have been published to assess the performance of each new device that becomes available. It should not be assumed that newer ambulatory devices have been tested (particularly by a third party) or are better. Test/retest 24-h ambulatory blood pressure shows less variability than office measurements; however, the percentage of patients with a mean difference greater than +/- 5 mm Hg on repeat 24-h blood pressure measurement after 1 week is still surprisingly high (49.3%, systolic; 52.1%, diastolic). European trials are in progress to assess the prognosis of hypertension assessed by ambulatory compared with office blood pressure. Ambulatory blood pressure monitoring has been restricted for use in several clinical situations and is not used for the routine evaluation and management of hypertension.

Echocardiography (ECHO) is useful to document changes in left ventricular mass (LVM) in groups of patients, but may be too variable for use in the individual patient. Magnetic resonance imaging (MRI) may be a more precise and reliable method to quantify the mass of the left ventricle. This study reports the accuracy, precision, and reliability of LVM estimates by MRI as compared to data obtained by ECHO in hypertensive patients.Accuracy referred to the comparison of LVM by MRI to anatomical LVM determined by autopsy. Precision was examined using 34 duplicate MRI images and by blindly reading 24 duplicate M-mode strips. Reliability was assessed by MRI in four subjects over 2 months, and by ECHO in 22 hypertensive patients over 2 weeks. Agreement between MRI and ECHO estimates of LVM was determined in the same 17 hypertensive patients using linear regression.MRI LVM estimates were within 17.5 g (95% CI) of the true LVM. The linear agreement between MRI and ECHO estimates of LVM could be described by the equation MRI = 0.61 x ECHO + 49.57 (r = 0.63, P < 0.1). The precision of LVM by MRI (11 g) was over twice that observed with ECHO (26 g). The reliability of MRI LVM estimates was more consistent (+/-8 g) than that for ECHO (+/-49 g).MRI appears to be a more precise and reliable method for measuring LVM, and would be more suitable than ECHO for the clinical evaluation of the individual patient.

Currently, echocardiography is the most accepted tool for diagnosing the left ventricular hypertrophy that characterizes hypertensive heart disease; electrocardiography is not adequately sensitive. The symptoms and signs of coronary artery disease (CAD) and of hypertensive heart disease are similar and include angina, myocardial infarction, systolic and diastolic heart failure, atrial fibrillation, ventricular ectopy, and sudden death. Thallium stress testing is useful for excluding significant CAD; a positive test requires cardiac catheterization to eliminate large-vessel disease as the cause of myocardial ischemia. Regression of left ventricular hypertrophy is a treatment goal.

The relationship of antihypertensive drugs have a long history of association with sexual dysfunction; however, this relationship is poorly documented. There appears to be a higher rate of sexual dysfunction in untreated hypertensive men compared with normotensive men. Sexual dysfunction increases with age and is associated with physical and emotional symptoms. There are few studies assessing sexual dysfunction with female and African-American hypertensive patients. Sexual dysfunction is associated with impairment of quality of life and noncompliance. Since group data may hide individual drug effects, baseline data should be collected on all patients before initiating therapy with any antihypertensive agent. Although questionnaires may not provide objective information on sexual dysfunction, the response rate to direct questioning may be less than the response rate on a questionnaire and may be affected by the gender or race of the interviewer. Research protocols using a double-blind, placebo-controlled design should assess sexual dysfunction in men and women in a standardized fashion.

