The mean reduction in nocturnal blood pressure was of a magnitude that is considered to be clinically relevant. Thus, with controlled-release melatonin, systolic blood pressure was reduced by 6 mmHg and diastolic blood pressure by 3 mmHg. The various studies were remarkably consistent in the nature and extent of the effects of bedtime controlled-release mela- tonin on blood pressure, and most of the benefit was observed in the late night-early morning hours, when blood pressure elevation is on the rise. Importantly, the fast-release melatonin doses (5 mg) exceeded those of the controlled-release prepara- tions (2–3 mg), and their inability to decrease nocturnal blood pressure is therefore not related to a lower dose.
Abdominal circumference was measured using spring- loaded tape ruler (SECA, Hamburg, Germany) according to the standardized manner in which the ruler was placed horizontally at the mid-level between lower mar- gin of the ribs and the iliac crest at the end of normal expiration in a standing position. BP was measured two times with 1 min interval after 5 min rest in sitting pos- ition using HEM 907 (Omron, Kyoto, Japan). The aver- age value was used for systolic blood pressure (SBP) and diastolic blood pressure (DBP). Blood samples were col- lected in the morning of the first day of the survey after 12-h fasting to measure fasting blood glucose, lipid pro- files, creatinine, and hemoglobin A1C.
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Although studies of younger persons have shown noctur- nal drop in SBP of 10% or less to be a risk marker, a drop of this size does not seem to be a risk marker at the age of those participating in the present study, at least not within reason- able limits. The limits to normal dipping in upper age brackets appear to be shifted in the direction of the drop being less than for younger persons. This could be regarded as a beneﬁ cial change that tends to prevent cerebral hypoperfusion. More short-term falls in BP have been shown earlier to sometimes have negative consequences. In a ﬁ ve-year follow-up study of healthy elderly women with a mean age 83 at baseline Elmståhl and Rosén (1997) found orthostatic hypotension to be associated with cognitive decline, as determined by EEG measurements. The pathological associations of nocturnal dipping may be indicative of cerebral autoregulation in the elderly being particularly vulnerable. The ﬁ ndings of the present study should be investigated further, whether lower cognitive performance is indicative as a risk factor of cogni- tive decline, due to moderate nocturnal drop of blood pressure however, preferably in longitudinal studies.
BP decrease in our CKD3-4 patients was mostly associated with life-style factors such as BMI and HbA1c rather than decreasing renal function. Furthermore, the results from the present study indicate that nondipping status in CKD3-4 patients is associated with longer duration of hypertension treatment with more antihypertensive drugs. Even though our study did not find the effect of renal function on nocturnal BP decrease, a possible effect of renal function cannot be ruled out, as the life-style factors may have been superior to renal function in this population. However, as nondipping was seen associated with longer period of antihypertensive treatment, this finding underlines the importance of regular 24-hour BP measurements in patients with renal diseases.
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The present study investigated the effects of aerobic exercise timing on circadian BP variations and sleep architecture. Contrary to our hypothesis, the main finding was that a bout of moderate-intensity aerobic exercise at 7A resulted in the most beneficial responses in BP and improved overall sleep quality compared to 1P or 7P. Exercise completed at the 7A time point evoked a greater drop in nocturnal BP and elic- ited more time spent in deep sleep, less time spent in REM sleep, shorter SOL, and a decreased number of awakenings following the onset of sleep.
Abstract: Nocturnal hypertension and non-dipping of blood pressure during sleep are distinct entities that often occur together and are regarded as important harbingers of poor cardiovascular prognosis. This review addresses several aspects related to these blood pressure abnormalities including definitions, diagnostic limitations, pathogenesis and associated patient profiles, prognostic significance, and therapeutic strategies. Taken together, persistent nocturnal hypertension and non-dipping blood pressure pattern, perhaps secondary to abnormal renal sodium handling and/or altered nocturnal sympathovagal balance, are strongly associated with deaths, cardiovascular events, and progressive loss of renal function, independent of daytime and 24-hour blood pressure. Several pharmacological and non-pharmacological approaches may restore nocturnal blood pressure and circadian blood pressure rhythm to normal; however, whether this translates to a clinically meaningful reduction in unfavorable cardiovascular and renal consequences remains to be seen.
