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Acute, ambulatory and central blood pressure measurements in diabetes
Linköping University, Department of Medical and Health Sciences, Internal Medicine. Linköping University, Faculty of Health Sciences.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: In patients with diabetes, high blood pressure is an established risk factor for cardiovascular disease. The aim of this thesis was to explore the associations between blood pressure levels measured with different techniques and during different circumstances, and the degree of cardiovascular organ damage and subsequent prognosis in patients with diabetes.

Methods: We analysed baseline data from patients with type 2 diabetes who participated in the observational cohort study CARDIPP (Cardiovascular Risk factors in Patients with Diabetes – a Prospective study in Primary care), and longitudinal data from patients registered in the Swedish national quality registry RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive care Admissions). Patients in CARDIPP underwent nurse-recorded, 24-hour ambulatory and non-invasive central blood pressure measurements. Patients in RIKS-HIA had their systolic blood pressure measured upon hospitalisation for acute chest pain.

Results: In CARDIPP, nearly one in three patients with office normotension (<130/80 mmHg) were hypertensive during the night (≥120/70 mmHg). This phenomenon, masked nocturnal hypertension, was significantly associated with increased arterial stiffness and increased central blood pressure. Furthermore, nearly one in five CARDIPP patients with office normotension had high central pulse pressure (≥50 mmHg), and there was a significant association between high central pulse pressure and increased carotid intima-media thickness and increased arterial stiffness. Among CARDIPP patients who used at least one antihypertensive drug, those who used beta blockers had significantly higher central pulse pressure than those who used other antihypertensive drugs, but there were no significant between-group differences concerning office or ambulatory pulse pressures. In CARDIPP patients with or without antihypertensive treatment, ambulatory systolic blood pressure levels were significantly associated with left ventricular mass, independently of central systolic blood pressure levels. When RIKS-HIA patients, admitted to hospital for chest pain, were stratified in quartiles according to admission systolic blood pressure levels, the risk for all-cause one-year mortality was significantly lower in patients with admission systolic blood pressure in the highest quartile (≥163 mmHg) than in patients with admission systolic blood pressure in the reference quartile (128-144 mmHg). This finding remained unaltered when the analysis was restricted to include only patients with previously known diabetes.

Conclusions: In patients with type 2 diabetes, ambulatory or central blood pressure measurements identified patients with residual risk factors despite excellent office blood pressure control or despite ongoing antihypertensive treatment. Ambulatory systolic blood pressure predicted left ventricular mass independently of central systolic blood pressure. In patients with previously known diabetes who were hospitalised for acute chest pain, there was an inverse relationship between systolic blood pressure measured at admission and the risk for one-year all-cause mortality.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. , 64 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1292
Keyword [en]
Ambulatory blood pressure, Arterial stiffness, Central blood pressure, Diabetes, Hypertension.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-75352ISBN: 978-91-7519-966-5OAI: oai:DiVA.org:liu-75352DiVA: diva2:506094
Public defence
2012-04-20, Berzeliussalen, Hälsouniversitetet, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2012-02-27 Created: 2012-02-27 Last updated: 2013-09-10Bibliographically approved
List of papers
1. Masked nocturnal hypertension - a novel marker of risk in type 2 diabetes.
Open this publication in new window or tab >>Masked nocturnal hypertension - a novel marker of risk in type 2 diabetes.
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2009 (English)In: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 52, no 7, 1258-64 p.Article in journal (Refereed) Published
Abstract [en]

AIMS/HYPOTHESIS: This study was designed to evaluate the prevalence of masked nocturnal hypertension (MNHT) and its impact on arterial stiffness and central blood pressure in patients with type 2 diabetes. METHODS: Middle-aged patients (n = 414) with type 2 diabetes underwent clinic and ambulatory BP measurements and applanation tonometry. RESULTS: MNHT (clinic BP < 130/80 mmHg and night-time BP > or = 120/70 mmHg) was found in 7.2% of patients (n = 30). Compared with patients with both clinical and nocturnal normotension (n = 70), patients with MNHT had higher aortic pulse wave velocity (PWV) (10.2 +/- 1.8 m/s vs 9.4 +/- 1.7 m/s; p = 0.03) and higher central BP (117.6 +/- 13.9/74.0 +/- 9.1 mmHg vs 110.4 +/- 16.4/69.7 +/- 9.6 mmHg, p = 0.04). In patients with clinical normotension, night-time systolic BP correlated significantly with PWV. CONCLUSIONS/INTERPRETATION: Thirty per cent of patients with clinical normotension had nocturnal hypertension. This was accompanied by increased arterial stiffness and higher central BP. We conclude that in clinically normotensive patients with type 2 diabetes, ambulatory BP measurement may help clinicians to identify patients with increased cardiovascular risk.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-18981 (URN)10.1007/s00125-009-1369-9 (DOI)19396423 (PubMedID)
Available from: 2009-06-07 Created: 2009-06-07 Last updated: 2013-09-10Bibliographically approved
2. Association between admission supine systolic blood pressure and 1-year mortality in patients admitted to the intensive care unit for acute chest pain.
Open this publication in new window or tab >>Association between admission supine systolic blood pressure and 1-year mortality in patients admitted to the intensive care unit for acute chest pain.
2010 (English)In: Journal of the American Medical Association (JAMA), ISSN 0098-7484, E-ISSN 1538-3598, Vol. 303, no 12, 1167-1172 p.Article in journal (Refereed) Published
Abstract [en]