In their recent article concerning indirect measurement of blood pressures, Bailey and Bauer1emphasize the importance of collection technique on the variability of indirect blood pressure measurements. In their conservative discussion of 24-hour automated blood pressure (ABP) monitoring (ABPM), the authors express a lack of confidence in the accuracy and reproducibility of ABPM, in part because of our experience with repeatability of ABPM during one of our research projects.2However, to fully appreciate the reproducibility of ABPM, the variability of office blood pressures (OBPs) using a standard mercury sphygmomanometer should be presented in comparison. We presented a direct comparison of the variability of office and 24-hour ABPs in a subsequent article,3which, although not referenced by the authors, contributes new information on the variability of indirect blood pressures and, thus, deserves comment. For the purposes of this discussion,reliabilityof blood pressures for an individual can be

Twenty-four-hour automated blood pressure measurements are representative of and more reliable than casual office blood pressure measurements; they also are more closely correlated with evidence of target-organ damage caused by hypertension and may have better diagnostic specificity. Nevertheless, broad use of automated monitoring in the routine evaluation and management of hypertension has been discouraged because of the lack of prospective epidemiologic studies linking automated measurements to cardiovascular morbidity and mortality, the inability to define a normal range for such measurements, and the cost of the monitoring. However, if it is accepted that conventions established for casual office blood pressure measurements are applicable to data obtained by automated methods, then routine use of automated monitoring is justified, since automated monitoring has better diagnostic capabilities that offset much of its cost.

Left ventricular mass calculations are often performed to assess the need or effectiveness of antihypertensive drug therapy. However, there are multiple potential errors that may affect the accuracy of these calculations, which can possibly include acute changes in preload. Therefore, to assess the hypothesis that acute volume depletion might alter calculated left ventricular mass, 15 normotensive healthy male volunteers underwent standard M-mode echocardiographic evaluations (at the level of the chordae tendineae guided by two-dimensional echocardiography) before and 2 h after 40 mg of intravenous furosemide. One patient was eliminated due to hypotension prior to the final echocardiogram. The echocardiograms were blinded to patient identity and the time sequence and read separately by two investigators. Four to five cycles were read per echocardiogram by each investigator. All values measured were the mean of the two investigators. Echocardiographic measurements were derived by both the American Society of Echocardiography and Penn conventions. An average urine volume of 1728 mL was collected, and the mean weight change 2 h after furosemide administration was 1.78 kg (P = .001). Penn left ventricular diastolic diameter (1.8 mm, P = .015) and left ventricular mass index (10 g/m2, P = .04) were significantly decreased; however, there was no significant change in septal, posterior, or relative wall thicknesses. As it is unreasonable to believe that acute remodeling of the left ventricle resulted in a decline in left ventricular mass in 2 hours, it is concluded that acute volume changes resulted in a decrease in left ventricular mass measurement due to the influence of diastolic diameter on the calculation of cardiac mass.

Preview Because unstable angina is often a precursor of myocardial infarction or death, patients with chest pain that persists for more than 20 minutes and is refractory to sublingual nitroglycerin should be hospitalized in an intensive care unit and given appropriate pharmacologic therapy. If symptoms persist despite adequate management with drugs, coronary arteriography should be performed and consideration given to an invasive procedure, such as angioplasty or coronary artery bypass grafting, for high-risk conditions. If necessary, the invasive procedure should be delayed until the patient's condition has stabilized.

The authors examined the efficacy and safety of the combination of verapamil and nifedipine in the control of hypertension. Retrospective analysis of blood pressures was obtained on 50 patients who had historically documented essential hypertension and were receiving verapamil and nifedipine. The patients had moderate to severe hypertension; 27 of 50 (54%) were uncontrolled on prescribed regimens of two or more separate classes of drugs. Control was defined by the ability to maintain a blood pressure of < or = 160/90 by providing doses of verapamil (max: 480 mg/day) and nifedipine (max: 180 mg/day). Twenty-nine (58%) were black and 21 (42%) were white. Ages ranged from 16 to 84 years. Mean duration of therapy was 1-2 years. Only 3 of 50 (6%) were control failures after providing verapamil and nifedipine. Three of 50 (6%) were discontinued because of side effects--reversible hepatitis (2) and rash (1). There were no serious adverse events, i.e., CHF or arrhythmias. Manageable ankle edema was seen in 14 of 50 (28%) patients. Verapamil and nifedipine, a combination of a dihydropyridine and a non-dihydropyridine calcium antagonist, was effective and safe in this group of patients with difficult-to-manage hypertension.