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HT: hypertension; TOD: target organ damage; LV: left ventricular; LVH: left ventricular hypertrophy; BP: blood pressure; ND: nocturnal blood pressure dipping; ACE: angiotensin‑converting enzyme; I/D: insertion/deletion; DM: diabetes mellitus; BMI: body mass index; MI: myocardial infarction; DLP: dyslipidemia; TC: total cholesterol; HDL‑c: high‑density lipoprotein cholesterol; LDL‑c: low‑density lipoprotein cholesterol fraction; TG: triglycerides; LVMI: left ventricular mass index; ABPM: ambulatory blood pressure monitoring; PCR: polymerase chain reaction; OR: odds ratio; CI: confidence interval; RAS: renin– angiotensin system.
We present simplified two-dimensional BP charts for boys and girls sourced from current standard Fourth Re- port thresholds as a simple alternative to use in screen- ing blood pressure in children above 3 years of age. According to the currently endorsed guidelines for chil- dren , six variables including systolic BP, diastolic BP, age, gender, height, and height percentile need to be de- termined in order to find upper BP thresholds from a detailed reference table  or lower BP thresholds from a different reference table or BP chart [19, 20]. Difficul- ties and inaccuracies using the current tables included in the Fourth Report have been documented in multiple studies. Bijlsma et al. recently showed that pediatric pro- viders often fail to look up BP percentiles and thus fre- quently underestimate BP abnormalities . Hansen et al. showed even when BP is measured, approximately 75 % of cases of hypertension and 90 % of cases of pre- hypertension in children and adolescents remain undiag- nosed . While efforts to create simpler and more practical tools to improve identification of hypertension in children have been suggested [21–24], none have be- come commonplace. Our charts alleviate the complexity of current BP classification by eliminating the need to determine height-percentile and by providing a quick visual representation of the child’s current BP percentile. The decision to reference BP by gender and height alone instead of age was based on a careful historical analysis of the development of current Fourth Report guidelines. Originally, the 1987 Second Task Force Re- port  introduced only age- and gender- specific BP percentile curves as the first graphical representation of BP in children. Upon further investigation, height per- centile was added to all subsequent updates because “body size is the most important determinant of BP in children and adolescents.” [5, 16] Additionally, height has been shown to be a better indicator of changes in BP than age and is independently related to BP in
The FLS is the world’s largest and oldest longitudinal observational study of human growth and body composi- tion. [7,8] Initiated in 1929 in Yellow Springs OH, the FLS has been housed at Wright State University in Day- ton, OH since 1977. Of the total enrollment of 2079 sub- jects eight percent have been lost to follow-up and 16 percent have died. Data of the lost and deceased partici- pants are used where appropriate. Childhood measure- ments made from birth through age 7 years include an- thropometrics and blood pressure. These data are re- corded during scheduled examinations at birth, 1, 3, 6, 9, and 12 months, then semi-annually to 18 years, and bi- ennially thereafter. Reliability in the FLS is excellent with reliability coefficients for most variables well above 90%.
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Several observations demonstrate that the amplitude and timing of wave reflections are directly related to the elastic properties of the arterial tree, stiffness index and time delay between the incident and reflected wave peaks are an example to estimate arterial stiffness . The contour of the ascending aortic pressure wave has been classified by analyzing the reflected wave amplitude and temporal characteristics [4–6]. These clas- sifications, however, are in close agreement with the age-related four classes of photop- lethysmography (PPG) contour . Moreover, it was demonstrated the age-related trend towards PPG contour triangulation , and showed the similar shape changes compared with the pressure wave. These results imply that PPG contour is dominantly controlled by pressure waveform, and contains cardiovascular information which includes vessel stiffness and BP.
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Cardiovascular disease accounts for approximately 17 million deaths a year, nearly one-third of the all- cause mortality. Of note, complications of hypertension ac- counted for 9.4 million deaths worldwide every year (World Health Organization, 2013). The common measurements of hypertension are SBP and DBP (DBP; Pickering et al.,2005). HR and PP (PP; i.e., the difference between SBP and DBP) serve as an additional predictors for cardiovascular diseases (Cooney et al., 2010; Franklin et al., 1999). In order to better control and prevent related diseases, understanding the eti- ology behind the blood pressure and HR is critical. Evidence from twin studies and family-based studies suggested that genetic variance might contribute to SBP, DBP, HR, and PP variance (Hottenga et al., 2006; Rice et al., 1989). Tradi- tional twin study is by far the most common approach to calculate the genetic contribution for certain phenotypes by comparing intra-pair concordance, which relies on strong assumptions about the relative environmental similarity of identical (monozygotic, MZ) and fraternal (dizygotic, DZ) twins (Conley et al., 2013).