CONTEXT: High resting blood pressure (BP) is among the best studied and established risk factors for cardiovascular disease. However, little is known about the relationship between BP under acute stress, such as in acute chest pain, and subsequent mortality. OBJECTIVE: To study long-term mortality related to supine BP in patients admitted to the medical intensive care unit (ICU) for acute chest pain. DESIGN, SETTING, AND PARTICIPANTS: Data from the RIKS-HIA (Registry of Information and Knowledge About Swedish Heart Intensive Care Admissions) was used to analyze the mortality in relation to supine admission systolic BP in 119,151 participants who were treated at the ICU for the symptom of chest pain from 1997 through 2007. Results from this prospective cohort study were presented according to systolic BP quartiles: Q1, less than 128 mm Hg; Q2, from 128 to 144 mm Hg; Q3, from 145 to 162 mm Hg; and Q4, at or above 163 mm Hg. MAIN OUTCOME MEASURE: Total mortality. RESULTS: Mean (SD) follow-up time was 2.47 (1.5) years (range, 1-10 years). One-year mortality rate by Cox proportional hazard model (adjusted for age, sex, smoking, diastolic BP, use of antihypertensive medication at admission and discharge, and use of lipid-lowering and antiplatelet medication at discharge) showed that participants in Q4 had the best prognosis (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.72-0.80, Q4 compared with Q2; corresponding risks for Q1 were HR, 1.46; 95% CI, 1.39-1.52, and for Q3, HR, 0.83; 95% CI, 0.79-0.87). Patients in Q4 had a 21.7% lower absolute risk compared with Q2, patients in Q3 had a 15.2% lower risk than in Q2, and patients in Q1 had a 40.3% higher risk for mortality than in Q2. The worse prognosis in Q2 compared with Q4 was independent of body mass index and previous diagnoses and similar when analysis was restricted to patients with a final diagnosis of angina or myocardial infarction (HR, 0.75; 95% CI, 0.71-0.80, Q4 compared with Q2). CONCLUSION: Among patients admitted to the ICU for chest pain, there is an inverse association between admission supine systolic BP and 1-year mortality rate.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-58765 (URN)10.1001/jama.2010.314 (DOI)20332402 (PubMedID)
Available from: 2010-08-26 Created: 2010-08-26 Last updated: 2013-09-10
3. ß-blocker Treatment is Associated with High Augmentation Index and with High Aortic, but not Brachial, Pulse Pressure in Type 2 Diabetes
Open this publication in new window or tab >>ß-blocker Treatment is Associated with High Augmentation Index and with High Aortic, but not Brachial, Pulse Pressure in Type 2 Diabetes
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2010 (English)In: The journal of clinical metabolism and diabetes, Vol. 1, no 1, 55-62 p.Article in journal (Refereed) Published
Abstract [en]