Patients with hypertension are more likely than those with normal blood pressure to have vascular disease, target-organ disease, and concomitant disorders, such as dyslipidemia, diabetes mellitus, obesity, arthritis, and renal and liver function problems. The authors describe how to correctly diagnose hypertension, identify associated problems, and arrive at the best therapeutic approach for the individual patient.

Although population studies have demonstrated a relationship between casual office blood pressures and target organ events, the variability of these blood pressure measurements for individual patients has generated an interest in the role of ambulatory blood pressure monitoring for defining the presence of hypertension and assessing the response to therapy. Noninvasive devices provide fewer data than intra‐arterial ambulatory blood pressure monitoring devices, but are safer. No current noninvasive device performs well during ambulation. Rigorous evaluation of these rapid proliferating electronic devices is important, as would be the case with any new antihypertensive agent. Although ambulatory blood pressure measurements correlate better with target organ damage for groups of patients than do casual office measurements, the predictability and limited data on reproducibility for individual patients does not support widespread application for routine testing for hypertensive patients. Ambulatory blood pressure monitoring should be viewed as a standard research tool for the evaluation of new cardiovascular drugs.

Blood pressure monitoring of hypertensives in the ambulatory state by automated portable devices (ABPM) as compared with casual office readings (COBPM) may predict outcome with greater precision and at an overall lower cost. Prospective trials that in random fashion require evaluation and management decisions on the basis of ABPM compared with COBPM are required to determine whether the above is true. End points such as death, stroke, or myocardial infarction occur at a low frequency rate. This would require thousands of patients to be followed 5 or more years to determine if evaluation and management by ABPM compared with COBPM results in a different outcome. A much smaller population can be used if end points are changes in left ventricular mass and left ventricular ischemia, arterial wall stiffness and thickness, endogenous creatinine clearance, renal albumin excretion, antihypertensive drug requirements, and adverse reactions. Until results from such a prospective trial are available, COBPM is the method of choice for evaluation and management of hypertensives. Automated blood pressure measurement can provide useful information in special circumstances and is of value for research purposes.

Blood pressure is a cardiovascular measurement with dynamic characteristics that can be influenced by a number of internal and external factors. The preferred blood pressure determination method would be one that reduces variability between measurements and that reflects the true blood pressure level. In this article, we present the variability of, and agreement between, the blood pressures collected by two indirect methods on the same patients during a hypertensive research project. Data obtained on patients in a typical clinical setting are also provided. Twenty-four-hour diastolic pressures obtained by the automated method demonstrated no regression to a lower mean, while blood pressures obtained casually in the office exhibited such regression. The 95% confidence interval of repeated measures for casual office blood pressure on a patient in a research setting (35/17 mm Hg) or in typical clinic practice (26/19 mm Hg) were similar, while the range of the mean 24-hour automated blood pressure monitoring (21/11 mm Hg) was smaller and demonstrated less variability. The magnitudes of the differences in blood pressures obtained on separate occasions in the same subjects were significantly lower with automated vs casual blood pressure determination methods (7.9/4.6 vs 13.7/7.4 mm Hg for both systolic and diastolic pressures). The agreement (95% confidence interval) between blood pressures obtained by the two methods (19/12 mm Hg) was found to be similar to the repeatability of automated blood pressure monitoring alone, and superior to that for data recorded casually in the office (35/17 mm Hg). Thus, the variability in mean 24-hour automated blood pressures is less than that for casual office blood pressures. The clinician should understand that the variability of blood pressures measured on an individual may be much greater than that reported for populations of hypertensive patients, and must be considered when applying epidemiologic group data to a specific patient. Moreover, any methodology of indirect blood pressure measurement that may reduce the variability and improve repeatability of casual office blood pressures deserves further consideration.