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According to Swedish Study of Air Pollution and Lung Disease in Adult (SPALDIA) wheezing in whatever forms, has a high diagnostic value as a symptom in asthma di- agnosis. Also wheezing and two nocturnal symptoms (chest tightness, dyspnea and cough) have a high sensi- tivity and specificity for asthma diagnosis. Both wheez- ing and wheezing with two nocturnal symptoms yield best Yoden index (which evaluate the diagnostic efficacy of a test)  meanwhile there was a survey which has scored each of asthma symptoms that has been used in ECRHS study to evaluate questionnaire based diagnosis versus clinical diagnosis. In this scoring study, “wheez- ing and dyspnea” has highest score as symptomatic asthma . In our study prevalence of “wheezing in last 12 months”, “wheezing with dyspnea” and “wheezing with two nocturnal symptoms” were 24%, 10.8% and 5% respectively.
Case presentation: We report the case of a 38-year-old Caucasian man with severe obstructive sleep apnoea syndrome, initially refractory to nasal continuous positive airway pressure (and subsequently also to a mandibular advancement devices), in which the visualization of the upper airway with sleep endoscopy and the concomitant titration of positive pressure were useful in the investigation and resolution of sleep disordered breathing. In fact, there was a marked reduction in the size of his nasopharynx, and a paresis of his left aryepiglotic fold with hypertrophy of the right aryepiglotic fold. The application of bi-level positive airway pressure and an oral interface successfully managed his obstructive sleep apnoea.
Methods and patients: One hundred and thirty-eight patients with essential hypertension were enrolled in this prospective, single-arm, open-label study. NGTS was administered for 24 weeks to achieve target BP of 140/90 mmHg. The dose could be uptitrated to 60 mg/d in case of unsat- isfactory BP reduction after 4-week treatment. Home blood pressure measurement was recorded through the initial 1–14 days, and office BP and heart rate were evaluated at 2, 4, 8, 12, and 24 weeks. Results: One hundred and seventeen patients (84.8%) completed the study, and their average BP decreased by 19.0/11.3 mmHg after 24 weeks. The reduction of either systolic or diastolic BP was positively correlated with baseline BP at weeks 2, 4, or 24 after treatment (r=0.603–0.762, all p0.05). The maximal BP reduction was observed in 83% of patients at 4 weeks of treat- ment even though the dose of nifedipine remained unchanged (30 mg/day).
a blood pressure (BP) of more than 140/90 mmHg with proteinuria .300 mg in a 24-hour urine sample (or 1 + on dipstick random urine test) after the 20th week of GA as the minimum criteria. The clinical diagnosis is more accurate in the presence of higher BP and proteinuria levels, persistent visual disturbance, and headache, as well as epigastric pain. Symptomatically, persistent headache and persistent visual disturbance have been documented as sufficient criteria to identify worsening of a pre-eclamptic condition. Visual disturbance is known to occur in 30%–100% of patients with PE. 11 Eclampsia is the end point of untreated PE. This
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Moreover, most researchers believe that blood pressure (BP) changes at high altitude are principally due to in- creases in autonomic and sympathetic activity [3-8]. Pro- longed hypoxia for up to several days increases systemic pressure gradually, especially diastolic BP (DBP) and mean arterial BP (MABP), in parallel with increases in plasma concentrations of norepinephrine [9,10]. In particular, ex- cessive elevation of arterial BP is detrimental to our health and can cause acute mountain sickness (AMS) or some AMS symptoms, e.g., headache, dizziness, and insomnia. Some cases may even progress to life-threatening cerebral or pulmonary edema, known as high-altitude cerebral