Aims: To explore the associations between ß-blocker treatment and clinic, ambulatory, and central pulse pressure (PP) and central augmentation index (AIx), and left ventricular mass index (LVMI), respectively, in patients with type 2 diabetes.Methods: In 124 middle-aged patients with type 2 diabetes who were treated in primary care and used at least one antihypertensive drug, we measured clinic PP (mean value of three nurse-recorded measurements in the sitting position) and ambulatory PP (24-hour ambulatory measurements with the Spacelab 90217 measurement device). Central PP was measured non-invasively, using applanation tonometry (SphygmoCor), which also yielded values of AIx. LVMI was determined echocardiographically in all patients.Results: Patients whose antihypertensive drug regimen included a ß-blocker (n=67) had significantly higher central PP compared with patients whose antihypertensive drug regimen did not include a ß-blocker (ß-blocker: 49.6±12.2 mmHg, no ß-blocker: 45.1±10.2 mmHg; p=0.03) despite having similar clinic PP (ß-blocker: 60.4±16.3 mmHg, no ß-blocker: 58.9±13.1 mmHg; p=0.59) and similar ambulatory PP (ß-blocker: 55.2±9.1 mmHg, no ß-blocker: 54.8±10.6 mmHg; p=0.40). Patients treated with ß-blockers also had significantly higher AIx (ß-blocker: 30.7±8.4%, no ß-blocker: 25.8±8.8%; p<0.01) and higher LVMI (ß-blocker: 129.5±29.7 g/m2, no ß-blocker: 117.4±27.4 g/m2; p=0.02) compared with patients who were not treated with ß-blockers.Conclusions: In our cohort, ß-blocker use was associated with high central but not brachial PP and with high central AIx and high LVMI. Non-invasive measurement of central hemodynamic parameters may improve the evaluation of antihypertensive treatment efficacy in patients with type 2 diabetes.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-66160 (URN)
Available from: 2011-03-04 Created: 2011-03-04 Last updated: 2013-09-10Bibliographically approved
4. Central pulse pressure elevation is common in patients with type 2 diabetes and office normotension, and is associated with markers of atherosclerosis
Open this publication in new window or tab >>Central pulse pressure elevation is common in patients with type 2 diabetes and office normotension, and is associated with markers of atherosclerosis
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

The aim of this study was to describe the prevalence of elevated central pulsepressure (CPP) in patients with type 2 diabetes and office normotension, and to investigatewhether elevated CPP was associated with markers of atherosclerosis in these patients. Wedetermined office and central blood pressure, carotid intima-media thickness (IMT) and aorticpulse wave velocity (PWV) in 167 patients with type 2 diabetes and office normotension(<130/80 mmHg). Patients with office normotension and CPP ≥50 mmHg (n=32) hadsignificantly higher carotid IMT (0.76±0.2 mm vs 0.71±0.1 mm, p=0.041) and aortic PWV(11.0±2.5 m/s vs 9.5±1.8 m/s, p<0.01) than patients with office normotension and CPP <50mmHg (n=135). We conclude that almost one in five patients with type 2 diabetes and officenormotension had elevated CPP, and that this was associated with markers of both structuraland functional atherosclerosis.

Keyword
Type 2 diabetes, central pulse pressure, hypertension, pulse wave velocity
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-76136 (URN)
Available from: 2012-03-28 Created: 2012-03-28 Last updated: 2013-09-10Bibliographically approved
5. Ambulatory systolic blood pressure predicts left ventricular mass in type 2 diabetes, independently of central systolic blood pressure
Open this publication in new window or tab >>Ambulatory systolic blood pressure predicts left ventricular mass in type 2 diabetes, independently of central systolic blood pressure
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2012 (English)In: Blood Pressure Monitoring, ISSN 1359-5237, E-ISSN 1473-5725, Vol. 17, no 4, 139-144 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Both ambulatory and central blood pressures have been reported to correlate more closely than office blood pressure with left ventricular mass index (LVMI). The aim of this study was to test whether ambulatory systolic blood pressure (SBP) predicts LVMI independently of central SBP in patients with type 2 diabetes.

Methods: We determined office, ambulatory and central blood pressures and performed echocardiography in 460 patients with type 2 diabetes, who participated in the CARDIPP (Cardiovascular Risk factors in Patients with Diabetes – a Prospective study in Primary care) study (ClinicalTrials.gov number NCT 01049737).

Results: In separate multivariable regression models, both 24-hour ambulatory SBP, ambulatory day-time SBP, and ambulatory night-time SBP were significantly associated with LVMI, independently of central SBP, age, sex, BMI, ambulatory 24-hour heart rate, duration of known diabetes and presence or absence of any antihypertensive medications (r = 0.19, 0.17 and 0.18, respectively, P <0.01). All ambulatory SBP parameters, but not central SBP, were significantly associated with LVMI independently of office SBP.

Conclusions: Ambulatory SBP predicted LVMI independently of central SBP in patients with type 2 diabetes. The use of ambulatory blood pressure measurements may be encouraged as a tool for refined risk stratification of patients with type 2 diabetes.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2012
Keyword
ambulatory blood pressure, central blood pressure, hypertension, left ventricular hypertrophy, target organ damage, type 2 diabetes
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-76137 (URN)10.1097/MBP.0b013e328355fdfb (DOI)000306330300001 ()
Available from: 2012-03-28 Created: 2012-03-28 Last updated: 2013-09-10Bibliographically approved

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