BACKGROUND The repeatability of 24-hour automatic ambulatory blood pressure measurements recorded by noninvasive equipment (Del Mar Pressurometer IV) was assessed to determine the intrapatient variability of this test. METHODS The usual antihypertensive medications of 73 patients with documented essential hypertension (supine diastolic blood pressure of 95 to 119 mm Hg) were withdrawn, and the patients were treated with placebo medication for 6 weeks. At the end of the placebo period, ambulatory blood pressure measurements of each patient were recorded every 15 minutes for 24 hours on two separate occasions 1 week apart. RESULTS There was no significant difference in either the 24-hour systolic or diastolic blood pressure for the entire group between weeks. A mean difference for individual patients between the first and second recording within 5 mm Hg was observed in 49.3% and 52.1% of patients for 24-hour systolic and diastolic blood pressure, respectively. The correlation coefficient for 24-hour systolic blood pressure was greater than 24-hour diastolic blood pressure (r = .87 vs r = .67). A difference greater than 18.1/14.9 mm Hg for systolic/diastolic blood pressure would be required to assign a significant (P less than .05) change in blood pressure between two recordings in the same patient. CONCLUSIONS These data quantify the usefulness of 24-hour ambulatory blood pressure measurements for a group of subjects. However, mean 24-hour ambulatory blood pressure varies significantly for individuals. Intrapatient variability may limit the usefulness of a single 24-hour ambulatory recording for an individual patient and suggests the need for more than one measurement to establish a level of blood pressure.

Data from 2 separate multicenter, double-blind clinical studies following the same protocol, except for the selection of doses, were pooled to evaluate the efficacy and tolerability of fixed doses of a new sustained-release (SR) formulation of nifedipine compared with placebo in 388 patients wtth mild to moderate uncomplicated essential hypertension. After a 3–6 week placebo washout period, the patients were randomized to receive either placebo or nifedipine SR-20 mg (study I only), 50 mg, 100 mg, or 150 mg (study II only). Among the 278 patients who completed 6 weeks of active therapy, mean supine diastolic blood pressure reductions from pretreatment baseline were 5.9,9.3,9.2,111, and 13.2 mm Hg hi the placebo, 20-, 50-, 100-, and 150-mg groups, respectively. The reductions achieved in each of the nifedipine SR groups were statistically significant versus baseline values (p <0.001). All nifedipine-SR doses reduced supine systolic blood pressure significantly more than placebo (p <0.001). In addition, there was a significant linear relationship between the log of the dose and the blood pressure reduction (p <0.05). Automated ambulatory blood pressure recordings performed in 221 of the patients showed that the blood pressure was lowered evenly through the entire 24-hour dosing period. The doses that were effective and associated with the fewest adverse reactions were 20 mg and 50 mg once daily.

The evaluation and management of hypertension is based on indirect blood pressures obtained in the office (COBPs) using the mercury sphygmomanometer. The usefulness of COBPs is limited by factors such as observer bias, which confound the ability to discern the true blood pressure value. Automated portable monitors have been marketed, which also measure blood pressure (ABP) indirectly throughout 24 hours, but without human intervention. Acceptance of a new device that indirectly records blood pressure depends largely on its the agreement with the established method of blood pressure measurement. This review compares the variability of blood pressures collected indirectly by standard mercury sphygmomanometer and by an auscultatory automated portable blood pressure monitor. The results indicate that blood pressure, when measured indirectly in a hypertensive patient, is quite variable. Automated blood pressures were lower and demonstrated less within‐subject variability during repeated measures than COBPs. The agreement between ABPs and COBPs was better than the agreement between COBPs alone on successive visits. In addition, the mean hourly blood pressure profiles recorded throughout 24 hours by automated and manual methods from ten hypertensive patients were nearly identical. These data suggest that blood pressures measured by auscultatory automated methods are similar to and representative of those obtained manually.

In a patient with a gastroplasty, gastric outlet obstruction developed after the dosage of nifedipine GITS (gastrointestinal therapeutic system) was increased from 30 to 60 mg/d. The hard, insoluble shell for this extended-release tablet appears causative.