The Systemic High Blood Pressure (SHBP) is a chronic non- contagious disease (CNCD) characterized by the increase of high blood pressure levels (Malachias et al., 2016). This pathalogy can be associated to metabolic disorders, functional and/or structural alterations of target organs worsens in the presence of otherrisk factors such as dyslipidemia, abdominal obesity, intolerance to glucoseand diabetes mellitus (Weber et al., 2014). The Brazilian Society of Cardiology, High Blood Pressure and Nephrology (2010) estimates the prevalence of theSHBP between children and adolescents is of 2% to 13% in Brazil.Young people that show elevated high blood pressure levels tend to keep this health state when adults, although the existence of public health policies, the prevalence of pediatric obesity has not decreased (Baroncini et al., 2017). The inadequate food allied to the lack of physical exercises and sleep elevates the level of obesity between adolescents and are prone to the CNCD, besides the cardiovascular risk that can unleash hemodynamic alterations (ESPINOSA et al., 2016). The obesity in children and adolescentes representes one of the most important problems ofpublic health due to their associated metabolic and cardiovascular comorbidities (D’ADAMO et al., 2015). The overweight and obesity are in the rise in the developing countries, especially in urban environments. More than 30 million of overweight children live in the developing countries and 10 million in the developed countries (WHO, 2002). In Brazil, this information does not diverge, according to the Family Budgets Research (FBR) carried out by Brazilian Institute of Geography and Statistics (BIGS), there was progressive reduction of malnutrition in children in the last decades, whereas overweight
Finally, both a strength and a weakness of the current study was that the HF subjects held their HF medications the night before the study. This was a strength in that the potentially confounding effects of these medications were removed, thus allowing the study of 'native' cardiac and vascular function. A potential weakness of this strategy is that HF patients are prescribed these therapies to improve survival; thus they frequently take them. It is conceivable that the magnitude of the LBF differential may have been less, if for example, an ACEI or ARB had been continued in the HF participants at the time of exercise CMR. In conclusion, in elderly patients with HF, functional impairment, and exercise intolerance, submaximal exer- cise induced femoral arterial blood flow is reduced even though cardiac output is preserved. This finding occurs after accounting for thigh muscle area, age, gender, and co-morbidities associated with poor vascular function. In contrast to our original hypothesis, these results indicate that mechanisms other than low cardiac output are responsible for reduced LBF during submaximal exercise in the elderly with HF. For these reasons, future studies should address whether a) inappropriate distribution of LBF in the absence of abnormalities of submaximal exer- cise induced changes in cardiac output are present in eld- erly disabled individuals with exercise intolerance, and b) therapies that improve LBF without necessarily modifying LVEF can reduce exercise intolerance and disability observed in elderly HF.
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It is dif ﬁ cult to determine if antihypertensive group or timing of drug administration are responsible for the favour- able effect on nocturnal BP reduction and modi ﬁ cation from nondippers and reverse dippers to dippers and extreme dip- pers. The bene ﬁ t of conversion in extreme dipping BP pattern is debatable because this circadian might be associated with nocturnal hypoxemia, coronary hypoperfusion, morning sympathetic activation, which could result with cerebro- and cardiovascular events, particularly in elderly patients. 50 Chronotherapy probably represents the best therapeutic approach in nocturnal hypertension. The MAPEC study compared the administration time between morning dose (taking all prescribed drugs in the morning) and bedtime doses (taking more than one drug at bedtime), and after a mean follow-up of 5.6 years in 2156 hypertensive patients reported that the bedtime dose provided better BP control. 51 Patients who were taking ≥ 1 drug at bedtime showed sig- ni ﬁ cantly lower relative risk of total cardiovascular disease events, compared to those taking all drugs in the morning. The prevalence of nondipping signi ﬁ cantly reduced (62% vs 34%) and prevalence of well-controlled BP increased (62% vs 53%) in patients receiving medication at bedtime. 51
Elevated intraocular pressure (IOP) is a primary risk factor for the development of glaucoma. However, some patients develop glaucomatous damage to the optic nerve in the absence of elevated IOP, known as normal tension glaucoma (NTG). The importance of lowering IOP to reduce the progression of glaucomatous damage was demonstrated by the Collaborative Normal Tension Glaucoma (CNTG) study group which showed that lowering IOP by 30% from baseline reduces the risk of progres- sion of visual field loss in NTG patients. However, 12% of treated patients progressed during five years of follow-up versus 35% of an untreated group. 1,2